SMA CONFERENCE

Tendinopathy

Context Considerations

What type of clients/ Athletes do we see ?

What type of tendinopathies do we see ?

Where do we start someone?

In season/ Out of season.

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Classifying the type of Tendinopathy

• Reactive: Younger, rapid onset, generally load related, Fusiform swelling of tendon, easily aggravated slow to settle, common in athletes
• Degenerative: Older, long history of symptoms, variable swelling and thicknesses, often self manage with deload
• Reactive on Degenerative: Most common, flare up of the normal part of the tendon when overloading
• Tenosynovitis: external friction / inflammation around the tendon, sometimes audible.

Session 1: Jill Cook and Ebonie Rio: Managing tendons

This was a Q&A based session so information was primarily guided by audience interest and designed to build on assumed knowledge

General tendon information

• Most tendons accumulate load over lifespan and are thus exposed to pathology; exception is patella tendon.
• Important to discriminate between tendinopathy versus tenosynivits or peritendon
• If you suspect a presentation of both, it was recommended to treat the peritendon first and then the tendinopathy
• No true “insertional tendinopathies” only tendinopathy or enthesopathy

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Achilles

• Management
• Recommended heel raises outside of shoe, 2-3cm
• Remove aggravating factors
• “Stable pain” is the aim
• Stair runs at 90 steps per minute while maintaining range
• Monitor squat and deadlift for tibial angle�
• Return to sport
• Return to run criteria achilles tendon
• Strength: 4x6 reps 2xBW SLCR
• Endurance: 30-35+ SLCR
• Must get through full range
• Consider client population and practicality athlete vs weekend warrior
• Consider rate of force production in rehab

Other areas

• Medial hamstring tenosynivitis
• Double therapy -> CSI -> ZKB depending on severity
• Hip based hamstring work for distal; knee based for proximal
• Measuring for crepitus will be relevant in this area, stethoscope?�
• Anterior knee pain
• Really important to get a history of activity levels during adolescence as previously discussed; was there too much load at critical time point?�
• Plantarfascia
• Similar principles to tendon, however not a contractile tissue
• Load proximally
• 30 degree MTP flexion with stair climbing -> neutral isometric off a step -> isometric off step just above/below plantargrade
• Check for neural involvement with SLR

Session 2: Brooke Combes: Central Nervous System Mechanism in Tendinopathy and its Effect on Exercise

Nociceptive Pain- Actual or threatened tissue, inflammation or overload

Nociplastic pain - No evidence of actual or threatened tissue damage

Lateral elbow tendinopathies

• Low load sustained exercise did not provide analgesic effects in this study
• Patella: analgesia, achilles: no change, tennis elbow: hypergesia
• MWM showed short term increases in grip strength (6x10sec, 2-3 sets of pain free contractions)
• Manual therapy can be used as adjunct�
• Quantify load and pain response to load
• Reduce strong stimuli “don’t poke the bear”
• Reduce fear or maladaptive pain beliefs
• Reduce pain contingent behaviours; boom/bust cycle
• Consider adjuncts to exercise
• Tailor to individual eg more nociceptive or nociplastic

Session 3: Jill Cook. Why Funky interventions fail us in Tendinopathy

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• Consider why “funky treatments” appeal
• Athlete:
• Ease of treatment
• Quickness of treatment
• Clinician
• Ease
• Appear to be doing something
• Economic benefit
• Coming and going: prolotherapy, bleeding into tendon, viscosupplementation
• Can use these as adjuncts but be realistic and honest with athlete about treatment and likely outcomes
• Standard exercise treatment works; but need to consider realistic timeframes
• isometrics , heavy slow resistance, energy storage (force absorption), energy storage & release

“Contract with patient is some form of touch for change in pain, education and key rehabilitation principles”

Session 4: Jill Cook. Tendinopathy research gaps and how this affects clinic practice.

• Rate of loading (energy storage and release loads)
• Breakdown of interfasicular matrix can be seen up to 2-4 days after load; then fasicles start taking load
• Compressive tendon load is a much bigger problem when combined with tensile load
• Load accumulation; 50% of 50yo have rotator cuff degeneration
• How tendon move against surrounding tissue? Eg achilles underneath fat pad
• Retinaculum often first thing to get aggravated, thickens and secondarily compresses tendon
• Interesting note: aeroplane cause increase pain for >24hours after travel >2hours, not sure why; does not seem to affect cars or trains

Key rehab Stages in tendinopathy Management

1. Isometrics 5x45 seconds
2. Isotonics - Heavy slow
3. Energy Storage
4. Energy Storage and release

Session 5: Anthony Nasser. Recent Advances in Tendinopathy of the Hip; An update on assessment and management of gluteal and proximal hamstring tendinopathy

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Gluteal tendon

• Objective Ax:
• +ve sls, resisted fader, resisted adduction
• -ve palp tenderness to rule out
• 30% reduction in abduction strength (unrelated to severity of tendinopathy)
• Glute min most vulnerable to atrophy
• Functional closed chain exercises for glute med/min

* Nice spot for practical

Hamstring

• Edu, isometrics, load accumulation, return to run
• RTR marker 80-90% knee flexor strength

Testing to rule in or out Greater trochanteric pain

• Most useful for ruling out GT pain: Palpation
• Most useful for ruling out GT Pain:Tests that involve a muscle contraction in some hip adduction
• Single leg Stance
• FADER + resistance
• Adduction + resistance
• Useful for differentiating HIP OA & GT pain: FABER