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2/7/2018

Disclosure Information Tria Sports Medicine Conference - February 10,2018 Chris Kramer PT, DPT

Disclosure of Relevant Financial Relationships

I have the following financial relationships to disclose: Employee of: Park Nicollet, University of Minnesota, Evidence in Management of Lower Motion, 3 Fellows, Tracker

Extremity Disclosure of Off-Label and/or investigative Uses

I will not discuss off label use and/or investigational use in my presentation.

Chris Kramer PT, DPT Board Certified in Orthopedics Fellow, American Academy of Orthopedic Manual Physical Therapists

TRIA SPORTS MEDICINE CONFERENCE FEBRUARY 10TH, 2017

BRIEF INTRO Course Objectives

• Understand causes of pathology

• Evaluate and recognize tendinopathy

• Understand the value of load

• Be able to progress a patient with tendinopathy in a exercise prescription.

• Use manual therapy as an for those struggling Email: [email protected] with painful tendinopathy Twitter: @kramec2000 @3FellowsPT

Tendinopathy - Defined Tendinopathy - Defined

• Tendon injuries represent 50% of all sports injuries.1 • Tendinopathy presents in clinic with a wide ranging • Vast majority of tendon injuries are degenerative lacking the presentation and functional deficits.7 presence of inflammatory cells.1 • Load based exercises for this group have been proven • Tendonitis vs. tendonosis = tendinopathy to be effective however intensity, frequency and duration remain unknown.7 • Tendinopathy is a failed healing response2

• Tendonitis - acute tendon irritation with swelling and redness1 • Concentric-eccentric heavy slow loading x 3 per week vs. x2 per day for 7 days/wk have shown similar • Tendonosis - chronic degenerative problems as a result of results.7 overload.1

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Tendon response to load Tendon Response to Load

Optimized • Healthy tendon have normal collagen fibers tightly bundled in a parallel 2 Load fashion.

• Tendinopathy demonstrates unequal and irregular crimping of collagen fibers.2 Normal Tendon Adaption • Overloading causes minor ruptures triggering a healing response.

• Tendinopathy is the response in the tendon of a tendon that never fully heals2 Strengthen • This is a failed healing response initially2

• Mechanical loading and more specifically alterations in regular loading Cook & Purdham 2009 drive tendon change.1

Tendon Response to Load

• Fatigue to mechanical loading is a major driver of tendon related .1

• More common over the age of 30.1

• Tendinopathy appears to correlate with aging.1

• Random and inconsistent activity that is beyond the capacity will then drive a failed healing response. Phases of healing

Exercise is consistent and progressive.

Activity is random and inconsistent.

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Mechanotherapy & • Mechanotransduction refers to the process by which the Mechanotransduction: body converts mechanical loading into a cellular response • Mechanotherapy is the clinical application of mechanotransduction.

• Research shows that tendon loading is a dynamic response tissue to load. Turning tissue loading into tissue repair • Key is controlling the load after injury for optimal healing.

• Progressive and consistent

• Mechanical forces direct cellular forces to induce tissue adaption.

• Cells can modify their micromechanical environment via cystoskeletal arrangement, which feeds back to alter cellular sensitivity to incoming forces.

• Constant push pull with healthy tendons., think Cook and Purdham Clinically what does this look like?

Khan and Scott et al.2009

Gluteal Tendinopathy: Gluteal Tendinopathy Objective • Hallmark for GT is sensitivity to touch on the lateral aspect of the .3

• For young - is more common manifestation of GT.3 • 10-25% occur between the 4- 6th decade of life3 • Loud audible snapping and sometimes painful • 2nd to anterior fibers of the glute max and ITB band migrate • 2-5x’s more common in posterior to anterior over the greater trochanter as hip moves from females3 extension to flexion.

• Abductor tendon degeneration is the most common reason for this pain.3

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Gluteal Tendinopathy: Gluteal Tendinopathy: Objective Objective • Clinical Cluster for gluteal tendinopathy(Mulligan 2015) - Not tested

• Pain at end range of motion of hip abd/add • Single leg stance 30 seconds neutral pelvis3 • Pos. Faber • 97% specificity • Pain with resisted hip abduction • 100% sensitivity • Pain with palpation over greater trochanter

• No patterning

Gluteal Tendinopathy: Treatment

• Exercises that maximize gluteal medius and minimizes iliotibial band.4

• Patient needs to feel an increase in their symptoms when performing the exercise.3

• Think mechanotherapy and mechanotransduction

• Start in non. wt. bearing and progress to wt. bearing Gluteal Tendinopathy: EMG muscle activation Selkowitz et al. 2012

Patellar Tendinopathy

• Most commonly found as insertional tendinopathy12

• Data shows that >1/3 of athletes are not able to return to sport after 6 mos.15

• 53% of athletes with patellar tendinopathy were forced to Patellar Tendinopathy retire.15

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Patellar Tendinopathy: Patellar Tendinopathy: Objective Objective

• Hallmark features of patellar tendinopathy15 • Tendon pain occurs instantly with loading and usually ceases • Pain localized to the inferior pole of patella when load is removed.15

• Load-related pain that with demand on extensors • Tendon pain rarely occurs with rest15

• Patellofemoral and patellar tendinopathy can both occur • Irritability is critical in recognizing in clinical decision making15 with squatting, stairs and prolonged sitting.15 • Pain greater then 24 hours of loading - irritable • Pain is often increased the day after increased loading.15 • Pain less then 24 hours after loading - stable

Patellar Tendinopathy: Patellar Tendinopathy: Treatment Treatment

• Eccentric exercise is the most • Rio et al. demonstrated the investigated exercise for immediate analgesic effects of patellar tendinopathy.15 isometrics in the short term in a 4 week study.18 • Example decline squat program 3 sets of 15 reps x2 • Eccentric exercise can be poorly per day. tolerated but in combination with isometrics the tolerance to load could increase.18 • However this could be too aggressive for highly • 5 x 45 second holds - 80% MVC. irritable tendons • 1 min between sets • Also does not address other weakness in the LE chain • 60° of flexion

Patellar Tendinopathy: Treatment

• Malliaras et al. proposed a 4 stage program that address pain reduction, eccentric strengthening and lower quarter weakness.

• Isometric exercise for pain control

• Isotonic exercise to address load tolerance

• Energy-storage exercises to address neuro re- education

• Progressive return to sport

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Patellar Tendinopathy: Treatment

• Smith et al. ( 2018) examined the psychological effects of achilles tendinopathy

“I had to go to the hospital once to have x-rays... I don’t know if he [doctor] was trying to scare me into doing some exercise or something, but he basically said the only thing they could do is break both of my thighs and twist them a bit and then heal them back together. And it would take me years to get back to walking properly. “ Achilles Tendinopathy

Achilles Tendinopathy: Achilles Tendinopathy Objective

• Evidence has shown both increased and decreased dorsiflexion is a risk factor. • Elite long distance runners have a 52% risk of developing1 • Abnormal subtalar ROM • Reoccurrence rates as high as 27% with soccer players1 • Decreased plantar flexion strength • However 30% are sedentary1 • NSAIDS have shown no benefit with this problem17 • Extrinsic risk factors include training errors, environmental factors and faulty equipment.10 • Altered hip biomechanics in runners commonly seen secondary to weak hip abductors.16

Achilles Tendinopathy: Alfredson et al. Program Treatment

• Alfredson et al. study most famous study looking at the effects of tendon loading with .19

• 3 sets of 15 reps of heel drops x 2 per day for 180 reps.

• Both gastroc and soleus emphasized

• Were instructed to progress with more aggressive loading if they did not feel it in their .

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Achilles Tendinopathy: Achilles Tendinopathy: Treatment Treatment

• Beyer et al. compared eccentrics and high load slow 8 resistance and that both offered equally good results. • Mc Auliffe et al. ( 2018) examined the psychological effects of achilles tendinopathy. • High load slow resistance had higher patient satisfaction at 12 weeks but not 52 weeks “I've gone to a lot of physios and they tell me its an overuse injury but I don't • Eccentric group performed 3 sets of 15 reps x 2per day think it is ‘cause I've stopped. People say stop and don't do anything for 6 or 8 for 12 weeks both with knee straight and flexed. weeks but if I did stop and went back even for a jog a couple of miles after • HSR was done x 3 per week goal of progressing to 1 RM. not doing anything for a period of time id still be in pain like it never stopped.” • Prognosis is 2-8 years out 71-100% resolution.

Take Home Message

Exercise is consistent and progressive.

Activity is random and inconsistent.

BRIEF INTRO

Thank You!

Email: [email protected] Twitter: @kramec2000 @3fellowsPT

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Bibliography

1. Abat F, Alfredson H, Cucchiarini M, et al. Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part I: biology, biomechanics, anatomy and an exercise-based approach. Journal of Experimental Orthopaedics. 2017;4(1). doi:10.1186/s40634-017-0092-6.a1.

2. D’Addona A, Maffulli N, Formisano S, Rosa D. in tendinopathy. The Surgeon. 2017;15(5):297-302. doi:10.1016/j.surge.2017.04.004.

3. Mulligan EP, Middleton EF, Brunette M. Evaluation and management of greater trochanter pain syndrome. in Sport. 2015;16(3):205-214. doi:10.1016/j.ptsp.2014.11.002.

4. Selkowitz DM, Beneck GJ, Powers CM. Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Lata? Electromyographic Assessment Using Fine-Wire Electrodes. The Journal of orthopaedic and sports physical therapy. 2012;43(2):54–64.

5. Rathleff MS, Petersen KK er, Arendt-Nielsen L, Thorborg K, Graven-Nielsen T. Impaired Conditioned Pain Modulation in Young Female Adults with Long-Standing Patellofemoral Pain: A Single Blinded Cross-Sectional Study. Pain Medicine. 2015:pnv017.

6. Rio E, van Ark M, Docking S, et al. Isometric contractions Are more analgesic than isotonic contractions for patellar tendon pain: an in-season randomized clinical trial. Clinical Journal of Sport Medicine. 2017;27(3):253–259.

7. Mallows AJ, Debenham JR, Malliaras P, Stace R, Littlewood C. Cognitive and Contextual Factors to Optimise Clinical Outcomes in Tendinopathy. BMJ Publishing Group Ltd and British Association of Sport and Exercise Medicine; 2017.

8.Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. The American Journal of Sports Medicine. 2015;43(7):1704-1711. doi:10.1177/0363546515584760.

9. Kongsgaard M, Kovanen V, Aagaard P, et al. injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scandinavian Journal of Medicine & Science in Sports. 2009;19(6):790-802. doi:10.1111/j.1600-0838.2009.00949.x.

10. Carcia CR. Achilles Pain, Stiffness, and Muscle Power Deficits: . J Orthop Sports Phys Ther. September 2010. doi:10.2519/jospt.2010.0305.

11. Jayaseelan DJ, Kecman M, Alcorn D, Sault JD. Manual therapy and eccentric exercise in the management of Achilles tendinopathy. Journal of Manual & Manipulative Therapy. 2017;25(2):106-114. doi:10.1080/10669817.2016.1183289.

12. Maganaris CN, Chatzistergos P, Reeves ND, Narici MV. Quantification of Internal Stress-Strain Fields in Human Tendon: Unraveling the Mechanisms that Underlie Regional Tendon Adaptations and Mal-Adaptations to Mechanical Loading and the Effectiveness of Therapeutic Eccentric Exercise. Frontiers in Physiology. 2017;8. doi:10.3389/fphys.2017.00091.

13. Cook J, Docking S. “Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ‘tissue capacity’: a core concept for clinicians. British Journal of Sports Medicine. 2015;49(23):1484-1485. doi:10.1136/bjsports-2015-094849.

14. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine. 2008;43:409-416. doi:10.1136/bjsm.2008.051193.

15. Malliaras P, Cook J, Purdam C, Rio E. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. Journal of Orthopaedic & Sports Physical Therapy. 2015;45(11):887-898. doi:10.2519/jospt.2015.5987.

16. Creaby MW, Honeywill C, Franettovich Smith MM, Schache AG, Crossley KM. Hip Biomechanics Are Altered in Male Runners with Achilles Tendinopathy: Medicine & Science in Sports & Exercise. 2017;49(3):549-554. doi:10.1249/MSS.0000000000001126.

17. Rio E, van Ark M, Docking S, et al. Isometric contractions Are more analgesic than isotonic contractions for patellar tendon pain: an in-season randomized clinical trial. Clinical Journal of Sport Medicine. 2017;27(3):253–259.

18. Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British Journal of Sports Medicine. 2016;50(19):1187-1191. doi:10.1136/bjsports-2015-095422.

19. Alfredson H akan, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. The American journal of sports medicine. 1998;26(3):360–366.

20. Mc Auliffe S, Synott A, Casey H, Mc Creesh K, Purtill H, O’Sullivan K. Beyond the tendon: Experiences and perceptions of people with persistent Achilles tendinopathy. Musculoskeletal Science and Practice. 2017;29:108-114. doi:10.1016/j.msksp.2017.03.009

21.Smith BE, Moffatt F, Hendrick P, et al. The experience of living with patellofemoral pain—loss, confusion and fear-avoidance: a UK qualitative study. BMJ Open. 2018;8(1):e018624. doi:10.1136/bmjopen-2017-018624

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