Tendinopathy I Dr.RAJAT JANGIR JAIPUR

Treating athletes with
tendinopathy in
season

Articular Cartilage Injury
Dr.RAJAT JANGIR
Consultant Arthroscopy and Orthopedic Surgeon
Saket Hospital, Mansarovar
Assistant Professor
Mahatma Gandhi Medical College, Jaipur
Fellowship In Arthroscopy(South Korea)
International Olympic Committee Diploma Sports Medicine(UK)
Sports Physician RIO Olympic 2016

Why are tendons a problem?
• Disabling
– Athletes unable to perform at their usual level
• Lose power
– Jumping, change of direction, deceleration
– Anti-gravity tendons affected most
» Achilles, patellar
• Slow to respond
– Very happy to give bone and ligament weeks to
recover yet we expect tendons to be ready the next
week
– Collagen turnover may be non–existent or very
limited after puberty
• Heinnemeyer et al 2013

Is the problem pathology or pain or both?
• Interesting question
– Pain & pathological change are unrelated
• Mainly pain
– Stops function, stops performance
– May not have (imaging) pathology
• But can be pathology
– Tendons rupture if not enough intact tendon
left to take load
• Quantity of intact tendon may be the key factor
• Can be painfree prior to rupture

When does tendinopathy occur?
load placed>>> tendons
capacity
• Load has to include
– Energy storage and release
• Tendon acting as a spring
– Compression
• Against bone or retinacular
structures
– Combination of both

Sequence of pathological events

Mechanically weaker tendon
Degenerative
tendinopathy
Normal tendon Adaptation
Optimised
Load
Strengthen
Sedentary Optimised
load
Excessive
load + individual
factors
Reactive tendinopathy
Tendon dysrepair
Appropriate
modified
load
Normal
or excessive
load +/- individual
factors
What is the tendon response to overload?
Cook & Purdam 2009

This is what we want
NORMAL TENDON Adaptation
Optimised
Load
Strengthen
• Balance between load capacity of the tendon and the
load placed on it
• Load must always be close to what is required in sport
otherwise the tendon capacity will decrease
• Like bone, use it or lose it
the normal part of the tendon

This is what we often get
• Reactive after
unloading
– Unloading decreases
• Tendon mechanical
properties
• Tendon capacity to
tolerate load
– Present after a period
of time off
• Injury, off-season
– Return to loading at
previous levels
• Tendon reacts to load
Mechanically weaker tendon
Unloaded
Normal
or excessive
load +/‐
individual
factors
Reac<ve tendinopathy
Normal tendon

Management of in season
tendinopathy

Etiology
• A change in load
– One session or over several sessions
• One session
– Single high intensity session
– Direct blow
• Several sessions
– Increased frequency of training esp high loads
– Pre-season training!
• Either
– Different drills
» Sprints at the end of training
– Change in footwear
– Change in track/surface
» Soft sand
» Uneven surfaces

Treating tendons in season
• Challenges
– Full rehabilitation is impossible
– Kinetic chain dysfunction
increases over season
– Activated tendon difficult to settle
when abusive loads continue
• Research
– Eccentric exercises do not
help
» Visnes et al 2005, Fredberg et
al
– ESWT does not help
» Zwerver et al 2011
Visnes et al 2005
Zwerver et al 2011

Bases of tendon management in
season
– Define the stage of tendinopathy
• Assume it is reactive or reactive on degenerative
– Quantify tendon symptoms and kinetic chain
function
– Modify load
• Training
• Biomechanical, kinetic chain
– Maintain whatever you can
• Strength, power

Bases of reducing in season
tendon pain
• Reduce the sensitisation of the tenocytes
– Key if the cells are the source of pain
• Attempt to reduce the proteoglycan
deposition in the matrix
– Key to prevent further matrix disruption and
poorer load tolerance
• Local interventions to the neurovascular
structures

What are we trying to achieve with
in-season rehab?
• Maintain/improve function of
muscle
• Unload the affected tendon
– Maximise other contributions to
the kinetic chain
• Avoid exacerbation of the
tendon
– Load management
• Unload and load appropriately
• Prioritise performance and pain
control

How do we do manage
tendinopathy with unloading?
• Decrease frequency of high tendon load
– Energy storage and release
– Train every second or third day
• Decrease length of loading
– Shorten training
• Decrease load in training
– Take out key overloads
• Drills and training that excessively load the tendon
• Decrease compressive loads
– Specific movements and drills

Reload appropriately
• Isometric loading
– Great to decrease pain in a reactive tendon
– Mechano-transduction
• Cells are activated and producing excess proteins
– Slower/less intense loading less likely to up-regulate
the tenocytes
• Cells are integrally connected to the matrix
– Connections through proteoglycans and integrins
with connection through to the cell nucleus
– Through cilia (Lavorgnino)
» Alter gene expression in response to mechanical
load
• So attempt to load the tendon without
stimulating cell through matrix movement

Can imaging help in season?
• Ultrasound tissue
characterisation (UTC)
– Improve staging and
diagnosis
– Detect asymptomatic changes
in tendon structure
– Determine load tolerance in at
risk tendons
– Monitor recovery of structure
independent of symptoms

What else can we use for in
season tendinopathy?
• Medications
– Affect the tendon response
• Injections
– Affect the tendon response
– Analgesia
• Adjunct treatments
– Analgesia

What medications can we use
for the tendon?
• Tenocyte inhibitors
– Ibuprofen (Tsai et al 2004), celecoxib
• Aggrecan inhibitors
– Ibuprofen, naproxen, indomethacin (Dingle1999, Riley
2001)
• TNF alpha inhibitors
– Doxycycline (Fallon et al 2009)
• Inhibits MMP13 (Bedi et al 2010)
– Green tea (Cao et al 2007)
– Omega 3 (Mehra et al 2006)

What medications can we use
for the tendon?
• Corticosteroid is a knock out blow on cell activity and
proliferation
– Short acting and non-colloidal eg dexamethasone
– Not into tendon
– Can be oral
– ONLY in very reactive tendons
• What about the bad press?
– Used inappropriately
• Wrong stage
• Wrong corticosteroid
• Wrong rehab
• Wrong reasons

What about injections?
• Analgesia/ anaesthetic
• Well if it is only pain why not get rid of the pain?
– Progressive increase in symptoms
• Other injections – PRP, cells
• Intratendinous injections have no place for their use in
in-season management
• Peri-tendinous injections used but untested to date

What else?
• Do NOT rest tendinopaths in the off season
– Immediately start to improve load capacity in the tendon
• Prehab
Ensure good tendon capacity of all athletes
• Monitoring
• Monitor either pathology with UTC or pain with loading tests
• Early intervention
• Change load when tendon first declares its intolerance with pain or loss of
structure
– Waiting and hoping not recommended

Summary
• Not just a simple assessment
– Stage pathology
– Determine response to load
– Determine what loads are affecting tendon
• Not a simple management
– Based on above
• Manage pathology
• Manage load
• Manage pain
• Manage long term outcome for the athlete

How can the presented evidence helped
clinicians in the management of
tendinopathies ??
• One of your players
experiences sudden
onset of pain at the
insertion of the
Achilles tendon
during training but
only during high
loading
• What to do?

• Sudden onset
insertional pain
unusual
– Examine the
loading that is
causing the pain
• Should be a compressive aetiology
• If not differential diagnosis
– May be insertional plantaris
• If it is tendon, decompress it
– High heel raise
• High during the day and as high as
possible during training
– Consider training in good running shoes
with heel raise
• Limit high loads
• Start isometrics and heavy slow
loading away from dorsiflexion

Case 1
• A young talented player
with symptoms in the
patellar tendon (on and
off pain during warm up
or after training, better
during activity) during
the preseason training
• What to do?
– continue training?
– adjust training?
– add treatment?
1. Likely reactive on degenerative
tendinopathy
1. Not severe, but will be if not
attended to immediately
1. Back off loads, frequency,
extreme load drills
2. Attend to deficits in kinetic chain
Especially quads and calf deficits
3. Allow TIME for this to resolve
4. Medicate with triple therapy
5. Address fully in the off-season

Case 2
• A very important
player during season
experience
increasing symptoms
(pain and stiffness in
the morning) in the
patellar tendon
weeks before an
important match
• What to do?
• Consider the diagnosis
– Patellar tendons are
rarely sore in the am
• Balance the load with
the tendon capacity
– Decrease abusive loads
• Frequency, length of
training and specific drills
• Start loads that help
pain and function
– Isometrics and heavy
slow isotonics
– Strengthen calf and gluts
to assist quads
• Medicate to settle
tendon

Tendinopathy I Dr.RAJAT JANGIR JAIPUR

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