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Eccentric Exercise Interventions for Tendinopathies Daniel Lorenz, PT, DPT, ATC, CSCS, USAW Providence Medical Center, Kansas City, Kansas

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Eccentric Exercise Interventions for Tendinopathies Daniel Lorenz, PT, DPT, ATC, CSCS, USAW Providence Medical Center, Kansas City, Kansas Available at: http://www.nsca-cc.org/ceus/quizzes.html Eccentric Exercise Interventions for Tendinopathies Daniel Lorenz, PT, DPT, ATC, CSCS, USAW Providence Medical Center, Kansas City, Kansas SUMMARY resulted in 30% of all running-related programs to accommodate the athletes injuries, and elbow tendon injuries can who have these conditions throughout TENDON INJURIES OR TENDINO- be as high as 40% in tennis players (26). the training cycle and during the com- PATHIES ARE A CHALLENGING People of all ages and skill levels, as petitive season. Being able to recognize AND PERPLEXING CONDITION FOR well as nonathletes can be afflicted by an ‘‘itis’’ or an ‘‘osis’’ is a crucial step STRENGTH AND CONDITIONING these conditions. Tendon pathologies because the management of the ath- PROFESSIONALS. TENDON can not only lead to lost time in sports lete’s training is vastly different. An INJURIES CAN BE DEBILITATING but also can result in long-term damage inflamed ‘‘itis’’ often has sharp localized AND RESULT IN LOST TIME FROM to tendons that can even affect daily pain with activity and in the morning SPORTS PARTICIPATION. IF LEFT function and let alone sports perfor- or after periods of long rest. Pain may UNTREATED, TENDON INJURIES mance. There is discrepancy in the actually decrease during activity but CAN PROGRESS TO AFFECT DAILY literature about how to manage these worsens at rest. On the contrary, FUNCTION. FURTHERMORE, injuries as well as the proper terminol- a chronic ‘‘osis’’ has fairly constant TENDON INJURIES AFFLICT ALL ogy to use when referring to them. pain that is more of a dull ache and AGES AND SKILL LEVELS. IN THE The term ‘‘tendonitis’’ is often used poorly localized. Usually, a chronic PAST 10 YEARS, ECCENTRIC as a catchall term for tendon injuries. degenerative tendon gets worse with EXERCISE HAS GAINED SUPPORT Histological studies have shown that activity. A comprehensive review by IN THE LITERATURE AS AN EFFEC- oftentimes, no inflammation exists Nirschl (22) about stages of tendon TIVE NONSURGICAL NONPHAR- (20,21). The suffix ‘‘itis’’ indicates that injury has been published previously in the Table. MACOLOGICAL INTERVENTION TO an inflammatory process is present. TREAT THESE INJURIES. THE Leadbetter (19) has previously defined Within the past few years, eccentric PURPOSE OF THIS REVIEW IS TO tendonitis as a symptomatic degener- exercise has shown promise in multiple DISCUSS THE RELEVANT TERMI- ation of a tendon with vascular disrup- studies as a potential nonoperative and NOLOGY AS WELL AS THE tion and inflammatory repair. More effective training modality for tendino- ANATOMY AND PHYSIOLOGY OF recently, the term ‘‘tendinopathy’’ has pathies. The purpose of this review is TENDONS AND TENDON INJURY. been used as an all-encompassing term 3-fold. First, a brief discussion about ADDITIONALLY, THE CONCEPT OF for tendon injuries, whereas the term tendon anatomy and physiology will ECCENTRIC EXERCISE IN TREAT- ‘‘tendinosis’’ has been used to describe set the foundation for discussing why ING TENDINOPATHIES WILL BE chronic tendon issues. Leadbetter (19) eccentric exercise is of physiologic DISCUSSED, AND EXERCISE has also defined tendinosis to be a focal benefit to tendons. Second, a review INTERVENTIONS WILL BE area of noninflammatory degeneration of the causes of tendinopathies will be briefly discussed. Finally, exercise PROVIDED FOR COMMON that may be asymptomatic. The suffix interventions will be provided for TENDINOPATHIES. ‘‘osis’’ implies that a degenerative pro- cess is present. Complicating this mat- common tendinopathies as well as a framework for how to implement ter further is that there are significant them effectively. INTRODUCTION differences in the physiological healing endon injuries account for responses of acutely and chronically diseased tendons (15). KEY WORDS: 30–50% of injuries in sports (16). tendon; tendonitis; tendinopathy; Strength and conditioning professionals T Specifically, chronic problems tendinosis; eccentric exercise caused by overuse of tendons have often have to develop training 90 VOLUME 32 | NUMBER 2 | APRIL 2010 Copyright Ó National Strength and Conditioning Association Table Nirschl’s stages of tendinopathy Stage Diagnosis Macroscopic pathology Histologic findings Clinical signs 0 Healthy No inflammation Organized collagen, Firm tendon, not painful, absent absent blood cells swelling, normal temperature I Acute tendinitis Symptomatic tendon Degenerative changes Acute swelling, pain, local degeneration, increased with microtears, tenderness, warmth, cellularity, vascular disruption, inflammatory cells in dysfunction inflammation of paratenon paratenon, focal collagen disorientation II Chronic tendinitis Increased tendon degeneration Greater evidence of Chronic pain with tenderness, and vascularity microtears, increased increased dysfunction, person levels of collagen voluntarily unloads structure disorientation in tissue hypercellularity III Tendinosis Intratendinous degeneration Increased cellularity, Palpable tendon enlargement, because of microtrauma, neovascularization, swelling of tissues, increased cellular/tissue aging, vascular focal necrosis, collagen dysfunction with or without compromise disorganization pain, tendon sheath may be and disorientation swollen IV Rupture Tendon failure Complete disruption of Weak and painful muscle testing, fibers inability to move affected joint, positive clinical tests for tendon disruption ANATOMY ‘‘insertional’’ tendinopathy. Regardless the tendon will be in a perpetual state Tendons transmit force generated by of location, management is very similar of breakdown and attempted but failed muscle to bone and act as a buffer and eccentric exercise can be used. healing. The end result is pain, dys- by absorbing external forces to limit Tendons are prone to injury because of function, and, for the athlete, lost time muscle damage (27). Tendons them- a ‘‘tendon paradox’’ that exists. Oxygen from sport. selves are relatively avascular but get consumption is 7.5 3 lower in tendons their innervations and vascular supply and ligaments than skeletal muscle CAUSES OF TENDON INJURIES from the paratenon, the sheath around (33). To minimize the risk of ischemia, Tendons respond to repetitive overload the tendon proper. Tendons are com- which is a decrease in blood supply, beyond the physiological threshold by posed of 30% type I collagen, gly- a low metabolic rate and anaerobic inflammation of their sheath, degener- cosaminoglycans, elastin, and 68% generating capacity in tendons are ation of their body, or a combination of water (23). Collagen’s role is to resist needed to carry loads and maintain both (27). There are a host of reasons tensile forces, whereas elastin functions tension for long periods. In the case of that tendon injuries occur, but the to increase the flexibility of tendons. tendons, risk of inadequate or deficient etiology remains unclear, and many The structure of tendons reveals that blood supply is reduced because of the causes have been theorized (27). Typ- they have a wavelike appearance at lower metabolic rate. The lower met- ically, there are 2 main types of injury rest, indicating that it is susceptible to abolic rate indicates that there is less mechanisms that have several potential and allow stretch. need for oxygen for tendons during sources in each category (5). Intrinsic Tendon injuries can happen essentially functional tasks. However, the low causes are factors contributed to an at 2 locations. Tendon injury can be metabolic rate in tendons results in athlete’s makeup. Intrinsic risk factors midsubstance or in the body of the slow healing after injuries. Thus, this include, but are not limited to such tendon proper. There is also potential may explain why tendon injuries things as anatomical abnormalities or for injury at the enthesis, which is the persist or develop chronic issues (32). malalignments (i.e., genu valgum, or attachment of a tendon, ligament, or If an athlete does not rest from the ‘‘knock kneed’’, and leg length discrep- joint capsule to the bone (28). Injury at aggravating stimulus or provide the ancies), age, gender, flexibility, joint the enthesis is commonly referred to correct environment for regeneration, laxity, muscle weakness, biomechanics/ Strength and Conditioning Journal | www.nsca-lift.org 91 Eccentric Exercise in Tendinopathies sport technique, fatigue, and psycho- in one location leads to changes in concentric/positive work, there is a logical factors. Intrinsic causes may or distant cells, even though the distal cell concurrent increase in cellular metab- may not be adjusted or changed and did not receive the mechanical stimulus olism. Thus, more waste products may be something that the athlete directly. Mechanotransduction closes will be generated, leading to chemical must learn to live with or possibly with the effector cell response. Here, irritation of nerves and eventually pain. make modifications in training or the mechanical stimulus on the outside Abbott and Bigland (1) did a study equipment. The other causes are due of the cell promotes intracellular pro- measuring oxygen uptake in subjects to extrinsic factors. Unlike intrinsic cesses, leading to matrix remodeling using a bicycle ergometer. Positive factors, extrinsic factors can usually through alterations in biochemical work (concentrics) always resulted in be easily changed and modified to help pathways and gene expression. In the more oxygen consumption than nega- the athlete. The 2 main extrinsic causes case of tendons, load-induced responses tive
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