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Tendinopathy I Dr.RAJAT JANGIR JAIPUR
The document discusses the management of tendinopathy in athletes, emphasizing the importance of understanding tendon load capacity and adaptation. It highlights various treatment strategies, including load modification, pain management, and the use of medications, while also noting that full rehabilitation may not be achievable in-season. The importance of early intervention and monitoring to prevent worsening of symptoms is underscored, along with case examples to illustrate practical applications.
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Tendinopathy I Dr.RAJAT JANGIR JAIPUR
- 1. Treating athletes with tendinopathyin season
- 2. Articular Cartilage Injury Dr.RAJATJANGIR 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
- 3. Why are tendonsa 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
- 4. Is the problempathology 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
- 5. When does tendinopathyoccur? 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
- 6. Sequence of pathologicalevents
- 7. Mechanically weaker tendon Degenerative tendinopathy Normaltendon 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
- 8. This is whatwe 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
- 9. This is whatwe 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
- 11. Management of inseason tendinopathy
- 12. Etiology • A changein 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
- 13. Treating tendons inseason • 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
- 14. Bases of tendonmanagement 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
- 15. Bases of reducingin 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
- 16. What are wetrying 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
- 17. How do wedo 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
- 18. Reload appropriately • Isometricloading – 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
- 19. Can imaging helpin 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
- 20. What else canwe use for in season tendinopathy? • Medications – Affect the tendon response • Injections – Affect the tendon response – Analgesia • Adjunct treatments – Analgesia
- 21. What medications canwe 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)
- 22. What medications canwe 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
- 23. 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
- 24. What else? • DoNOT 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
- 25. Summary • Not justa 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
- 26. How can thepresented 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?
- 27. • Sudden onset insertionalpain 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
- 28. Case 1 • Ayoung 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
- 30. Case 2 • Avery 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
- 31.