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Home , Enthesopathy, Hypermobility (joints), Rotator cuff tear, Tendinopathy

Disclosures

. Founder, RunSafe™ . Founder, SportZPeak Inc. Basic Strategy for . Sanofi, Investigator initiated grant Diagnosis and Treatment

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

05/22/2019

Approach to Tendinopathy Terminology

. Tendinopathy – . UNDERSTANDING . TREATMENT “ that originates from 1. How do they occur? 1. Basic Strategy intrinsic and extrinsic 2. Identify risk factors 2. Problem Areas etiological factors” . Usually not . EVALUATION 1. History “tendinitis” 2. Physical Exam

1 ARS: 46 year old male plumber with overhead , difficulty lifting during work and pain sleeping on the . He had no injury. What is the likely Tendon Structure DIAGNOSIS? 33% 33% 33% . A. tendinitis types B. Shoulder

C. Rotator cuff tendinosis . Microfibril . Fibril D. Massive . Fascicle E. Frozen shoulder . Tendon 0% 0%

s s r r ti i a e i s e ld rs o t u . Endo, epi, u in ff o b d u h r n c s e te r n ld f to e paratenon u f a z o cu t ro h ro F S or t ve ta i o ss Rotator cuff tendinitis R a M

Spectrum of Tendon Disorders Tendon Load (Modified from Khan et al. 1999, Clancy 1990)

Pathologic Dx Macroscopic Histopathologic

Tendinosis Intratendinous Disorganized collagen, degeneration mucoid degen

Tendinitis Degeneration with Fibroblasts, inflammatory repair hemorrhage, granulation response tissue

Paratenonitis of Mucoid degen. if areolar paratenon only tissue, fibrinous exudate

Paratenonitis with As above As above tendinosis

2 Mechanics Where does the injury occur? . Usually Insertional surrounding with high degree of motion . Occurs at insertions . Usually tendons that near the cross two joints . Joint side . Eccentric overload Tears . Mechanical impingement . At the musculo- tendinous junction . Areas of friction

38 year old female ran her first marathon. She finished Pathophysiology of Tears 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 . Microtears Spot Diagnosis? need to be conservative with her. She wants to plan her next marathon? . Macrotears 42% A. 2 weeks

B. 4 weeks Miscellaneous 27% . Instability / C. 6 weeks 23% D. 12 weeks

. Calcific tendinosis E. 26 weeks 8% . F. Never 0% 0% .

s s s s r ek ek k k ve e e ee ee e w w w w N 2 4 6 weeks 12 26

3 Basic Science – Tendon Healing Tendon Healing . requires around 100 days to synthesize collagen Mild – 2 to 4 weeks Moderate – 4 to 6 weeks . Tendon healing creates more collagen fibrils and Severe – 6 to 12 weeks or longer 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

Tendinosis Risk Factors for Tendinopathy

. Hyaline degeneration Intrinsic Extrinsic . Mucoid degeneration . Anatomy . Training . Collagen Bundle . Muscle/Tendon . Technique disorganization imbalance . Footwear . Increased ground substance . . Increased tenocyte nuclei Growth . Surface . Vascular infiltrations and . Illness small nerve ingrowth . Nutrition . Presence of non-acute . Conditioning inflammatory cells Abat et al. Journal of . Psychology Experimental Orthopaedics, 2017

4 Risk Factors (Achilles) – Anatomy and Imbalances Age factor

. Tight Achilles and plantar Children . Hyperpronation . Tendons and . Cavus relatively stronger and . Advancing age - decreased blood flow more elastic than . Overweight epiphyseal plate . Poor footwear . Weak abductors and medial quadriceps . Insertional overuse Khan KM, et al. Phys Sportsmed 2000. (OSD, SLJ, . THINK ABOUT WHAT THE TENDON DOES Sever’s)

Age affects Flexibility

Young patients . “Programmed cell death” . Average stiffness 242 +/- 28 . No inflammation N/mm and an ultimate load . Increased proportion of apoptotic cells with age of 2160 +/- 157 N . Increased proportion of apoptotic cells in rotator Older patients cuff tears . Average stiffness 180 +/- 25 . ? Associated with stress-activated N/mm and an ultimate load kinases of 658 +/- 129 N . May affect collagen repair Woo , Lollis et al, Am J Sports Med, 1991.

5 Flexibility Flexibility Hyperlaxity Tight . Intuitively helpful . associations with . Patellofemoral . Associated with subluxation of the syndrome, development of some hip, patella, hamstring and quad injuries shoulder, and strains, . No conclusive proximal cervical apophysitises evidence that spine; also (OSD, Sever’s is helpful or , disease), and harmful chondrocalcinosis peripelvic apophyseal . Bad avulsion fractures

Hypermobility / Ehlers Danlos Fluoroquinolone- related Tendinopathy

Joint syndrome/Ehlers-Danlos syndrome- . Symptoms can present within hours of starting treatment or hypermobility type had more MSK symptoms vs controls up to 6 months after ceasing treatment They reported: . Suggest less aggressive approach early in rehabilitation . • Lower shoulder function (WOSI total: 49.9 versus 83.3; p < 0.001), In another series (N = 42), ofloxacin #1 for tendinopathy (38% of patients), #2 (31% of patients). • lower HRQol on SF-36 Physical Component Scale (PCS: 28.1 was the least reported. versus 49.9; p < 0.001) . Achilles tendon was the principal tendon affected in 88 cases • higher pain intensity (NRS: 6.4 versus 2.7; p < 0.001) (89.8%). Neck and shoulder joints were rated as primary painful . Lewis and Cook, J Athl Train, 2014 areas in both groups, with significantly higher frequency in JHS/EDS-HT (: 90% versus 27%; shoulder: 80% versus 37%). Johannessen et al. Disabil Rehabil, 2016

6 Fluoroquinolone- related Tendinopathy Guidelines for Fluoroquinolone Use in . Fluoroquinolones display a high affinity for , Athletes particularly in cartilage and 1. Avoid the use of fluoroquinolones unless no alternative is . Risk factors for fluoroquinolone-associated tendinopathy available. include older than 60 yrs, concomitant therapy, 2. Oral or injectable should not be used renal dysfunction, and history of solid organ transplantation concomitantly with fluoroquinolones. Biddell et al. Pharmacotherapy 2016. 3. Athletes, coaches, and training staff should understand the . In an evaluation of more than 11 000 patients, rates of 2.4 potential risk for developing this complication. incidences per 10 000 patient prescriptions for tendinitis and 1.2 per 10 000 for tendon rupture were cited. 4. Close monitoring of the athlete should be undertaken for 1 Lewis and Cook, J Athl Train, 2014 month after fluoroquinolone use.

Glucocorticoid Steroids Kinesiophobia

. Described in 1990 by Kori et al.

. Low-dose corticosteroids in isolation have been implicated in . Kinesiophobia is described as irrational, weakening and rupture devastating fear of movement and activity stemming from the belief of fragility and susceptibility to injury. . Khaliq and Zhanel reported that 21 of 40 patients (52.5%) . Symptoms occur when individual has to increase activity with fluoroquinolone-related tendon rupture had received . Various defence mechanisms may appear, such as: systemic or inhaled corticosteroids. Patients prescribed both repression (removing from consciousness), negation fluoroquinolones and corticosteroids had a 46-fold greater (there is no need for movement), simulation and risk of than those taking neither projection (sports fan behaviour) or, most frequently medication. used, rationalisation (e.g. lacking time). Knapik A, et al. J Hum Kinet. 2011.

7 History Early tendinopathy symptoms

. Usually a history of overuse or acute . Pain when using the affected muscle/tendon . May be present at the start of an activity then pain decreases after “warm-up” Diagnosis . 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, ) . Check for underlying : Psoriasis, GI symptoms, STD

3 Basic P/E findings Location for tendinopathy . Point with One Finger ONLY

1. Tenderness on direct palpation 2. Reproduction of pain with resisted contraction (eccentric loading) 3. Reproduction of pain with passive stretch

8 Location How do you exam for lateral epicondylosis ?

. Achilles

Ultrasound Tendon How do you tell from a stress fracture?

. Hop test . 1 legged squat (look for weak . Pathological tendon maintains sufficient hip abductors) or Step Down amounts of aligned fibrillar structure by . Hip abductors and extensor increasing tendon dimensions (anteroposterior strength . VMO and activation diameter and total mean cross-sectional area) in . Flexibility parallel with the mean cross-sectional area of . Ober’s, Thomas test, Popliteal disorganization (ie, the more disorganization, angle, Ely’s test, the bigger the tendon). dorsiflexion

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9 Tendon Tears - Achilles Long axis at 6 months

Short Axis at 6 months Imaging 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

10 Conservative treatments BASIC STRATEGY

1. Modify Activity

. THINK ABOUT WHAT THEY ARE DOING? . WHAT DO THEY NEED TO DO? Treatment . Be Prescriptive . Examples for Achilles 1. NWB, or biking 2. Nonimpact upright activities 3. Sport-specific drills; limited sports 4. Full activities no restrictions

Evidence for Orthoses 2. Reduce Stress Wilson F et al. Br J Sports Med, 2018

. DME - Modify footwear . High to moderate level evidence of no difference - Heel lifts in pain (moderate) or function (high) between - Custom orthoses and control . Address foot mechanics . Low level evidence of no significant benefit in . Immobilize adding a night splint to an eccentric exercise - Walking boot program for function, and moderate level - Crutches - Night splints evidence for no reduction in pain

11 3. Physical Therapy for Achilles Alfredson H, Pietilä T, Jonsson P, et al. Am J Sports Med, 1998; Stretching Gastrocnemius 26:3: 360-366. . Improves pain and ROM stretch

Strengthening – eccentric . RCT – eccentric exercises (3 x 15 reps, 2 loading times/day, 7 days a week x 12 wks) . Mechanical loading . Results: Significant difference in pain levels VAS accelerates tenocyte metabolism 81.2 mm (+/- 18) to 4.8 mm (+/- 6.5) in Soleus stretch 12 weeks Modalities . 81% eccentric satisfied vs 38% concentric satisfied Calf / Achilles stretching Hold each stretch for 30 seconds

Update on Eccentric Exercises Eccentric Drop program

. There is no convincing clinical evidence to demonstrate that isolated eccentric loading exercise improves clinical outcomes more than other 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

12 Evidence for Eccentric Exercise Wilson F et al. Br J Sports Med, 2018 4. Pain Management Moderate level evidence Low level evidence . Little evidence to . Eccentric exercise over . Eccentric exercise was not support use of control for improving pain superior to stretching for and function in mid-portion pain or QoL. NSAIDs in tendinopathy management . Eccentric exercise over concentric exercise for reducing pain . Good . No significant difference in pain or function between eccentric exercise and heavy slow resistance exercise

NSAIDs Evidence ? Steroid Injections

. RCT Ibuprofen x 1 wk (600 mg tid) vs placebo, . Reduce inflammation n=26 with chronic achilles tendinopathy, biopsy . Decrease symptoms . PCR Expression of and TGF-β isoforms showed relatively low variation and . Inhibit phopholipase A2, was unaffected by ibuprofen treatment. stops formation of precursors . No changes were seen in tendon thickness or VISA-A score . Inhibit cell migration Heinemeier et al. J Appl Physiol, 2017.

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13 Steroid Injection Evidence ? 5. Platelet Rich Plasma Injections

Extensor Carpi Radialis Brevis What is it? . At short-term follow-up, only local corticosteroid injection . Concentrate the plasma by centrifugation improved pain; however, it was associated with pain worse than placebo at long-term follow-up . Blood must be drawn from a patient and the Lian J et al. Am J Sports Med, 2018 platelets are separated from other blood cells Plantar and concentration is increased . 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). . CANNOT USE ANESTHETIC . Steroid injection made no difference to average heel pain in the medium-term (1 to 6 months follow-up) https://orthoinfo.aaos.org David JA et al. Cochrane Database Syst Rev 2017

PRP Evidence ? – Tissue Healing PRP Evidence ? - Inflammation

. PRP has been shown to temporally increase the . PRP seems to control of the inflammatory process, angiogenetic phase and subsequently lead to a involving in particular the hepatocyte growth factor prompt reduction of this phenomenon, thus (HGF) accelerating the whole tendon healing process . PRP has been shown to activate Tumor Necrosis Factor TNF-alpha and NFkB pathways (pro-inflammatory) . PRP is not able to reverse late-stage tendinopathy including the infiltration of . Expression of genes related to cellular proliferation and tendon collagen remodeling seen after PRP mononuclear cells, permanent neovascularization, metaplastic non-tenocyte Hudgens et al. Am J Sports Medicine, 2016 differentiation of tendon cells and non-tendinous tissues

14 PRP Evidence ? What about a Needle Tenotomy ?

Overall . Passing the needle through the area of tendon . Patellar and lateral elbow tendinopathy showed improvement degeneration from PRP treatment . Ultrasound-guided . Achilles tendon and rotator cuff do seem not to benefit from intratendinous PRP PRP application with either conservative treatment or surgery injection may lead to both clinical and MRI . There is no consensus on efficacy improvements in tendon . This is mainly due to the lack of standard PRP preparation pathology. procedures or methods of application Wesner et al. PLoS Abat et al. Journal of Experimental Orthopaedics, 2018 One 2016 Patellar tendon (Abat et al.

61 Presentation Title

Plantar Fasciitis

. Tender on insertion on medial of calcaneus

Problem Areas . Associated with age, , pes planus and pes cavus

. More prolonged, more difficult to manage

15 Plantar Fascitis . Tender on insertion on medial aspect of heel . Tender on insertion on . Associated with: medial tubercle of - Age calcaneus - Pes planus and pes cavus - Obesity (OR =5.6 (95% C.I., 1.9-16.6) . Associated with age, - Poor shoes, working on feet (OR = 3.6 (95% C.I., 1.3-10.1) obesity, pes planus and pes - ≤0 degrees of dorsiflexion had OR = 23.3 (95% C.I. , 4.3 to cavus 124.4) Riddle et al. JBJS-A, 2003 - Limb leg discrepancy (longer leg associated with plantar . More prolonged, more fasciitis) difficult to manage Mahmood et al, J Am Podiatr Med Assoc, 2010

Posterior tibialis tendinopathy Posterior tibialis tendinopathy

. >50 y.o. . >50 y.o. . F > M . F > M . Obese, pronation . Obese, pronation . Sudden collapse of . Sudden collapse of the arch the arch . Short AFO . Short AFO . Surgery . Surgery

16 Patellar tendinosis Patellar tendinosis “Jumper’s ” “Jumper’s knee” . Pain over inferior pole . Pain over inferior pole of the patella in of the patella in supine (less pain supine (less pain when knee flexed to when knee flexed to 90°) 90°) . Pain with squat . Pain with squat . U/S and MRI useful . U/S and MRI useful for confirming for confirming diagnosis diagnosis

Lateral epicondylitis Tendinitis

“ Elbow”

. Extensor carpi radialis brevis . Tender over the anterior tendinosis shoulder . Tender lateral epicondyle . Can be very painful rd . Resisted 3 digit extension and wrist . Pain with reaching overhead extension and behind . Passive wrist flexion . Related to poor posture . extended

. Check thumb abduction strength

17 Summary – Basic Strategy

Evaluation Treatment . Think tendinopathy: . Modify Activity Activity related, improves . Reduce Stress with rest . PHYSICAL THERAPY . Physical Exam: . Pain Management - #1 Tender on palpation, . Induce Healing – PRP ? - #2 Resisted eccentric contraction, - #3 Passive stretching 14th UCSF Primary Care Sports Medicine Conference San Francisco, Dec 12-14, 2019 Hotel Intercontinental

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