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

26/09/16 Tendon hierarchy Eccentric exercise for tendon rehabilita2on (?) ECM S. Peter Magnusson PG & GAG Ins+tute of Sports Medicine Copenhagen & Musculoskeletal Rehabilita+on Research Unit Bispebjerg Hospital, Copenhagen, Denmark Faculty of Health & Medical Science, University of Copenhagen, Denmark Magnusson et al, Nature Reviews Rheum 2010 Collagen synthesis and tendon metabolism in vivo Lack of 2ssue renewal in human adult Achilles tendon 13% MVC PICP (ug/l) Langberg et al, 1999, 2001 Core Achilles tendon +ssue, n= 28 (+ 4 muscle samples) Birth year range: 1945 - 1983 Time of death: year 2000 14 C level measured with accelerator mass spectrometry (AMS) Kadler. Biochem J 1996 Heinemeier et al. FASEB J, 2013 Bojsen-Moller et al, J Appl Physiol 2006 1

26/09/16 Region specific adapta2on to months and Do tendons adapt/grow in years of high load on patellar tendon response to loading? 4-6% 20-28% Stress (N/m 2 , MPa) CSA (mm 2 ) Strain (%) Kongsgaard et al, ACTA Physiol 2007 Couppé et al, JAP 2008 Achilles & patellar tendon load Tendon hypertrophy/adapta2ons in response to loading ? Patella Achilles Finni et al 2000 Komi 1990 Heinemeier et al, FASEB 2013 2

26/09/16 What is an overuse injury ? Intratendinuous force transmission: Tendinopathy Is there a weak link? Region specific? Microtear ? Lian et al, AJSM 2005 Effect of NSAID on Achilles tendinopathy region Management of tendinopathy? in response to acute exercise • ! Corticosteroid injections • ! Eccentric training • ! Sclerosing therapy • ! PRP • ! NSAID • ! Surgery • ! Ultrasound therapy • ! Shockwave therapy • ! Oxygen therapy • ! Stretching NSAID (600 mg x 3/day/1 week) • ! Cryotherapy Treadmill running x 1h • ! ……… .. Biopsy 2h aeer • ! ……… .. Gold standard? Pingel et al, EJAP 2013 3

26/09/16 Surgery as a Treatment for Patellar Tendinopathy Effect of corticosteroids? Eccentric exercises +/- surgery Surgery: open tenotomy (+ exercise, incl ecc) Ecc, 12 weeks, twice daily, 3 x 15 reps (Smidt et al, Lancet 2002) (Kongsgaard et al, SJMSS 2009) Bahr et al. JBJS 2006 How to treat tendinopathy ? Eccentric Exercise in Chronic Tendini2s • ! NSAID • ! Cor+costeroid injec+ons • ! ‘The pa+ent, from a standing posi+on, • ! Sclerosing therapy flexes the knees and drops to a squaWng posi2on abruptly, then recoils to the • ! PRP standing posi2on ’ • ! NSAID • ! The progression of the exercise protocol • ! Surgery with aba+ng symptoms is then – ! to increase the speed of the Loading based rehab • ! movement, • ! Eccentrics – ! and thereaeer an external load is • ! Ultrasound therapy added for addi+onal progression • ! Shockwave therapy • ! Oxygen therapy Stretch-shortening Stretching • ! Eccentric-concentric • ! Cryotherapy • ! ……….. Stanish et al, Clin Orthop, 1986 • ! ……….. 4

26/09/16 Superior short-term results with eccentric calf muscle training Heavy-Load Eccentric Calf Muscle Training compared to concentric training in pa2ents with chronic Achilles For the Treatment of Chronic Achilles Tendinosis tendinosis Contrac2on mode or load magnitude? 189 Eccentric training Concentric training 1.0 BW 380 1+ BW 1+ BW Isolated eccentric ‘Gold Standard’ ‘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.’ 0.5 BW Mafi et al, Knee Surg, 2001 Alfredson et al, AJSM, 1998 Corticosteroid injections, eccentric decline squats and Corticosteroid injections, eccentric decline squats and heavy slow resistance training in patellar tendinopathy heavy slow resistance training in patellar tendinopathy Thursday Morning Mee2ng 8/11-07 RCT 12 weeks of: CORT ECC HSR 2 peritendinous cor+costeroid Twice per day. 3 +mes per week injec+ons 3 x 15 unilat eccentric Leg-press, squat, hack-squat 4 wks between each injec+on squats on decline board. 3 x 6-15 RM Load progressively increased SLOW movements (6 sec) Kongsgaard et al, SJMSS 2009 Kongsgaard et al, SJMSS 2009 5

26/09/16 Corticosteroid injections, eccentric decline squats and Collagen content and cross-link density heavy slow resistance training in patellar tendinopathy Treatment sa+sfac+on 6 month follow up Eyre et al 2008 CORT group E CC group HSR group ! (%) ! (%) ! (%) ± 9 ± 1 ± 27 Collagen $ - 1 6 - 1 5 + 1 4 (mg/mg) ± 3 5 ± 1 ± 1 Pentosidine $ + 1 4 2 - 1 6 - 23 3 Sa+sfied (nmol/Coll) Not sa+sfied ± 1 ± 1 ± 1 HP/LP ratio - 1 1 0 + 9 9 + 1 9 3 $ Kongsgaard et al, SJMSS 2009 Kongsgaard et al, SJMSS 2009 Heavy slow resistance versus eccentric training as treatment of Achilles tendinopathy ‘…. liale clinical or mechanis2c evidence for isola2ng the eccentric component , ….’ ‘……whether eccentric exercise is more effec2ve than other forms of therapeu2c exercise ….. remains ‘Eccentric’ program Heavy slow resistance 2x daily ques2onable.’ 3 / wk Beyer et al, AJSM 2015 6

26/09/16 Intramuscular collagen expression response to Tendon collagen expression response to contrac2on to similar force level contrac2on to dissimilar force level 4 days of s+mula+on 4 sessions Garma et al, J Appl Physiol 2007 Heinemeier et al, J Physiol 2007 Tendon and muscle hypertrophy independent of resistance exercise contrac2on mode Open – concentric Closed - eccentric Eccentric load 120% of concentric Farrup et al, SJMSS, 2013 7

26/09/16 Plas2city of human Achilles tendon mechanical and Tendon mechanical proper2es morphological proper2es in response to cyclic strain 90 % MVC 55 % MVC Couppe et al, JOSPT 2015 Force (N) 1 s loading, 1 s unloading Deforma+on (m) ‘ Ut tensio sic vis ’ , As the extension so the force ’ Arampatzis et al, J Biomech, 2010 Robert Hooke, ’ De potenNa resNtuva ’ , 1679 Plas2city of human Achilles tendon mechanical and Adapta2onal responses of the human Achilles tendon morphological proper2es in response to cyclic strain by modula2on of the applied cyclic strain magnitude 90 % MVC 55 % MVC 90 % MVC 55 % MVC 1 s loading, 1 s unloading 3 s loading, 3 s unloading Fewer reps, same volume as 1s Arampatzis et al, J Exp Biol, 2007 Arampatzis et al, J Biomech, 2010 8

26/09/16 Adapta2onal responses of the human Achilles tendon Eccentric or Concentric Exercises by modula2on of the applied cyclic strain magnitude for the Treatment of Tendinopathies? 90 % MVC 55 % MVC Couppe et al, JOSPT 2015 The focus on eccentric exercise has overshadowed other 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. 3 s loading, 3 s unloading Arampatzis et al,J Exp Biol, 2007 “ It is what we think we know that keeps us from learning ” Claude Bernard 9