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Tendinopathy Disclosures . Founder, RunSafe™ Tendinopathy . 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 “tendon injury 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 pain, difficulty lifting during work and pain sleeping on the shoulder. He had no injury. What is the likely DIAGNOSIS? A. B. Rotator cuff tendinitis C. Shoulder bursitis D. Rotator cuff tendinosis E. Massive rotator cuff tear Frozen shoulder 33% 33% Spectrum of Tendon Disorders 33% (Modified from Khan et al. 1999, Clancy 1990) Pathologic Histopathologic Macroscopic Dx e d n s sIntratendinousTendinosis Rotator cuff tendinitis e d n tsDegenerationTendinitis with Shoulder bursitis Rotator cuff tendinosis 0% Tendon Structure Paratenonitis Inflammation of Massive rotator cuff tear 0% degeneration Frozen shoulder Paratenonitis with . tendinosis inflammatory repair Collagen response types . Microfibril paratenon only . Fibril Disorganized collagen, . Fascicle s a o eAs aboveAs above mucoid degen Tendon 2 Fibroblasts, . hemorrhage, granulation Endo, epi, tissue paratenon Mucoid degen. if areolar tissue, fibrinous exudate Tendon Load Mechanics Where does the injury occur? . Usually tendons Insertional surrounding joints with high degree of motion . Occurs at insertions . Usually tendons that near the joint 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% Subluxation D. 12 weeks . Calcific tendinosis E. 26 weeks 8% . Enthesopathy F. Never 0% 0% . Contractures 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 fascia Children . Hyperpronation . Tendons and ligaments . Cavus foot relatively stronger and . Advancing age - decreased blood flow more elastic than . Overweight epiphyseal plate . Poor footwear . Weak hip abductors and medial quadriceps . Insertional overuse Khan KM, et al. Phys Sportsmed 2000. injuries (OSD, SLJ, . THINK ABOUT WHAT THE TENDON DOES Sever’s) Age affects Flexibility Apoptosis 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 protein 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 stretching is helpful or osteoarthritis, disease), and harmful chondrocalcinosis peripelvic apophyseal . Bad sprains avulsion fractures Hypermobility / Ehlers Danlos Fluoroquinolone- related Tendinopathy Joint hypermobility 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), ciprofloxacin #2 (31% of patients). Levofloxacin • 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 (neck: 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 connective tissue, Athletes particularly in cartilage and bone 1. Avoid the use of fluoroquinolones unless no alternative is . Risk factors for fluoroquinolone-associated tendinopathy available. include older than 60 yrs, concomitant corticosteroid therapy, 2. Oral or injectable corticosteroids 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 Achilles tendon 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 Achilles tendon rupture 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 strain . 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, elbow) . Check for underlying spondyloarthropathy: 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 atrophy 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, Ankle the bigger the tendon). dorsiflexion 39 9 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
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