Managing Tendinopathy in season

1. Treating athletes with
tendinopathy in
season
Jill Cook
5th MuscleTech Network Workshop
Barcelona 2013

2. 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

3. 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

4. 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

5. Sequence of pathological events"

6. What is the tendon response to overload?
Mechanically weaker tendon
Sedentary
Normal
or excessive
load +/- individual
factors
Optimised
load
Normal tendon
Excessive
load + individual
factors
Appropriate
modified
load
Optimised
Load
Adaptation
Strengthen
Reactive tendinopathy
Tendon dysrepair
Degenerative
tendinopathy
Cook & Purdam 2009

7. This is what we want
Optimised
Load
Normal tendon
Pathological tendon
Adaptation
Strengthen the normal part of the tendon
• 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

8. This is what we often get
• Reactive after
unloading
Mechanically
weaker
tendon
– 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
Normal
or
excessive
load
+/-­‐
individual
factors
Unloaded
Normal tendon
Reac<ve
tendinopathy

9. What about the commonest clinical
presentation?
• An
increase
in
pain
is
most
likely
to
be
a
degenera<ve
lesion
Your key forward
with
some
reac<ve
aspects
who has occasional
• What
causes
a
degenera<ve
starts ecome
Achilles tendon paintendon
to
ba reac<ve?
• Mismatch
between
load
tolerance
and
capacity
of
the
plyometric program andt
then hobbles
tendon
and
the
load
placed
on
i
• egenera<ve
tendon
bears
liEle
oad
in forDtreatment a couple lof days later
Normal
tendon
Degenera(ve
area
Reac(ve
tendon
Degenera(ve
area

10. Management of in season
tendinopathy

11. 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

12. Treating tendons in season
• Challenges
– Full rehabilitation is impossible
– Kinetic chain dysfunction
increases over season
– Activated tendon difficult to settle
when abusive loads continue
Visnes
et
al
2005
• Research
– Eccentric exercises do not
help
» Visnes et al 2005, Fredberg et
al
– ESWT does not help
» Zwerver et al 2011
Zwerver
et
al
2011

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. Diagnosis – staging the pathology
Reactive tendinopathy

22. Diagnosis – staging the pathology
Reactive on degenerative pathology
January
August
Pathological
lesion
has
not
changed
over
3
years.
The
tendon
has
had
no
symptoms
between
January
and
August

23. 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

24. Monitoring recovery
31st
Jan,
2011
Prox
Mid
11th
Jun,
2012
14th
Jan,
2013

25. Monitoring recovery
Overall
echopa2ern
for
R
patellar
tendon
100%
Percentage
of
each
echotype
90%
80%
70%
60%
50%
40%
30%
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%

26. Monitoring change in structure
before symptoms
10th
Dec,
2012
17th
Dec,
2012
19th
Feb,
2013
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
Black
Blue
Red
Green

27. What else can we use for in
season tendinopathy?
• Medications
– Affect the tendon response
• Injections
– Affect the tendon response
– Analgesia
• Adjunct treatments
– Analgesia

28. 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)

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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