Treating athletes with tendinopathy in season Jill Cook 5 th MuscleTech Network Workshop Barcelona 2013
Jan 14, 2015
Treating athletes with tendinopathy in
season
Jill Cook 5th MuscleTech Network Workshop
Barcelona 2013
Why are tendons a problem? • Disabling
– Athletes unable to perform at their usual level • Lose power
– Jumping, change of direction, deceleration – Anti-gravity tendons affected most
» Achilles, patellar
• Slow to respond – Very happy to give bone and ligament weeks to
recover yet we expect tendons to be ready the next week
– Collagen turnover may be non–existent or very limited after puberty
• Heinnemeyer et al 2013
Is the problem pathology or pain or both?
• Interesting question – Pain & pathological change are unrelated
• Mainly pain – Stops function, stops performance – May not have (imaging) pathology
• But can be pathology – Tendons rupture if not enough intact tendon
left to take load • Quantity of intact tendon may be the key factor • Can be painfree prior to rupture
When does tendinopathy occur? • Both pain and pathology
occur when the load placed on the tendon exceeds the tendons capacity
• Load has to include – Energy storage and release
• Tendon acting as a spring – Compression
• Against bone or retinacular structures
– Combination of both
Sequence of pathological events"
Mechanically weaker tendon
Degenerative tendinopathy
Normal tendon Adaptation
Optimised Load
Strengthen
Sedentary Optimised load
Excessive load + individual
factors
Tendon dysrepair
Reactive tendinopathy
Appropriate modified
load
Normal or excessive
load +/- individual factors
What is the tendon response to overload?
Cook & Purdam 2009
This is what we want
Normal tendon Adaptation
Optimised Load
Strengthen
• Balance between load capacity of the tendon and the load placed on it
• Load must always be close to what is required in sport otherwise the tendon capacity will decrease • Like bone, use it or lose it
Pathological tendon
the normal part of the tendon
This is what we often get • Reactive after
unloading – Unloading decreases
• Tendon mechanical properties
• Tendon capacity to tolerate load
– Present after a period of time off
• Injury, off-season – Return to loading at
previous levels • Tendon reacts to load
Mechanically weaker tendon
Normal or excessive load +/-‐ individual factors
Reac<ve tendinopathy
Normal tendon Unloaded
What about the commonest clinical presentation?
Degenera(ve area
Normal tendon
Degenera(ve area
Reac(ve tendon
• An increase in pain is most likely to be a degenera<ve lesion with some reac<ve aspects
• What causes a degenera<ve tendon to become reac<ve? • Mismatch between load tolerance and capacity of the tendon and the load placed on it • Degenera<ve tendon bears liEle load
Your key forward who has occasional Achilles tendon pain starts a plyometric program and then hobbles in for treatment a couple of days later
Management of in season tendinopathy
Aetiology • A change in load
– One session or over several sessions • One session
– Single high intensity session – Direct blow
• Several sessions – Increased frequency of training esp high loads – Pre-season training!
• Either – Different drills
» Sprints at the end of training – Change in footwear – Change in track/surface
» Soft sand » Uneven surfaces
Treating tendons in season • Challenges
– Full rehabilitation is impossible – Kinetic chain dysfunction
increases over season – Activated tendon difficult to settle
when abusive loads continue
• Research – Eccentric exercises do not
help » Visnes et al 2005, Fredberg et
al
– ESWT does not help » Zwerver et al 2011
Visnes et al 2005
Zwerver et al 2011
Bases of tendon management in season
– Define the stage of tendinopathy • Assume it is reactive or reactive on degenerative
– Quantify tendon symptoms and kinetic chain function
• Subjective • Objective
– Modify load • Training • Biomechanical, kinetic chain
– Maintain whatever you can • Strength, power
Bases of reducing in season tendon pain
• Reduce the sensitisation of the tenocytes – Key if the cells are the source of pain
• Attempt to reduce the proteoglycan deposition in the matrix – Key to prevent further matrix disruption and
poorer load tolerance • Local interventions to the neurovascular
structures
What are we trying to achieve with in-season rehab?
• Maintain/improve function of muscle
• Unload the affected tendon – Maximise other contributions to
the kinetic chain
• Avoid exacerbation of the tendon – Load management
• Unload and load appropriately • Prioritise performance and pain
control
How do we do manage tendinopathy with unloading?
• Decrease frequency of high tendon load – Energy storage and release – Train every second or third day
• Decrease length of loading – Shorten training
• Decrease load in training – Take out key overloads
• Drills and training that excessively load the tendon
• Decrease compressive loads – Specific movements and drills
Reload appropriately
• Isometric loading – Great to decrease pain in a reactive tendon – Mechano-transduction
• Cells are activated and producing excess proteins – Slower/less intense loading less likely to up-regulate the
tenocytes • Cells are integrally connected to the matrix
– Connections through proteoglycans and integrins with connection through to the cell nucleus
– Through cilia (Lavorgnino) » Alter gene expression in response to mechanical load
• So attempt to load the tendon without stimulating cell through matrix movement
How we use it in tendons • Sustained contraction
– Away from compression – Short tendon length – Often have no or little pain
• Heavy loads – Needs to be machine based is possible
• Don’t be shy with load • Research loads are 80% MVC, 4 x 45 sec holds
• Avoid exercise that requires postural control – Seated or lying – If standing, good support
• Do 3-4 times a day if needed – Immediate and sustained pain relief – Can be done pre training and playing
• No detriment to function • Even post playing
Can imaging help in season?
• Ultrasound tissue characterisation (UTC) – Improve staging and
diagnosis – Detect asymptomatic changes
in tendon structure – Determine load tolerance in at
risk tendons – Monitor recovery of structure
independent of symptoms
Ultrasound tissue characterisation
Echotype I-‐ Intact, aligned bundles Echotype II-‐ Increased waviness/separa:on of fibrils Echotype III-‐ Decreased fibrillar integrity Echotype IV-‐ Absence of fibrillar organisa:on
Diagnosis – staging the pathology Reactive tendinopathy
January August
Pathological lesion has not changed over 3 years. The tendon has had no symptoms between January and August
Diagnosis – staging the pathology Reactive on degenerative pathology
Monitoring load response • Achilles tendon response in AFL
players – 20 players screened
• Day 0 ,2 and 4 – All normal Achilles
• Some had patellar tendinopathy – Clear temporal response in those without
tendinopathy • Those with had a variable response
31st Jan, 2011 11th Jun, 2012 14th Jan, 2013
Prox
Mid
Monitoring recovery
1/31/2011 6/29/2011 6/11/2012 1/14/2013 Black 10,9% 2,7% 2,5% 1,6%
Blue 24,2% 22,5% 16,3% 16,4%
Red 16,6% 3,2% 2,4% 1,2%
Green 48,3% 71,5% 78,9% 80,8%
30%
40%
50%
60%
70%
80%
90%
100%
Percen
tage of e
ach echo
type
Overall echopa2ern for R patellar tendon
Monitoring recovery
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
Black
Blue
Red
Green
10th Dec, 2012 17th Dec, 2012 19th Feb, 2013
Monitoring change in structure before symptoms
What else can we use for in season tendinopathy?
• Medications – Affect the tendon response
• Injections – Affect the tendon response – Analgesia
• Adjunct treatments – Analgesia
What medications can we use for the tendon?
• Tenocyte inhibitors – Ibuprofen (Tsai et al 2004), celecoxib
• Aggrecan inhibitors – Ibuprofen, naproxen, indomethacin (Dingle1999, Riley
2001)
• TNF alpha inhibitors – Doxycycline (Fallon et al 2009)
• Inhibits MMP13 (Bedi et al 2010)
– Green tea (Cao et al 2007) – Omega 3 (Mehra et al 2006)
What medications can we use for the tendon?
• Corticosteroid is a knock out blow on cell activity and proliferation – Short acting and non-colloidal eg dexamethasone – Not into tendon – Can be oral – ONLY in very reactive tendons
• What about the bad press? – Used inappropriately
• Wrong stage • Wrong corticosteroid • Wrong rehab • Wrong reasons
What about injections?
• Analgesia/ anaesthetic • Well if it is only pain why not get rid of the pain?
– Progressive increase in symptoms • Some steroid-like effects of local anaesthetics
(Piper et al) • Some long term effects of local anaesthetics
• Other injections – PRP, cells • Intratendinous injections have no place for their use in
in-season management • Peri-tendinous injections used but untested to date
What else? • Do NOT rest tendinopaths in the off season
– Immediately start to improve load capacity in the tendon
• Prehab • Ensure good tendon capacity of all athletes
• Control the coach – Ramp into pre-season training for tendinopaths
• Monitoring • Monitor either pathology with UTC or pain with loading tests
• Early intervention • Change load when tendon first declares its intolerance with pain or loss of
structure – Waiting and hoping not recommended
Summary
• Not just a simple assessment – Stage pathology – Determine response to load – Determine what loads are affecting tendon
• Not a simple management – Based on above
• Manage pathology • Manage load • Manage pain • Manage long term outcome for the athlete
How can the presented evidence helped clinicians in the management of
tendinopathies ??
• One of your players experiences sudden onset of pain at the insertion of the Achilles tendon during training but only during high loading
• What to do?
• Sudden onset insertional pain unusual – Examine the loading that is
causing the pain • Should be a compressive aetiology • If not differential diagnosis
– May be insertional plantaris
• If it is tendon, decompress it – High heel raise
• High during the day and as high as possible during training
– Consider training in good running shoes with heel raise
• Limit high loads • Start isometrics and heavy slow
loading away from dorsiflexion
Case 1 • A young talented player
with symptoms in the patellar tendon (on and off pain during warm up or after training, better during activity) during the preseason training
• What to do? – continue training? – adjust training? – add treatment?
1. Likely reactive on degenerative tendinopathy
1. Not severe, but will be if not attended to immediately
1. Back off loads, frequency, extreme load drills
2. Attend to deficits in kinetic chain Especially quads and calf deficits
3. Allow TIME for this to resolve 4. Medicate with triple therapy 5. Address fully in the off-season
Case 2 • A very important
player during season experience increasing symptoms (pain and stiffness in the morning) in the patellar tendon weeks before an important match
• What to do?
• Consider the diagnosis – Patellar tendons are
rarely sore in the am • Balance the load with
the tendon capacity – Decrease abusive loads
• Frequency, length of training and specific drills
• Start loads that help pain and function – Isometrics and heavy
slow isotonics – Strengthen calf and gluts
to assist quads • Medicate to settle
tendon