mechanisms underlying tendinopathies and the basis for ... · level 4: full wb on step; heel...
TRANSCRIPT
Annual Orthopaedic Section Meeting April 21-22, 2017
Kornelia Kulig 1
Lower Extremity Tendinopathies:
Tissue, Joint and Whole Body
Kornelia Kulig, PT, PhD, FAPTAFounding Member of the AAOMPT
Professor
Division of Biokinesiology and Physical Therapy
Department of Orthopaedic Surgery
University of Southern California
Clinical Facts• High percentage of patients treated by physical
therapists arrived with a diagnosis of “tendonitis”
• “Tendonitis” is seen in upper and lower extremity
– Achilles tendon injuries are among three most frequent
sports-related injuries of foot and ankle1
– Patellar tendon injuries have high prevalence amongst
competitive athletes2
– Tibialis Posterior Tendinopathy leads to one of the most
debilitating foot condition
1 Werd, JAPMA, 20072 Lian et al., Am J Sports Med, 2005
BLUF (Bottom Line Up Front) 2017
Painful tendons do not suggest the same underlying pathology
Combined clinical and imaging evaluations help determine the
stage and location of the pathology
Stage and location dictate the approach to intervention
If degeneration is present in mid-substance – the tendon is more
compliant, providing rationale for progressive resistive exercises
Peripheral and central adaptation to degeneration do occur and some are
reversible
Movement strategies are altered and require modification
Musculotendinous junction lesions require relative rest and
reloading
Teno-osseous junction require careful modifications of movement
strategies
Annual Orthopaedic Section Meeting April 21-22, 2017
Kornelia Kulig 2
“Stage” matters
• Severity
• Irritability
• Nature
• Stage; -itis or -osis
Continuous refinement of Terminology for
tendinopathies
Reactive
-tis
Degenerative
-osis
Reactive
on
Degenerative
Cook and Khan, CSM 2016
“Stage” matters
• Cliff notes on pure –itis
–relative rest
–assess technique for
overload
wrong load
Annual Orthopaedic Section Meeting April 21-22, 2017
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“Stage” matters
• Cliff notes on pure –osis
–reloading (overload) to
stiffen the tendon
–assess technique for
overload
wrong load
“Location” matters
Location Associated
with…
Common
Intervention
Musculo-
tendinous
junction
• Immobilization
(under loading)
• relative rest
Mid-substance •Overuse/wrong use
• Middle-aged
•Loading and
overloading
Teno-osseous
junction
•Collagen disease
•Wide-range age
•Surgery
•casting
• Technique training
•Shockwave therapy
Fahlstrom et al., Knee Surgery Traumatol Arthrosc, 2003
“Location” matters
Annual Orthopaedic Section Meeting April 21-22, 2017
Kornelia Kulig 4
The Myotendinous Junction
• Membrane infolding
• Redirection of
tensile stresses into
shear stresses
Rest – even several days - diminishes the
infolding of the musculotendinous junction
Typical
After immobilization
Fortunately, it also adapts rather rapidly to gradual re-loading
Mid-substance
Achilles
Tendon
• Most common
• Well studied
• Drives the guidelines for
treatment approach
Annual Orthopaedic Section Meeting April 21-22, 2017
Kornelia Kulig 5
DistalProximal
Superficial
Deep
Normal
Degenerated
Macro-Morphology
Chronic Use Adaptations
Chronic Wrong-use Mal-adaptations
• Cellularity
• Vascularity
• Collagen type III
• Water content
Video clip: Isometric Plantarflexion
Medial
Gastrocnemius
Aponeurosis
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Achilles Tendon Stiffness
Arya S and Kulig K, J App Physiol., 2010
, N=12
, N=12
Kornelia Kulig
NORMAL
DEGENERATED
Distal
Pro
xim
al Superficial
Deep
Calc
Calc
Distal
Proximal
Su
perfic
ial
Deep
Mechanical response to pathology
• 2010 Clinical Practice Guidelines linked to ICF.
Achilles Pain, Stiffness and Muscle Power Deficits: Achilles
Tendinitis1
Diagnosis based on self-reported pain and perceived stiffness
Interventions targeting tendon and foot only
• Soft tissue mobilization Expert Opinion
• Taping Expert Opinion
• Heel lift Conflicting Evidence
• Stretching Weak Evidence
• Orthoses Weak Evidence
• Low-level laser Moderate Evidence
• Iontophoresis Moderate Evidence
• Eccentric loading to tendon Strong Evidence
1 Carcia CR, Martin RR, Huck J, and Wukich DK: Clin Pract Guide., JOSPT, 2010
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Main
intervention
ingredient for
Achilles
tendinosis1
• Slow and controlled, involving cognition, “think about it”
• Strain (% elongation) exceeding that during walking
• Lowering allows more repetitions than rising, especially if
more strain is desired!
• High volume and progressively adding load (overload)
1Alfredson, AJSM, 1998
Kornelia Kulig
LEVEL 1: non-weight-bearing eccentric ankle plantar flexion with theraband
LEVEL 2: partial WB on ground; extra upper extremity support
LEVEL 3: full WB on ground; minimal UE support
LEVEL 4: full WB on step; heel lowered below
LEVEL 5: 10% body weight in backpack
LEVEL 6: 15% BW in backpack
LEVEL 7: 20% BW
LEVEL 8: 25%
BW
Progressively Resistive
Reloading Program
What changed as a result of an
eccentric overload program?
0.76%
3.55%
-2.85%
-17.30%
19.76%
-8.49%
-20.00% -15.00% -10.00% -5.00% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00%
Pre-Activation
Stiffness
Thickness
Involved
Non-Involved
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Do patients present to a
clinic because one of their
tendons is less stiff?
PAIN
Where is the pain coming from?
Deep
Superficial
ProximalDistal
Within the tendon --
Neo-vascularization
substance P
Paratenon changes - even before
changes in tendon proper – highly
vascularized and innervated, signs of
thickening, Stecco et al, Surg Radiol Anat,
2014
Annual Orthopaedic Section Meeting April 21-22, 2017
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Location Associated
with…
Common
Intervention
Musculo-
tendinous
junction
• Immobilization
(under loading)
• relative rest
Mid-substance •Overuse/wrong use
• Middle-aged
•Loading and
overloading
Teno-osseous
junction
•Collagen disease
•Wide-range of
age
•Surgery
•casting
• Technique training
•Shockwave therapy
Fahlstrom et al., Knee Surgery Traumatol Arthrosc, 2003
“Location” matters
Insertional
Tendinopathy
• Less common
• Not well studied*
• Very limited exposure in the
Guidelines for management of
Achilles tendinopathy
* note recent elegant studies by Chimenti et al.
calc
aneus
Insertional Tendinopathy
• Recalcitrant to resistive exercise program and
other rehabilitative interventions1
• Therefore the common treatment approaches
are:
– Casting or boot
– Shockwave therapy2,3,4
– Surgery5
1 Fahlstrom et al. (2003) Knee Surg Sports Traumatol Arthrosc. 2 Rompe et al (2009) AJSM, RCT. RSWT vs. Eccentric + ESWT with favorable outcome for the combined group. Level I3 Rompe et al (2008). JBJS, RCT. RSWT vs. eccentric loading. Better outcome for ESWT. Level I4 Rasmussen et al (2008) Acta Orthop. RCT. ESWT vs. Placebo ESWT. Better outcome with the ESWT. Level I5 Traina at al. (2016) J Biol Regul Homeost Agents
Annual Orthopaedic Section Meeting April 21-22, 2017
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We can do better!
…but how?
Video of runner on treadmill
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From the Laboratory and Literature:Percent Contribution to Support Moment during Running
Belli, et al., Int J Sports Med ,2002
Case with Unilateral TendinopathyPercent Contribution to Support Moment during Running
Hip, 30.6%
Knee, 21.0%
Ankle, 48.4%
Hip, 25.2%
Knee, 27.2%
Ankle, 47.6%
Right
(Involved)
Left
Tendon and Muscle Length
Changes During Walking Gait
Fukunaga et al., Proc R Soc Lond, 2001
Tendon
MuscleMTU
Single
support
Double
support
Length
change (
mm
)
15
10
5
0
-5
-10
-15
Push-
off
SWING STANCE
SH
OR
TE
NIN
GL
EN
GT
HE
NIN
G
M-T unit
Joint
Body
Annual Orthopaedic Section Meeting April 21-22, 2017
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Loading Phase of Running:
Frontal plane foot position
Insertional Tendinopathy
• Recalcitrant to resistive exercise program and
other rehabilitative interventions
• Therefore a strong consideration for an
addition to common treatment approaches
ought to be:
– Casting or boot
– Shockwave therapy
– Surgery
– Training/Coaching of Running Technique