Tendinopathy Founder, RunSafe Founder, SportZPeak Inc. Basic - PowerPoint PPT Presentation

Disclosures Tendinopathy  Founder, RunSafe™  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 – “ tendon injury that  UNDERSTANDING  TREATMENT originates from How do they occur? Basic Strategy 1. 1. intrinsic and extrinsic Identify risk factors Problem Areas 2. 2. etiological factors ”  Usually not  EVALUATION “tendinitis” History 1. Physical Exam 2. 1

ARS: 46 year old male plumber with overhead pain, difficulty lifting during work and pain sleeping on the Tendon Structure shoulder. He had no injury. What is the likely DIAGNOSIS?  Collagen 33% 33% 33% Rotator cuff tendinitis A. types Shoulder bursitis B.  Microfibril Rotator cuff tendinosis C.  Fibril Massive rotator cuff tear D.  Fascicle Frozen shoulder E.  Tendon 0% 0% Frozen shoulder  Endo, epi, Rotator cuff tendinitis Shoulder bursitis Rotator cuff tendinosis Massive rotator cuff tear paratenon Tendon Load Spectrum of Tendon Disorders (Modified from Khan et al. 1999, Clancy 1990) Pathologic Dx Macroscopic Histopathologic Tendinosis Intratendinous Disorganized collagen, degeneration mucoid degen Tendinitis Degeneration with Fibroblasts, inflammatory repair hemorrhage, granulation response tissue Paratenonitis Inflammation of Mucoid degen. if areolar paratenon only tissue, fibrinous exudate Paratenonitis with As above As above tendinosis 2

Mechanics Where does the injury occur?  Usually tendons Insertional surrounding joints with  Occurs at insertions high degree of motion near the joint  Usually tendons that cross two joints  Joint side  Eccentric overload Tears  Mechanical  At the musculo- impingement 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 need to be conservative with her. She wants to plan her Spot Diagnosis? next marathon?  Macrotears 42% 2 weeks A. 4 weeks B. Miscellaneous 27% 6 weeks C.  Instability / 23% Subluxation 12 weeks D.  Calcific tendinosis 26 weeks E. 8%  Enthesopathy Never F. 0% 0%  Contractures s s s s s r k k k k k e e e e e e v e e e e e e w w w w w N 2 4 6 2 6 1 2 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 Risk Factors for Tendinopathy Tendinosis Intrinsic Extrinsic  Hyaline degeneration  Mucoid degeneration  Training  Anatomy  Collagen Bundle  Technique  Muscle/Tendon disorganization imbalance  Footwear  Increased ground substance  Growth  Surface  Increased tenocyte nuclei  Illness  Vascular infiltrations and small nerve ingrowth  Nutrition  Presence of non-acute  Conditioning inflammatory cells  Psychology Abat et al. Journal of 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  Insertional overuse  Weak hip abductors and medial quadriceps injuries (OSD, SLJ, Khan KM, et al. Phys Sportsmed 2000. Sever’s)  THINK ABOUT WHAT THE TENDON DOES Apoptosis Age affects Flexibility 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 Tight Hyperlaxity  Intuitively helpful  Patellofemoral  associations with  Associated with syndrome, subluxation of the development of some hamstring and quad hip, patella, injuries strains, shoulder, and apophysitises  No conclusive proximal cervical (OSD, Sever’s evidence that spine; also disease), and stretching is helpful or osteoarthritis, peripelvic harmful chondrocalcinosis 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 up to 6 months after ceasing treatment hypermobility type had more MSK symptoms vs controls  Suggest less aggressive approach early in rehabilitation They reported:  In another series (N = 42), ofloxacin #1 for tendinopathy (38% Lower shoulder function (WOSI total: 49.9 versus 83.3; p < 0.001), • 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 Athletes  Fluoroquinolones display a high affinity for connective tissue, 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 4. Close monitoring of the athlete should be undertaken for 1 1.2 per 10 000 for tendon rupture were cited. month after fluoroquinolone use. Lewis and Cook, J Athl Train, 2014 Kinesiophobia Glucocorticoid Steroids  Described in 1990 by Kori et al.  Kinesiophobia is described as irrational, weakening and  Low-dose corticosteroids in isolation have been implicated in devastating fear of movement and activity stemming Achilles tendon rupture from the belief of fragility and susceptibility to injury.  Symptoms occur when individual has to increase activity  Khaliq and Zhanel reported that 21 of 40 patients (52.5%) 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  Pathological tendon maintains sufficient  1 legged squat (look for weak hip abductors) or Step Down amounts of aligned fibrillar structure by  Hip abductors and extensor increasing tendon dimensions (anteroposterior strength diameter and total mean cross-sectional area) in  VMO atrophy and activation parallel with the mean cross-sectional area of  Flexibility disorganization (ie, the more disorganization,  Ober’s, Thomas test, Popliteal angle, Ely’s test, Ankle the bigger the tendon). dorsiflexion 39 9