Various physical therapies

in

TENDINOPATHY

Jakub Jeníček

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Objectives

Definition of the clinical condition and diagnostics

Basics of patophysiology

Most common types of tendinopathy

Goals of treatment

Various treatment approaches – from conventional up to advanced ones

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Tendinopathy – definition and diagnostics

primary disorder of the tendons – common, often chronic, difficult treatment

diagnosis is in most clinical activity-related pain, pain at rest decreased function, ADL stiffness of the tendon localized swelling palpable crepitations muscle tone imbalances

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Tendinopathy – pathogenesis

repetitive or excessive mechanical overloading and subsequent activation of noxious mechanisms

tendon loses its reparative capacity

inflammation and degeneration work together in the pathogenic cascade

confusion in terminology – tendinitis / tendinosis / tendinopathy

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Tendinopathy – most common types

certain tendons are especially susceptible to degenerative pathology:

rotator cuff in the shoulder forearm extensor tendons (tennis

elbow) forearm flexor tendons (golfer´s

elbow) patella tendon (jumper´s knee) Achilles tendon small feet muscles tendon

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Tendinopathy – epidemiology

most commonly diagnosed musculoskeletal disorders (Forde et al., 2005):

tendinopathies (19%) discopathies (18%) shoulder bursopathies (15%) carpal tunnel syndrome (12%) sum of all other disorders (36%)

high lifetime prevalence in sportsmen tennis (40%!), volleyball (20%) squash, basketball, soccer, running, jumping, cycling

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Tendinopathy – therapeutic intervention

in many cases remains uneffective – especially when treatment is only analgesic or anti-inflammatory monotherapy!

choice of adequate therapy:

phase of disorder - acute / chronic

- more inflammatory / degenerative nature

goals of treatment...

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Tendinopathy – Goals of treatment

analgesia

reducing inflammation

elimination of the swelling

tendon structure recovery (elasticity)

muscle normotonia, trigger points elimination

detection of primary causes of the disorder: muscle imbalance in segment, hypertonia incorrect movement stereotypes overloading activities, ergonomics other individual factors

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Tendinopathy – range of treatments

Conventional treatment

Non-steroidal anti-inflammatory drugs, corticosteroids

Biomechanical alterations – braces, taping, Kinesio-taping

Cryotherapy, Rest

Manual therapy techniques

Therapeutic ultrasound

Electrotherapy, Iontophoresis

Advanced treatment

Low-intensity laser therapy

Shockwave therapy

Stem-cell or gene therapy

Platelet-rich plasma

Sclerosant injections

numerous different types of treatment in literature

poor evidence base – mostly empirical findings from clinicians

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Tendinopathy – treatment in acute stage

predominance of inflammation

pain, swelling, redness, crepitations

typically occurs after prolonged stereotypical work (e.g. screwing)

treatment rest, cryotherapy orthotics – supportive braces, Kinesio-taping drugs – NSAId, antiphlogistics, corticosteroids injections manual therapy techniques

analgesic physical modalities – electrotherapy – TENS, DD, interferential currents

myorelaxant physical modalities – ultrasound or combined therapy ultrasound + electro

distinguish acute x chronic tendinopathy!

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Tendinopathy – clinical suggestions

most effective combination of physical modalities for patient with acute tendinopathy:

analgesia electrotherapy – DD currents – sequence of DF (1 min.) +

CP (5 min.) x LP (6 min.), polarity reverse in the middle

myorelaxation ultrasound – subaqual application from the distance of 10

cm (1 MHz, 1 W/cm2, 20% duty factor)

combined therapy (electro + ultrasound) for trigger points – 1 cm2 ultrasound head (3MHz, 0,5 W/cm2, 50% duty factor) + large electrode (TENS, f 100 Hz, motor treshold intensity)

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Tendinopathy – treatment in chronic stage

predominance of degeneration

pain, structural changes in tendon, stiffness, dysfunction

typically occurs after long-term overloading and microtraumatization (incorrect sport load, work position)

treatment manual therapy techniques physical modalities to modify the structure

and promote healing of affected tendon:

laser therapy (anti-inflammatory, analgesic, biostimulation)

shockwave therapy (analgesic, reparative)

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Tendinopathy – clinical suggestions

most effective combination of physical modalities for patient with chronic (degenerative) tendinopathy:

analgesia and biostimulation, reparation laser therapy – focused with laser probe

1. dose 20 J/cm2, continuous frequency do deliver energy to the tissue

2. dose 10 J/cm2, pulsed frequency to modulate desired effect

structure modification and healing shockwave therapy – optimum 2 bar in pathologic spot,

2000 pulses with frequency 10 - 15 Hz

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Thank you for your attention!