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RCT in eccentric exercise.
From theory to practice: a tendinopathy pathway

Dr Dylan Morrissey
Consultant Physiotherapist ...
•  How do you conservatively manage
tendinopathy now?
•  Is your approach evidence-based?
•  What do you think it might be...
Dr Dylan Morrissey
What is the most important element of your
management pathway?
Progressive loading – mechanotransduction
Does it work quic...
Tendon loading:
clinical reasoning
Young
Very active
Reasonable strength
High load demands

Middle aged
recreational
Moder...
•  A young talented player
•  on and off pain during warm
up or after training, better
during activity
–  Grade 3- out of ...
Tendon loading:
clinical reasoning
Younger
active
Reasonable strength
High load demands

Middle aged
recreational
Reasonab...
•  A very important player during season,
increasing symptoms (pain and stiffness
in the morning) in the Patellar Tendon
w...
Tendon loading: clinical reasoning
Activity
specific
rehabilitation
Tendon
loading for
tendon
health

ADL

Time
under
tens...
Balancing ‘tendon loading for tendon health’
with activity–specific rehab and ADL
Tendon
healing

Day
AM

PM

Other activi...
Tendon ecc and con loading –
mechanisms ?
•  Tendon	
  Stress,	
  strain,	
  
force,	
  s0ffness	
  
Perturba0on	
  /vibra0...
Where do the (good) vibrations come
from?

Adaptation may be muscle-driven, as well as tenocyte mechanotransduction
Top ‘tickets to treatment’
(tendon loading)

•  And think about
prevention

ostic
iagn on
D
pici
sus

SWT
R

lume
h vo n
H...
Aim = rapid return to sport / activity with minimal
intervention OLD PATHWAY

Time Diagnostic 2
0
suspicion

4

6

8

10

...
Shockwave Therapy
Study or Subgroup

Control/Alternative

Mean

Total

Mean

SD

Total

22

50.3

36.3

27

SD

Std. Mean ...
Acute effects of ESWT on tendon interleukins.
Waugh C, Morrissey D, Maffulli N, Screen H – unpublished data
Percentage Bas...
IL-6

Concentration (pg/ml)

1000000
100000
10000
1000
100
10
1

Concentration (pg/ml)

1000000
100000
10000
1000
100
10
1...
•  One of your players
experiences sudden onset
of pain in the Insertional
Achilles tendon during
training but only during...
Diagnostic suspicion as a ‘ticket to
treatment’ (tendon loading)
•  Intra Tendinous tears
• 

(Morton, Chan, Morrissey et ...
Diagnostic suspicion as a ‘ticket to
treatment’ (tendon loading)
•  Fascia crura tears
(Webborn, Chan, Morrissey BASEM
201...
•  One of your players
experiences sudden onset
of pain in the Insertional
Achilles tendon during
training but only during...
Tendon tear and loading: clinical
reasoning: elite rugby league
Early
0-2 weeks
Reduced strength
Low load demands

Late
4-...
Power and running training: tendon tear
SO – late stage from ~5-7 weeks
Initial
late
Mderate power demands

Middle late

F...
Usual post tear progression – SO 3
• 

From Wednesday, twice per day each day: ALL 3s up 3s
down
1.  Day 1: Double leg WB ...
HVIGI as a ‘ticket to treatment’
(tendon loading)
•  Do not get too excited!
•  ~50ml ( saline + LA +
steroid)
•  Image-gu...
How put it all together?

Dr Dylan Morrissey
AMENDED PATHWAY

Time 0

2

4

Prevention a
research
priority

6

8

10

12

14

16

18

20

22

24 weeks
Risk	
  factors	
  –	
  TA	
  (n	
  =	
  421)	
  

Age-­‐	
  and	
  weight-­‐
matched	
  
analysis	
  	
  
	
  

Highly	
 ...
Join in!
http://patellartendinopathyquestionnaire.blogspot.com/
http://www.achillestendinopathyquestionnaire.blogspot.co.u...
Now ... Going forward
•  What is your conservative management
paradigm now?
•  Is it evidence-based?
•  What do you think ...
In summary
•  A simple inter-disciplinary care pathway
•  Good evidence for success of different
elements
•  Developing ev...
It is all about teamwork
Thank you
Sports and Exercise Medicine MSc
Treatment for difficult to help patients
17th Annual Scientific Meeting
Septemb...
Dylan Morrissey. Senior Clinical Lecturer and Consultant Physiotherapist Centre for Sports and Exercise Medicine William H...
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Dylan Morrissey. Senior Clinical Lecturer and Consultant Physiotherapist Centre for Sports and Exercise Medicine William Harvey Research Institute Bart’s and the London School of Medicine and Dentistry Queen Mary University of London

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Dylan Morrissey. Senior Clinical Lecturer and Consultant Physiotherapist Centre for Sports and Exercise Medicine William Harvey Research Institute Bart’s and the London School of Medicine and Dentistry Queen Mary University of London

  1. 1. RCT in eccentric exercise. From theory to practice: a tendinopathy pathway Dr Dylan Morrissey Consultant Physiotherapist and Senior Clinical Lecturer d.morrissey@qmul.ac.uk N Webborn, V Rowe, S Hemmings, S Chaudhry, HRC Screen, N Padhiar, T Crisp, JB King, P Malliaras, O Chan, N Maffulli, JD Perry, C Waugh, H Abdulhussein, S Morton, S Mani-Babu, H Langberg, A Chauhan
  2. 2. •  How do you conservatively manage tendinopathy now? •  Is your approach evidence-based? •  What do you think it might be in two years?
  3. 3. Dr Dylan Morrissey
  4. 4. What is the most important element of your management pathway? Progressive loading – mechanotransduction Does it work quickly or is it too slow? ‘Recent literature concerning the rehabilitation of tendinopathy confirms that the most important treatment modality is appropriate loading.’ Scott A, et al. Br J Sports Med 2013;47:536–544. doi:10.1136/bjsports-2013-092329
  5. 5. Tendon loading: clinical reasoning Young Very active Reasonable strength High load demands Middle aged recreational Moderate strength Lower load demands Stress shielded? Older sedentary Weak Co-morbidities Stress shielded++ P Endurance then load then speed A Isometrics Isometrics? Isometrics? I Eccentrics Con-ecc Eccentrics Con-ecc Con-ecc N Power Strength-endurance
  6. 6. •  A young talented player •  on and off pain during warm up or after training, better during activity –  Grade 3- out of 5 •  Pre-season training •  what to do? Case 1
  7. 7. Tendon loading: clinical reasoning Younger active Reasonable strength High load demands Middle aged recreational Reasonable strength Lower load demands Older sedentary Weak intrinsic factors+++ e.g. adiposity, menopause P Endurance then load then speed A Isometrics Isometrics? Isometrics? I Eccentrics Con-ecc Eccentrics Con-ecc Con-ecc N Power Strength-endurance
  8. 8. •  A very important player during season, increasing symptoms (pain and stiffness in the morning) in the Patellar Tendon weeks before an important match •  What to do ?? Case 2
  9. 9. Tendon loading: clinical reasoning Activity specific rehabilitation Tendon loading for tendon health ADL Time under tension
  10. 10. Balancing ‘tendon loading for tendon health’ with activity–specific rehab and ADL Tendon healing Day AM PM Other activity that loads tendon Mon ✓ ✓ Gym (core and UL) Tue ✓ ✸ Train pm Wed ✓ ✓ Thurs ✓ ✸ Gym with tendon load Fri ✸ ✓ Train am Sat ✸ ✓ Shopping +++ Sun ✓ ✸ train
  11. 11. Tendon ecc and con loading – mechanisms ? •  Tendon  Stress,  strain,   force,  s0ffness   Perturba0on  /vibra0on       Vibration at 1*BW Vibration at 1*BW + 15kg
  12. 12. Where do the (good) vibrations come from? Adaptation may be muscle-driven, as well as tenocyte mechanotransduction
  13. 13. Top ‘tickets to treatment’ (tendon loading) •  And think about prevention ostic iagn on D pici sus SWT R lume h vo n Hig ctio inje
  14. 14. Aim = rapid return to sport / activity with minimal intervention OLD PATHWAY Time Diagnostic 2 0 suspicion 4 6 8 10 12 14 16 18 20 22 24 weeks
  15. 15. Shockwave Therapy Study or Subgroup Control/Alternative Mean Total Mean SD Total 22 50.3 36.3 27 SD Std. Mean Difference IV, Fixed, 95% CI Std. Mean Difference IV, Fixed, 95% CI RSWT as a ‘ticket to treatment’ 2.2.1 Mid-Portion or Insertional Tendinopathy 2.2.2 3 Month VAS 0.20 Costa 2005 SW v P 34.5 34.2 -0.95 0.96 22 -0.24 0.24 27 -1.05 [-1.65, -0.45] -1.55 35 22 4.23 20 27 -0.21 [-0.77, 0.36] -88 10 24 -81 16 24 -0.52 [-1.09, 0.06] 4.4 0.9 34 7.1 0.9 34 -2.97 [-3.67, -2.27] 2.9 1.2 34 6.5 0.6 34 -3.75 [-4.56, -2.95] 0.10 Rompe 2007 SW v Ec 4 2.2 25 3.6 2.3 25 0.17 [-0.38, 0.73] 0.10 Rompe 2007 SW v Wait 4 2.2 25 5.9 1.8 25 -0.93 [-1.52, -0.34] 2.1 1.1 34 2.9 1.8 34 -0.53 [-1.01, -0.05] 0.10 Rompe 2007 SW v Ec -70.4 16.3 25 -75.6 18.7 25 0.29 [-0.27, 0.85] 0.10 Rompe 2007 SW v Wait -70.4 16.3 25 -55 12.9 25 -1.03 [-1.62, -0.44] 0.10 Rompe 2009 EcSW V Ec -86.5 16 34 -73 19 34 -0.76 [-1.25, -0.27] 4.2 2.4 35 8.2 1.1 33 -2.10 [-2.70, -1.50] 2.9 2.1 35 7.2 1.3 33 -2.42 [-3.05, -1.78] 3 2.3 25 5 2.3 25 -0.86 [-1.44, -0.27] -79.4 10.4 25 -63.4 10 25 -1.54 [-2.18, -0.91] 2.2.3 FIL 0.20 Costa 2005 SW v P -0.44 [-1.01, 0.13] (tendon loading) 2.2.4 EQol Systematic Review Submitted 0.20 Costa 2005 SW v P 2.2.5 AOFAS Var Rasmussen 2008 SW v P 2.2.6 Mid-Portion Tendinopathy 2.2.7 1 Month VAS 0.21 Furia 2008 SW v Cons 2.2.8 3 Month VAS ASSERT trial 0.21 Furia 2008 SW v Cons 2.2.9 4 Month VAS 0.10 Rompe 2009 EcSW V Ec SWT R 2.2.10 VISA-A 2.2.11 Insertional Tendinopathy 2.2.12 1 Month VAS 0.21 Furia 2006 SW v Cons 2.2.13 3 Month VAS 0.21 Furia 2006 SW v Cons 2.2.14 4 Month VAS 0.12 Rompe 2008 SW v Ec 2.2.15 VISA-A 0.12 Rompe 2008 SW v Ec -4 -2 0 2 Favours Shockwave Therapy Favours Control/Alt 4
  16. 16. Acute effects of ESWT on tendon interleukins. Waugh C, Morrissey D, Maffulli N, Screen H – unpublished data Percentage Baseline (%) IL-6 Concentration (% Pre) 1000000 100000 10000 1000 100 10 1 IL-8 Concentration (% Pre) 1000000 100000 10000 1000 100 10 1
  17. 17. IL-6 Concentration (pg/ml) 1000000 100000 10000 1000 100 10 1 Concentration (pg/ml) 1000000 100000 10000 1000 100 10 1 IL-8
  18. 18. •  One of your players experiences sudden onset of pain in the Insertional Achilles tendon during training but only during high loading. •  What to do ? Case 3
  19. 19. Diagnostic suspicion as a ‘ticket to treatment’ (tendon loading) •  Intra Tendinous tears •  (Morton, Chan, Morrissey et al 2013 BJSM in review ) •  N = 37, 5% of 740 Achilles scanned over 48 months. •  Younger, more athletic, sudden increase pain, 92% co-existing TAopathy, impact related pain. ostic iagn on D pici sus
  20. 20. Diagnostic suspicion as a ‘ticket to treatment’ (tendon loading) •  Fascia crura tears (Webborn, Chan, Morrissey BASEM 2013) •  N = 12 (+35) Younger, more athletic, sudden increase pain, most co-existing TAopathy, impact related pain. ostic iagn on D pici sus
  21. 21. •  One of your players experiences sudden onset of pain in the Insertional Achilles tendon during training but only during high loading. •  What to do ? –  Image –  ?prolotherapy –  Immobilise –  Graduated rehab Case 3
  22. 22. Tendon tear and loading: clinical reasoning: elite rugby league Early 0-2 weeks Reduced strength Low load demands Late 4-6 Respect pain at all stages Reasonable strength Moderate load demands Strength normalised High load demands Endurance then strength then power and impact. Running last Build numbers then load then speed in later stages Isometrics / ADL Con-ecc Build endurance Loaded con-ecc Strength > power Power work Run focus
  23. 23. Power and running training: tendon tear SO – late stage from ~5-7 weeks Initial late Mderate power demands Middle late Full training High power demands Interaction between tendon rehab and sports specificity Initial running: building distance then speed From jogging to run Fast starts, Max speed, With slow starts spikes etc. Possibly after period of partial weight bearing sprints – eg aqua / alter-G
  24. 24. Usual post tear progression – SO 3 •  From Wednesday, twice per day each day: ALL 3s up 3s down 1.  Day 1: Double leg WB calf raises 4 sets by 8 reps 3s up 3s down (to the floor) twice daily for a day 2.  4 by 12 for a day 3.  Day 3: Progress to single leg 4 sets by 8 reps for a day 4.  4 by 12 for a day 5.  Day 5: Progress to over step 2 legs 4 by 8 for a day 6.  4 by 12 for a day 7.  Day 7: Progress to one leg 1 day over step 4 sets by 8 reps 8.  4 by 12 for a day •  Progress to adding load: 10 kg per week to 50% bodyweight •  Relative tendon rest days in between strong loading sessions
  25. 25. HVIGI as a ‘ticket to treatment’ (tendon loading) •  Do not get too excited! •  ~50ml ( saline + LA + steroid) •  Image-guided –  Deep to tendon –  Adjacent to primary area of neo-vascularisation Reduces pain AND Allows lume h vo n loading Hig tio injec WORKS REALLY WELL – see Anders Boesen presentation!
  26. 26. How put it all together? Dr Dylan Morrissey
  27. 27. AMENDED PATHWAY Time 0 2 4 Prevention a research priority 6 8 10 12 14 16 18 20 22 24 weeks
  28. 28. Risk  factors  –  TA  (n  =  421)   Age-­‐  and  weight-­‐ matched   analysis       Highly  significantly   associated  (p<0.01)   Significantly   associated  (p<0.05)   Not  associated   Male  gender,  scia0ca,    low  arched  feet,     contracep0ve  use,     post-­‐menopausal  status,     diabetes,  smoking    and  hypercholesterolaemia   Hamstring  and   calf  strain,  ankle   sprain,  back  pain   and  0ght   hamstring   muscles   Tight  calf  muscles   and  hypertension  
  29. 29. Join in! http://patellartendinopathyquestionnaire.blogspot.com/ http://www.achillestendinopathyquestionnaire.blogspot.co.uk/ @DrDylanM
  30. 30. Now ... Going forward •  What is your conservative management paradigm now? •  Is it evidence-based? •  What do you think it might be in two years?
  31. 31. In summary •  A simple inter-disciplinary care pathway •  Good evidence for success of different elements •  Developing evidence about mechanisms •  Key points –  Progressive load management –  Diagnostic suspicion –  Tickets to treatment –  Combined treatments
  32. 32. It is all about teamwork
  33. 33. Thank you Sports and Exercise Medicine MSc Treatment for difficult to help patients 17th Annual Scientific Meeting September 2014 @DrDylanM d.morrissey@qmul.ac.uk

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