Rehabilitation Considerations of Lower Extremity

Tendinopathy

Patrick S. Pabian PT, DPT, SCS, OCS, CSCSUniversity of Central Florida

LE Tendinopathy

• Objectives for Treatment– Multifaceted / Comprehensive Examination

– Rehabilitation Science

– Stewards of the Research for Best Practice

– Integration of Care

Predisposing Factors

• ExtrinsicTraining ErrorsSurfacesShoesEquipmentEnvironmentPsychological FactorsNutrition

• IntrinsicMalalignmentLeg Length DiscrepancyMuscle ImbalanceMuscle WeaknessMuscle FlexibilityGender. Size, Body compOther (metabolic, genetic, endocrine)

Brukner & Kahn. Clinical Sports Medicine. 2012.

• Examination & Treatment of LE Tendinopathy

“Whole” “Part” “Whole”

Rehabilitation Science

• Goals:– Improve understanding of injury

– Identify influence of our treatment

Lorenz & Reiman. IJSPT 2011.

Cook & Purdam. Br J Sports Med. 2009.

Alternate Classification - Continuum

• Reactive Tendinopathy– Tensile / compressive overload (acute)– Repair proteins, proteoglycans prominent (water in

matrix)• Tendon Dysrepair– Myofibroblasts present– Disorganization starting: collagen separation

• Degenerative Tendinopathy– Absent cell nuclei, little collagen– Heterogeneous signal on MRI, US

Normal vs. Excessive Loading

Normal• Tendon cells spindle

shaped• Minimal ground

substance• Linear, tight bundled

collagen• Minimal intratendinous

nerves• Minimal vascularity

Tendinopathy• Rounded nuclei, fewer

tenocytes• Increased ground

substance• Disrupted collagen• Ingrowth of

intratendinous nerves• Prominent vessels

Brukman & Kahn. Clinical Sports Medicine. 2012

Treatment Focus: “Part”

Modalities? Exercise? Rest? Activity Modification? How long conservative?

• Do any of these reverse the aforementioned processes / biological characteristics of tendinopathy?

Mechanotransduction

Process by which “mechanical loading” creates a cellular response

1. Mechanical trigger (mechanocoupling)– Can be in just isolated region– Shear or compression

2. Cell to cell communication– “signaling proteins” (Ca and inositol triphosphate)

3. Effector cell response– Tissue repair & remodeling

Kahn & Scott. Br J Sports Med. 2008

Mechanotransduction

Up-regulation of Insulin growth factor (IGH-I)

= cellular proliferation & matrix remodeling within tendon

= increase rate of collagen synthesis

**Best Facilitated through Eccentric Exercise**Landberg. Scand J Med sci Sports. 2007.

Eccentric vs. Concentric Exercise

• Patella Tendinitis – Pain, satisfaction, return to sport, future care

• Johnssen et al. Br J Sports Med 2005.

• Achilles Tendinitis – 82% vs. 36% return to prior activity

• Mafi et al. Knee Surg sports Traumatol Arthrosc 2001.

– Decreased intratendinous signal (3 mo. and 4 yr)• Gardin et al. Skeletal radiol. 2010.

Prescription of Eccentric Exercise

• Original source:Alfredson’s Heel-Drop Protocol for Achilles Tendinopathy• 180/day• Overload theory• Pain• Add resistance / weight

(up to 50kg)

Alfredsen et al. Am J Sports Med 1998Fahlstrom et al. Knee Surg sports Taumatol Arthrosc. 2003Roos et al. Scand J Med Sci Sports 2004.

Training Program Effectiveness

12 week eccentric training program6x15, BID, 7d/wk

26 patientsMean 50 y/o with pain 17 months

Results: 1. Significant reduction in cross sectional size of tendon2. 19 of the 26 had normal return of structural integrity

based on US examination.Ohberg, Leretzon, Alfredsen. Br J Sports Med. 2004

Research on Effectiveness (RCT)

• Eccentric vs. Concentric– ECC = higher recovery, ROM, less pain

• Silbernagle et al. 2001

• Low Level Laser + ECC vs. Placebo + ECC– LLLT showed tendency for improve at wk 4 but not week 12

• Stergioulas et al. 2008

• PRP + ECC vs. Placebo + ECC– No benefit at 6,12,24 weeks

• De Vos et al. 2010

Research on Effectiveness (RCT)

• ECC + Night splint vs. ECC alone– ECC alone better at 6,12,24,53 weeks

• Roos et all 2004.

• ECC + Low-energy shockwave vs. ECC alone– ECC + SWT better at 4 months but no diff 1 yr.

• Rompe et al. 2009.

• Surgical treatment vs. ECC– No difference at 12 weeks. Surgical took twice as long to RTP.

• Alfredson et al. 1998.

Connect the Whole

Proximal Distal

• Landing Strategies– Forefoot Landing reduces vertical ground reaction

forces by 25%– Only 40% of landing energy transmitted proximally

***Gastroc / Soleus Strength essential***

Cook et al. Scan J Med Sci Sports. 2000.

Integration of Care

• “Connect the whole”• Address all Intrinsic & Extrinsic factors with

appropriate personnel– ATC, Strength Coach, etc.

Keep the Focus

• Multifaceted / Comprehensive Examination

• Rehabilitation Science

• Stewards of the Research for Best Practice

• Integration of Care

• Thank You!!