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