26/09/16 Tendon hierarchy Eccentric exercise for tendon - - PDF document

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Eccentric exercise for tendon rehabilita2on (?)

• S. Peter Magnusson

Ins+tute of Sports Medicine Copenhagen & Musculoskeletal Rehabilita+on Research Unit Bispebjerg Hospital, Copenhagen, Denmark Faculty of Health & Medical Science, University of Copenhagen, Denmark

ECM

PG & GAG

Tendon hierarchy

Magnusson et al, Nature Reviews Rheum 2010

Collagen synthesis and tendon metabolism in vivo

Langberg et al, 1999, 2001

PICP (ug/l)

Bojsen-Moller et al, J Appl Physiol 2006

13% MVC

• Kadler. Biochem J 1996

Heinemeier et al. FASEB J, 2013

Lack of 2ssue renewal in human adult Achilles tendon

Core Achilles tendon +ssue, n= 28 (+ 4 muscle samples) Birth year range: 1945 - 1983 Time of death: year 2000

14C level measured with accelerator mass spectrometry (AMS)

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Stress (N/m2, MPa) Strain (%)

Do tendons adapt/grow in response to loading?

Region specific adapta2on to months and years of high load on patellar tendon

Kongsgaard et al, ACTA Physiol 2007

CSA (mm2)

Couppé et al, JAP 2008

4-6% 20-28%

Tendon hypertrophy/adapta2ons in response to loading ?

Heinemeier et al, FASEB 2013

Komi 1990 Finni et al 2000

Achilles & patellar tendon load

Patella Achilles

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Intratendinuous force transmission: Is there a weak link?

Microtear ?

Region specific?

Lian et al, AJSM 2005

What is an overuse injury ? Tendinopathy Management of tendinopathy?

• !

Corticosteroid injections

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Eccentric training

• !

Sclerosing therapy

• !

PRP

• !

NSAID

• !

Surgery

• !

Ultrasound therapy

• !

Shockwave therapy

• !

Oxygen therapy

• !

Stretching

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Cryotherapy

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………..

• !

………..

Gold standard?

Effect of NSAID on Achilles tendinopathy region in response to acute exercise

NSAID (600 mg x 3/day/1 week) Treadmill running x 1h Biopsy 2h aeer Pingel et al, EJAP 2013

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(Smidt et al, Lancet 2002)

(Kongsgaard et al, SJMSS 2009)

Effect of corticosteroids?

Surgery: open tenotomy (+ exercise, incl ecc) Ecc, 12 weeks, twice daily, 3 x 15 reps Bahr et al. JBJS 2006

Surgery as a Treatment for Patellar Tendinopathy

Eccentric exercises +/- surgery

How to treat tendinopathy ?

• !

NSAID

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Cor+costeroid injec+ons

• !

Sclerosing therapy

• !

PRP

• !

NSAID

• !

Surgery

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Loading based rehab

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Eccentrics

• !

Ultrasound therapy

• !

Shockwave therapy

• !

Oxygen therapy

• !

Stretching

• !

Cryotherapy

• !

………..

• !

………..

Eccentric Exercise in Chronic Tendini2s

• !

‘The pa+ent, from a standing posi+on, flexes the knees and drops to a squaWng posi2on abruptly, then recoils to the standing posi2on’

• !

The progression of the exercise protocol with aba+ng symptoms is then –! to increase the speed of the movement, –! and thereaeer an external load is added for addi+onal progression Stanish et al, Clin Orthop, 1986

Stretch-shortening Eccentric-concentric

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Heavy-Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis

Alfredson et al, AJSM, 1998 ‘Our treatment model with heavy-load eccentric calf muscle training has a very good short-term effect on athletes in their early for+es’ Controls; ‘… the pa+ents in this group were res+ng and were not on any training regimen.’ Isolated eccentric ‘Gold Standard’ 380

Superior short-term results with eccentric calf muscle training compared to concentric training in pa2ents with chronic Achilles tendinosis

Mafi et al, Knee Surg, 2001 Concentric training Eccentric training Contrac2on mode or load magnitude? 0.5 BW 1.0 BW 1+ BW 1+ BW 189

Thursday Morning Mee2ng 8/11-07

Corticosteroid injections, eccentric decline squats and heavy slow resistance training in patellar tendinopathy RCT 12 weeks of:

CORT 2 peritendinous cor+costeroid injec+ons 4 wks between each injec+on ECC Twice per day. 3 x 15 unilat eccentric squats on decline board. Load progressively increased HSR 3 +mes per week Leg-press, squat, hack-squat 3 x 6-15 RM SLOW movements (6 sec)

Kongsgaard et al, SJMSS 2009

Corticosteroid injections, eccentric decline squats and heavy slow resistance training in patellar tendinopathy

Kongsgaard et al, SJMSS 2009

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CORT group E CC group HSR group ! (%) ! (%) ! (%) Collagen (mg/mg)

• 1

6 ±9

• 1

±1 5 + 1 4 ±27

$

Pentosidine (nmol/Coll) + 1 4 ±3 2

• 1

5±1 6

• 23

±1 3

$

HP/LP ratio

• 1

1 ±1 + 9 ±1 9 + 1 9 ±1 3

$

Collagen content and cross-link density

Eyre et al 2008

Kongsgaard et al, SJMSS 2009

Treatment sa+sfac+on

6 month follow up

Kongsgaard et al, SJMSS 2009 Sa+sfied Not sa+sfied

Corticosteroid injections, eccentric decline squats and heavy slow resistance training in patellar tendinopathy

Heavy slow resistance versus eccentric training as treatment of Achilles tendinopathy

Beyer et al, AJSM 2015 Heavy slow resistance 3 / wk ‘Eccentric’ program 2x daily

‘…. liale clinical or mechanis2c evidence for isola2ng the eccentric component, ….’ ‘……whether eccentric exercise is more effec2ve than

• ther forms of therapeu2c exercise ….. remains

ques2onable.’

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Intramuscular collagen expression response to contrac2on to similar force level

Garma et al, J Appl Physiol 2007 4 sessions Heinemeier et al, J Physiol 2007

Tendon collagen expression response to contrac2on to dissimilar force level

4 days of s+mula+on

Tendon and muscle hypertrophy independent of resistance exercise contrac2on mode

Farrup et al, SJMSS, 2013 Eccentric load 120% of concentric

Open – concentric Closed - eccentric

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Force (N) Deforma+on (m)

‘Ut tensio sic vis’, As the extension so the force’ Robert Hooke, ’De potenNa resNtuva’, 1679

Tendon mechanical proper2es

Couppe et al, JOSPT 2015

Plas2city of human Achilles tendon mechanical and morphological proper2es in response to cyclic strain

Arampatzis et al, J Biomech, 2010

1 s loading, 1 s unloading

90 % MVC 55 % MVC

Plas2city of human Achilles tendon mechanical and morphological proper2es in response to cyclic strain

Arampatzis et al, J Biomech, 2010

1 s loading, 1 s unloading

90 % MVC 55 % MVC

Adapta2onal responses of the human Achilles tendon by modula2on of the applied cyclic strain magnitude

Arampatzis et al, J Exp Biol, 2007

3 s loading, 3 s unloading Fewer reps, same volume as 1s

90 % MVC 55 % MVC

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Adapta2onal responses of the human Achilles tendon by modula2on of the applied cyclic strain magnitude

Arampatzis et al,J Exp Biol, 2007

3 s loading, 3 s unloading

90 % MVC 55 % MVC

Eccentric or Concentric Exercises for the Treatment of Tendinopathies?

The focus on eccentric exercise has overshadowed

• ther aspects of tendinopathy rehabilita+on, and

acknowledgement of the limited evidence may prompt a broader approach, including the use of heavy load and low speed, which has some support from both basic science and clinical trials.

Couppe et al, JOSPT 2015

“It is what we think we know that keeps us from learning”

Claude Bernard