Tendinopathy Founder, RunSafe Founder, SportZPeak Inc. Basic - - PowerPoint PPT Presentation

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05/22/2019

Anthony Luke MD, MPH, CAQ (Sport Med) Benioff Distinguished Professor in Sports Medicine

Tendinopathy

Basic Strategy for Diagnosis and Treatment

Disclosures

• Founder, RunSafe™
• Founder, SportZPeak Inc.
• Sanofi, Investigator initiated grant

Approach to Tendinopathy

• UNDERSTANDING

1.

How do they occur?

2.

Identify risk factors

• EVALUATION

1.

History

2.

Physical Exam

• TREATMENT

1.

Basic Strategy

2.

Problem Areas

Terminology

• Tendinopathy –

“tendon injury that

• riginates from

intrinsic and extrinsic etiological factors”

• Usually not

“tendinitis”

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ARS: 46 year old male plumber with overhead pain, difficulty lifting during work and pain sleeping on the

• shoulder. He had no injury. What is the likely

DIAGNOSIS?

A.

Rotator cuff tendinitis

B.

Shoulder bursitis

C.

Rotator cuff tendinosis

D.

Massive rotator cuff tear

E.

Frozen shoulder

Rotator cuff tendinitis Shoulder bursitis Rotator cuff tendinosis Massive rotator cuff tear Frozen shoulder

33% 33% 0% 0% 33%

Tendon Structure

• Collagen

types

• Microfibril
• Fibril
• Fascicle
• Tendon
• Endo, epi,

paratenon

Spectrum of Tendon Disorders

(Modified from Khan et al. 1999, Clancy 1990) Pathologic Dx Macroscopic Histopathologic Tendinosis Intratendinous degeneration Disorganized collagen, mucoid degen Tendinitis Degeneration with inflammatory repair response Fibroblasts, hemorrhage, granulation tissue Paratenonitis Inflammation of paratenon only Mucoid degen. if areolar tissue, fibrinous exudate Paratenonitis with tendinosis As above As above

Tendon Load

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Mechanics

• Usually tendons

surrounding joints with high degree of motion

• Usually tendons that

cross two joints

• Eccentric overload
• Mechanical

impingement

Where does the injury occur?

Insertional

• Occurs at insertions

near the joint

• Joint side

Tears

• At the musculo-

tendinous junction

• Areas of friction

Pathophysiology of Tears

• Microtears
• Macrotears

Miscellaneous

• Instability /

Subluxation

• Calcific tendinosis
• Enthesopathy
• Contractures

Spot Diagnosis?

38 year old female ran her first marathon. She finished but is limping one week after. She is happy to rest and do PT but is wondering how long will it take before she can be running painfree. She is TYPE A and you know you need to be conservative with her. She wants to plan her next marathon?

A.

2 weeks

B.

4 weeks

C.

6 weeks

D.

12 weeks

E.

26 weeks

F.

Never

2 w e e k s 4 w e e k s 6 w e e k s 1 2 w e e k s 2 6 w e e k s N e v e r

0% 8% 0% 23% 42% 27%

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Basic Science – Tendon Healing

• Tendon healing creates more collagen fibrils and

less mature cross-links with stress

• Period of relative weakness before remodeling
• Repetitive load can cause heat injury, hypoxia,

free-radical injury, and enzyme damage

• Degeneration becomes tendinosis

Tendon Healing

• requires around 100 days to synthesize collagen

Mild – 2 to 4 weeks Moderate – 4 to 6 weeks Severe – 6 to 12 weeks or longer

Tendinosis

• Hyaline degeneration
• Mucoid degeneration
• Collagen Bundle

disorganization

• Increased ground substance
• Increased tenocyte nuclei
• Vascular infiltrations and

small nerve ingrowth

• Presence of non-acute

inflammatory cells

Abat et al. Journal of Experimental Orthopaedics, 2017

Risk Factors for Tendinopathy

Intrinsic

• Anatomy
• Muscle/Tendon

imbalance

• Growth
• Illness
• Nutrition
• Conditioning
• Psychology

Extrinsic

• Training
• Technique
• Footwear
• Surface

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Risk Factors (Achilles) – Anatomy and Imbalances

• Tight Achilles and plantar fascia
• Hyperpronation
• Cavus foot
• Advancing age - decreased blood flow
• Overweight
• Poor footwear
• Weak hip abductors and medial quadriceps

Khan KM, et al. Phys Sportsmed 2000.

• THINK ABOUT WHAT THE TENDON DOES

Age factor

Children

• Tendons and ligaments

relatively stronger and more elastic than epiphyseal plate

• Insertional overuse

injuries (OSD, SLJ, Sever’s)

Age affects Flexibility

Young patients

• Average stiffness 242 +/- 28

N/mm and an ultimate load

• f 2160 +/- 157 N

Older patients

• Average stiffness 180 +/- 25

N/mm and an ultimate load

• f 658 +/- 129 N

Woo , Lollis et al, Am J Sports Med, 1991.

Apoptosis

• “Programmed cell death”
• No inflammation
• Increased proportion of apoptotic cells with age
• Increased proportion of apoptotic cells in rotator

cuff tears

• ? Associated with stress-activated protein

kinases

• May affect collagen repair

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Flexibility

• Intuitively helpful
• Associated with

development of some injuries

• No conclusive

evidence that stretching is helpful or harmful

Flexibility

Hyperlaxity

• associations with

subluxation of the hip, patella, shoulder, and proximal cervical spine; also

• steoarthritis,

chondrocalcinosis

• Bad sprains

Tight

• Patellofemoral

syndrome, hamstring and quad strains, apophysitises (OSD, Sever’s disease), and peripelvic apophyseal avulsion fractures

Hypermobility / Ehlers Danlos

Joint hypermobility syndrome/Ehlers-Danlos syndrome- hypermobility type had more MSK symptoms vs controls They reported:

• Lower shoulder function (WOSI total: 49.9 versus 83.3; p < 0.001),
• lower HRQol on SF-36 Physical Component Scale (PCS: 28.1

versus 49.9; p < 0.001)

• higher pain intensity (NRS: 6.4 versus 2.7; p < 0.001)

Neck and shoulder joints were rated as primary painful areas in both groups, with significantly higher frequency in JHS/EDS-HT (neck: 90% versus 27%; shoulder: 80% versus 37%).

Johannessen et al. Disabil Rehabil, 2016

Fluoroquinolone- related Tendinopathy

• Symptoms can present within hours of starting treatment or

up to 6 months after ceasing treatment

• Suggest less aggressive approach early in rehabilitation
• In another series (N = 42), ofloxacin #1 for tendinopathy (38%
• f patients), ciprofloxacin #2 (31% of patients). Levofloxacin

was the least reported.

• Achilles tendon was the principal tendon affected in 88 cases

(89.8%).

• Lewis and Cook, J Athl Train, 2014

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• Fluoroquinolones display a high affinity for connective tissue,

particularly in cartilage and bone

• Risk factors for fluoroquinolone-associated tendinopathy

include older than 60 yrs, concomitant corticosteroid therapy, renal dysfunction, and history of solid organ transplantation

Biddell et al. Pharmacotherapy 2016.

• In an evaluation of more than 11 000 patients, rates of 2.4

incidences per 10 000 patient prescriptions for tendinitis and 1.2 per 10 000 for tendon rupture were cited.

Lewis and Cook, J Athl Train, 2014

Fluoroquinolone- related Tendinopathy Guidelines for Fluoroquinolone Use in Athletes

• 1. Avoid the use of fluoroquinolones unless no alternative is

available.

• 2. Oral or injectable corticosteroids should not be used

concomitantly with fluoroquinolones.

• 3. Athletes, coaches, and training staff should understand the

potential risk for developing this complication.

• 4. Close monitoring of the athlete should be undertaken for 1

month after fluoroquinolone use.

Glucocorticoid Steroids

• Low-dose corticosteroids in isolation have been implicated in

Achilles tendon rupture

• Khaliq and Zhanel reported that 21 of 40 patients (52.5%)

with fluoroquinolone-related tendon rupture had received systemic or inhaled corticosteroids. Patients prescribed both fluoroquinolones and corticosteroids had a 46-fold greater risk of Achilles tendon rupture than those taking neither medication.

Kinesiophobia

• Described in 1990 by Kori et al.
• Kinesiophobia is described as irrational, weakening and

devastating fear of movement and activity stemming from the belief of fragility and susceptibility to injury.

• Symptoms occur when individual has to increase activity
• Various defence mechanisms may appear, such as:

repression (removing from consciousness), negation (there is no need for movement), simulation and projection (sports fan behaviour) or, most frequently used, rationalisation (e.g. lacking time).

Knapik A, et al. J Hum Kinet. 2011.

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Diagnosis

History

Early tendinopathy symptoms

• Usually a history of overuse or acute strain
• Pain when using the affected muscle/tendon
• May be present at the start of an activity then pain decreases

after “warm-up”

• Maybe painful for hours to days after activity
• Improves after activity modification (i.e. Stopped running)
• Usually does not radiate, but can in some cases (i.e.

Shoulder, elbow)

• Check for underlying spondyloarthropathy: Psoriasis, GI

symptoms, STD

3 Basic P/E findings for tendinopathy

• 1. Tenderness on direct palpation
• 2. Reproduction of pain with resisted

contraction (eccentric loading)

• 3. Reproduction of pain with passive

stretch

Location

• Point with One Finger ONLY

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Location

• Achilles

How do you exam for lateral epicondylosis ? How do you tell from a stress fracture?

• Hop test
• 1 legged squat (look for weak

hip abductors) or Step Down

• Hip abductors and extensor

strength

• VMO atrophy and activation
• Flexibility
• Ober’s, Thomas test, Popliteal

angle, Ely’s test, Ankle dorsiflexion

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Ultrasound Tendon

• Pathological tendon maintains sufficient

amounts of aligned fibrillar structure by increasing tendon dimensions (anteroposterior diameter and total mean cross-sectional area) in parallel with the mean cross-sectional area of disorganization (ie, the more disorganization, the bigger the tendon).

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Tendon Tears - Achilles Long axis at 6 months

Short Axis at 6 months Imaging Ultrasound vs MRI for Tendons

Rotator cuff:

• US, MRI and MRA in the characterisation of full-thickness RC

tears was high with overall estimates of sensitivity and specificity over 0.90.

• For partial RC tears and tendinopathy, overall estimates of

specificity were also high (>0.90), while sensitivity was lower (0.67–0.83).

• Roy et al. Br J Sports Med, 2015.

Gluteal tendon tears

• MRI Sensitivity = 0.33 to 1.00, whereas specificity = 0.92-1.00

(consistently high).

• Ultrasound - highly sensitive technique = 0.79-1.00

Westacott et al. Hip Int, 2011

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Treatment

Conservative treatments BASIC STRATEGY

• 1. Modify Activity
• THINK ABOUT WHAT THEY ARE DOING?
• WHAT DO THEY NEED TO DO?
• Be Prescriptive
• Examples for Achilles

1.

NWB, swimming or biking

2.

Nonimpact upright activities

3.

Sport-specific drills; limited sports

4.

Full activities no restrictions

• 2. Reduce Stress
• DME
• Modify footwear
• Heel lifts
• Custom orthotics
• Address foot mechanics
• Immobilize
• Walking boot
• Crutches
• Night splints
• High to moderate level evidence of no difference

in pain (moderate) or function (high) between

• rthoses and control
• Low level evidence of no significant benefit in

adding a night splint to an eccentric exercise program for function, and moderate level evidence for no reduction in pain

Evidence for Orthoses

Wilson F et al. Br J Sports Med, 2018

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• 3. Physical Therapy

Stretching

• Improves pain and ROM

Strengthening – eccentric loading

• Mechanical loading

accelerates tenocyte metabolism Modalities

Soleus stretch Gastrocnemius stretch

Calf / Achilles stretching

Hold each stretch for 30 seconds

Physical Therapy for Achilles

Alfredson H, Pietilä T, Jonsson P, et al. Am J Sports Med, 1998; 26:3: 360-366.

• RCT – eccentric exercises (3 x 15 reps, 2

times/day, 7 days a week x 12 wks)

• Results: Significant difference in pain levels VAS

81.2 mm (+/- 18) to 4.8 mm (+/- 6.5) in 12 weeks

• 81% eccentric satisfied vs 38% concentric

satisfied Eccentric Drop program

Update on Eccentric Exercises

• There is no convincing clinical evidence to

demonstrate that isolated eccentric loading exercise improves clinical outcomes more than

• ther loading therapies.
• Treatment protocols vary with respect to load

magnitude, speed of movement, and recovery period between exercise sessions

Couppé et al. J Orthop Sports Phys Ther, 2015

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Evidence for Eccentric Exercise

Wilson F et al. Br J Sports Med, 2018

Moderate level evidence

• Eccentric exercise over

control for improving pain and function in mid-portion tendinopathy

• Eccentric exercise over

concentric exercise for reducing pain

• No significant difference in

pain or function between eccentric exercise and heavy slow resistance exercise Low level evidence

• Eccentric exercise was not

superior to stretching for pain or QoL.

• 4. Pain Management
• Little evidence to

support use of NSAIDs in management

• Good Analgesic

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NSAIDs Evidence ?

• RCT Ibuprofen x 1 wk (600 mg tid) vs placebo,

n=26 with chronic achilles tendinopathy, biopsy

• PCR Expression of collagens and TGF-β

isoforms showed relatively low variation and was unaffected by ibuprofen treatment.

• No changes were seen in tendon thickness or

VISA-A score

Heinemeier et al. J Appl Physiol, 2017.

Steroid Injections

• Reduce inflammation
• Decrease symptoms
• Inhibit phopholipase A2,

stops formation of precursors

• Inhibit cell migration

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Steroid Injection Evidence ?

Extensor Carpi Radialis Brevis

• At short-term follow-up, only local corticosteroid injection

improved pain; however, it was associated with pain worse than placebo at long-term follow-up

Lian J et al. Am J Sports Med, 2018

Plantar Fasciitis

• Steroid injection may lead to lower heel pain (VAS) in the

short-term (< 1 month) (MD -6.38, 95% CI -11.13 to -1.64; 5 studies; I² = 65%; low quality evidence).

• Steroid injection made no difference to average heel pain in

the medium-term (1 to 6 months follow-up)

David JA et al. Cochrane Database Syst Rev 2017

• 5. Platelet Rich Plasma Injections
• Concentrate the plasma by centrifugation
• Blood must be drawn from a patient and the

platelets are separated from other blood cells and concentration is increased

• CANNOT USE ANESTHETIC

https://orthoinfo.aaos.org What is it?

PRP Evidence ? – Tissue Healing

• PRP has been shown to temporally increase the

angiogenetic phase and subsequently lead to a prompt reduction of this phenomenon, thus accelerating the whole tendon healing process

• PRP is not able to reverse late-stage

tendinopathy including the infiltration of mononuclear cells, permanent neovascularization, metaplastic non-tenocyte differentiation of tendon cells and non-tendinous tissues

PRP Evidence ? - Inflammation

• PRP seems to control of the inflammatory process,

involving in particular the hepatocyte growth factor (HGF)

• PRP has been shown to activate Tumor Necrosis Factor

TNF-alpha and NFkB pathways (pro-inflammatory)

• Expression of genes related to cellular proliferation and

tendon collagen remodeling seen after PRP

Hudgens et al. Am J Sports Medicine, 2016

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PRP Evidence ?

Overall

• Patellar and lateral elbow tendinopathy showed improvement

from PRP treatment

• Achilles tendon and rotator cuff do seem not to benefit from

PRP application with either conservative treatment or surgery

• There is no consensus on efficacy
• This is mainly due to the lack of standard PRP preparation

procedures or methods of application

Abat et al. Journal of Experimental Orthopaedics, 2018

Presentation Title 61

What about a Needle Tenotomy ?

• Passing the needle

through the area of tendon degeneration

• Ultrasound-guided

intratendinous PRP injection may lead to both clinical and MRI improvements in tendon pathology.

Wesner et al. PLoS One 2016 Patellar tendon (Abat et al.

Problem Areas

Plantar Fasciitis

• Tender on insertion on

medial tubercle of calcaneus

• Associated with age,
• besity, pes planus and pes

cavus

• More prolonged, more

difficult to manage

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Plantar Fasciitis

• Tender on insertion on

medial tubercle of calcaneus

• Associated with age,
• besity, pes planus and pes

cavus

• More prolonged, more

difficult to manage

Plantar Fascitis

• Tender on insertion on medial aspect of heel
• Associated with:
• Age
• Pes planus and pes cavus
• Obesity (OR =5.6 (95% C.I., 1.9-16.6)
• Poor shoes, working on feet (OR = 3.6 (95% C.I., 1.3-10.1)
• ≤0 degrees of dorsiflexion had OR = 23.3 (95% C.I. , 4.3 to

124.4)

Riddle et al. JBJS-A, 2003

• Limb leg discrepancy (longer leg associated with plantar

fasciitis)

Mahmood et al, J Am Podiatr Med Assoc, 2010

Posterior tibialis tendinopathy

• >50 y.o.
• F > M
• Obese, pronation
• Sudden collapse of

the arch

• Short AFO
• Surgery

Posterior tibialis tendinopathy

• >50 y.o.
• F > M
• Obese, pronation
• Sudden collapse of

the arch

• Short AFO
• Surgery

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Patellar tendinosis

“Jumper’s knee”

• Pain over inferior pole
• f the patella in

supine (less pain when knee flexed to 90°)

• Pain with squat
• U/S and MRI useful

for confirming diagnosis

Patellar tendinosis

“Jumper’s knee”

• Pain over inferior pole
• f the patella in

supine (less pain when knee flexed to 90°)

• Pain with squat
• U/S and MRI useful

for confirming diagnosis

Lateral epicondylitis

“Tennis Elbow”

• Extensor carpi radialis brevis

tendinosis

• Tender lateral epicondyle
• Resisted 3rd digit extension and wrist

extension

• Passive wrist flexion
• Arm extended
• Check thumb abduction strength

Biceps Tendinitis

• Tender over the anterior

shoulder

• Can be very painful
• Pain with reaching overhead

and behind

• Related to poor posture

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Summary – Basic Strategy

Evaluation

• Think tendinopathy:

Activity related, improves with rest

• Physical Exam:
• #1 Tender on palpation,
• #2 Resisted eccentric

contraction,

• #3 Passive stretching

Treatment

• Modify Activity
• Reduce Stress
• PHYSICAL THERAPY
• Pain Management
• Induce Healing – PRP ?

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