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Lower Extremity Tendinopathy

Michael O’Hearn PT, OCS, FAAOMPTmohearn@lakelandhealth.org

To be covered today…

• Definitions• Medical considerations for tendon pain• What causes the pain?• Do tendons heal?• The role of imaging• New(ish) concepts for treatment• General principles for rehab• Gluteal tendinopathy• Patellar tendinopathy• Achilles tendinopathy

What’s in a name?

• Tendinitis

• Tendinosis

• Tendinopathy

Medical Causes of Tendinopathy

• Systemic inflammatory conditions

• Medications

• Menopause

What causes the pain of tendinopathy?

• Not well understood – “elusive”

• Asymptomatic tendons rupture

• Deep tendon tissue lacks sensory innervation

• Pain & mechanical load are related

• Paracrine signaling by the tendon cells

• Sensitize mechanoreceptors near the peritendon?

Rio E Sports Med 2014

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What causes the pain of tendinopathy?

• Increased production of proteoglycans from injury will bind water causing the tendon to swell

→ Stimulates C fibers

→ Change in potassium & hydrogen concentrations

• More proteoglycans disrupts communication between cells altering neuronal excitability

• Pain mostly classified as peripheral nociceptive

• Some evidence of central sensitization

Rio E Sports Med 2014

Central Sensitization in Tendinopathy?

• Probably not as prominent as in other chronic conditions due to intermittent nature of the pain (Rio 2014)

• Patellar tendinopathy - increased vibration detection & increased sensitivity to pinprick testing (van Wilgen

2013)

Central Sensitization in Tendinopathy?

• Reduced conditioned pain modulation with Achilles tendinopathy? (Tompra 2015)

• Compared changes in PPTs in individuals with and without AT after a cold pressor test

• PPT measured at tendon

• Both groups had raised PPTs

• Greater in non-injured group

• Reviewed 20 studies

• 17 were of lateral epicondylalgia – results pooled for meta-analysis

British Journal of Sports Medicine 2014

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Is Imaging Helpful? Do tendons heal?

• Limited reversibility (Cook 2016)

• Does not seem to be a co-relation between structural changes and positive clinical outcome (Drew 2014)

• An exception may be with those that undertake a HSR (heavy slow resistance) routine (Kongsgaard 2009)

A Better Clinical Understanding of Tendinopathy

• Reactive Tendinopathy vs Reactive on Degenerative Tendinopathy

Cook et al Br J Sports Med 2016

A Better Clinical Understanding

• Reactive on Degenerative Tendinopathy

Clinical Implications

• Rehabilitation interventions should address…

• 1. Pain

• 2. Improving function and load capacity

• 3. Structure

New(ish) Concepts in Understanding and Treatment of Tendinopathy

• Compression & tendinopathy

• Motor control and tendon injury

• Isometric exercise

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The Role of Compression in Tendinopathy

• Many tendinopathies occur near but not at their insertion

Tendon Anatomical Site of Compression

Position of Compression

Achilles insertion Superior calcaneus Ankle dorsiflexion

Tibialis posterior Medial malleolus Anatomically permanent pivot

Hamstring (upper) Ischial tuberosity Hip flexion

Gluteus medius & minimus

Greater trochanter Hip adduction

Adductor longus/rectusabdominus

Pubic ramus Hip abduction/extension

Peroneal tendons Lateral malleolus Anatomically permanent pivot

Quadriceps Femoral condyle Deep knee flexion

Adapted from Cook & Purdham 2012

Compression

• Probably not true enthesopathies?

• Injury seems to occur over bony prominence before the insertion

• Occurs at transition from fibrocartilage to tendon

• Deep to superficial

Cook & Purdham Br J Sports Med 2012

Clinical Implications

• This stretch may not help someone with high hamstring tendinopathy

• Relieving compression component in early stages may be key to recovery

Clinical Implication: This stretch and this sleeping posture may delay recovery from gluteal tendinopathy

Tendinopathy & Motor Control

• Change in pain with nociceptive barrage

• Individuals with tendinopathy have both increased excitation and inhibition of the motor pool in the affected limb.

• Increased corticospinal excitation of the unaffected side with interhemispheric inhibition of the injured side

• ? Biological advantage

Rio 2015

Cortical inhibition

• Do auditory cues reduce inhibition?

• Use of a metronome

• What about music?

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Motor Control or Pain First?

• Better jumpers have greater risk for developing patellar tendinopathy (Visnes 2013)

• Individuals with PT have greatercorticospinal activity than those with anterior knee pain (Rio

2016)

Motor Control or Pain First?

• Neither group had pain provoked during testing

• No difference in force production

• Protect tendon?

• “On-off” with patellar tendinopathy

Isometric Exercises Make a Comeback

• May be a useful source of exercise induced analgesia

Isometric Exercise & Analgesia

• Naugle KM et al Pain Med 2014

• A 3 minute isometric handgrip at 25% MVC

• Increased forearm PPTs

• Reduced pain perception of heat stimuli

• Exercise induced analgesia (EIA)

• May reduce PPT on contralateral side (Koltyn 2007)

• Isometric vs Isotonic exercise

• Isometric = 5 x 45 sec holds at 70% MVC

• Isotonic = 4 x 8 reps (100% 8 RM)

• Assessed pain after a single leg decline squat

Br J Sports Med 2015

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Tendon Neuroplastic Training General Principles of Tendon Rehabilitation

• 1. Set realistic time frames

• 2. Stable versus irritable

• 3. Pain ≠ damage

• 4. Unload

• 5. Identify chain deficits

• 6. Progress load

• 7. Prevention

1. Set Realistic Time Frames

• Think 12 months (Beyer 2015)

• Prevent reactive tendinopathy progressing

2. Stable versus Irritable

• How long does the pain last after loading?

• Reactive versus Reactive on Degenerative

• Acute reactive tendinopathy needs active rest!

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3. Pain ≠ damage

• Set pain level guidelines

4. Unload

• Decrease compressive component

– E.g. Heel raise for insertional tendinopathy of Achilles

– E.g. Decreased sitting for high hamstring tendinopathy

– E.g. Sleep with pillow between knees for gluteal tendinopathy

• Rest – very important for reactive

• Load well leg?

Unload: A helpful stretch? Unload: Sleeping position…

5. Identify Chain Deficits

• Weak hip extensors in patellar tendinopathy?

• Weak hip extensors & abductors in Achilles tendinopathy?

• Weak trunk muscles in gluteal tendinopathy?

• Decreased hip extension in Achilles tendinopathy?

6. Progress load

• Running probably doesn’t load sufficiently

• ? Isometrics → Isotonic-concentric →Isotonic-eccentric

• ? High slow resistance (HSR)

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7. Prevention

• Maintaining the strength program is essential

• Be careful with eccentrics in season

A Closer Look at Some Common Tendinopathies

• 1. Gluteal tendinopathy

• 2. Patellar tendon

• 3. Achilles tendon

Gluteal Tendinopathy

Gluteal Tendinopathy (“Trochanteric Bursitis”)

• Gluteal tendinopathy

• Greater trochanter pain syndrome (GTPS)

• Generally Accepted Characteristics (Bird et al 2001, Strauss et al 2010)

– Lateral hip pain (unilateral or bilateral)

– Female 4:1

– Usually patient age between 4th & 6th decades

– Pain increased by

• Lying on affected side

• Stairs

• Walking / standing

Bursal Pain?

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Tendon pain?

What is causing the pain?

Most likely is a tendinopathy and not an inflammatory bursitis

Insertional tendinopathy with a compression component (Grimaldi

2015)

Bursal distension usually not noted in the absence of gluteus medius tears (Bird et al 2001)

Like the rotator cuff?

Area of secondary hyperalgesia?

The rotator cuff of the hip?

• Tears on undersurface where tensile stress is less

• Load shielding

• Tensile load increases with abduction

Grimaldi JOSPT 2015

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Clinical Presentation

• Segal N et al 2007

– Subjects were part of a longitudinal study investigating knee OA onset

– GTPS was associated with…

• Female

• Low back pain

• Iliotibial band tenderness

• Knee pain or knee OA

• Not associated with high BMI or loss of hip IR

Clinical Examination• Gait

• Increased hip adduction moment causing greater pelvic obliquity (Allison 2016)

• Pain on single leg stance

• Pain within 30 seconds of SLS predictive of MRI verified gluteal tendinopathy (+LR 12) (Grimaldi 2016)

• Pre-SLS strategies more noticeable & predictive of abductor weakness

• Foot to midline – pelvic shift

• Compensations while standing may be difficult to see

• (Hip adduction 4.70, Pelvic obliquity 2.90)

Gait & Posture 2016

• Weakness is bilateral

• 32% of symptomatic hip

• 23% of uninvolved hip

• 68% reported pain but only 20% found it limiting

Med Sci Sports Exerc 2016

• Hip is abducted 200, extended 100 & in full IR with knee at 450

• A positive test is a ≥ 10 cm drop

• Sn 89%, Sp 97%

Resisted Hip Abduction in Adduction

• Pain over lateral hip with resisted abduction in an adducted postion

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Treatment

• Physical therapy

• Cortisone injections

• Surgery

PT Treatment

• No stretching – even TFL/ITB feel “tight”

• Correct sleeping posture

• Look carefully at lumbar spine

• Start with isometrics?

• Progress to active strengthening

• Lumbar stabilization

Grimaldi JOSPT 2015

Grimaldi JOSPT 2015

Grimaldi JOSPT 2015

• Reviewed 24 articles

• Concluded:

– Most cases improve with conservative treatment without surgery

– Cortisone injection 1st order of treatment??????

Clin J Sports Med 2011

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Treat the Lumbar Spine

• A high percentage have LBP

AND

• High percentage of females who have diagnosis of chronic low back pain also have lateral hip pain (Sayegh 2004)

Lumbar Facet Joints (Fukui et al, 1997)

Referred pain distribution. 1, lumbar spinal region; 2,

gluteal region; 3, trochanter region; 4, lateral thigh region; 5, posterior thigh region; 6, groin region.

Hip Weakness and Lumbar Spine (Sasaji 2012)

• Glut med weakness in patients with L4/5 disc herniation or central canal stenosis

• Decompressive surgery improved hip abductor strength

Disc herniation (n-11) Central canal stenosis (n=15)

Age 56 ± 18 72 ± 7

Mean pre-op MMT 2.7 2.6

Mean post-op MMT 4.8 4.3

Outcome Tool: The VISA-G

• Used structured interviews to develop a questionnaire

• Reliability of 0.82

• No floor or ceiling effect

Manual Therapy 2015

Patellar Tendinopathy

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Patellar Tendinopathy

• High prevalence – 45% & 32% of elite volleyball & basketball players respectively (van Ark 2015)

• Point tender over inferior pole of patella

• Pain with single leg decline squat

– Sn 62.5%, Sp 85.1% (De Michelis Mendonica 2016)

• Isometric knee extensor exercises gave immediate pain relief on a single leg decline squat that lasted for at least 45 minutes (Rio 2015)

• A 4 week program of either isometric or isotonic strength training raised VISA-P scores and reduced pain on the single leg decline squat test (van Ark 2015)

Knee Isometrics

• 45 second hold x5

• With metronome?

• It can’t be a distraction

• RCT, N=39 (13 per group)

• Cortisone (2 injections), Eccentric or HSR exercise

• Increase in pain during exercise was acceptable as long as it did not increase after cessation of exercise

• Pain during recreational exercise not to exceed 3/10

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Results

Follow up was around 6 months

Cortisone for tendons?

Bisset et al BMJ 2006

Outcome Tool: VISA-P

• Scores less than 80 usually indicate symptomatic tendinopathy

• MCID = 13 points

Achilles Tendinopathy Achilles Tendinopathy

• Mid-belly (A) versus Insertional (B)

• 50% incidence among elite endurance runners

• 6 % amongst sedentary individuals

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A Compressive Component?

• Plantaris tendon?

• Stiffer than the Achilles tendon and may place a shearing or compressive load where it is invaginated in the Achilles tendon

• Can cause a tendinopathy in either or both tendons

Cook 2012

Achilles Tendinopathy Exercises

• 3 sets of 15 or lift heavy? Heavy = Heavy Slow Resistance (HSR)

Which exercises are best?

• No difference in 52 week outcomes between Eccentric & HSR protocols (Beyer 2015)

• Better compliance & satisfaction with HSR regime

• Is there really eccentric loading at the tendon?

Pain with Running

Pain on 0-100 mm VAS

Adapted from Beyer 2015

Don’t forget about the hip extensors Or the Soleus

• The relative demand on the soleus increases with greater walking and running speeds (Lai 2015)

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Lai J Appl Phyisol 2015

• Greater levels of soleus activity resulted in shorter fascicles which facilitated greater tendon stretch and recoil (Lai 2015)

Load the Achilles through the knee as well as the ankleWhat else might be helpful?

• Soft tissue techniques –tendon & ankle plantarflexors

• Joint mobilization

• Better way to improve ROM than stretching for insertional tendinopathy?

• Re-assess pain on toe walking?

Outcome Tool VISA-A Questions?