1. Tendinopathy and Joint Replacement Ch 15 & 16

2. Structure Made of collagen bundles Synovial sheaths surround those subjected to higher than normal friction –Achilles and biceps –Sheaths, when present, contain blood supply for tendon –2 layers with synovial fluid in the middle Tendinopathy rarely happens at the bone/muscle junction

3. Etiology Theories 1. Mechanical stresses repeatedly stress within normal stress ranges but cause fatigue leading to failure –Fibroblasts come in and cause scar tissue –Does not explain how stress applied at sub maximal level causes a problem Lack of good vascular supply –Best supply at junctions with muscle/bone –Most reduced vascularity & most tendinopathy Achilles, patellar, posterior tibial, biceps, supraspinatus –Tendinopathy causes hypervascularity but inc blood supply promotes pain and chronicity, does not aid in repair

4. Etiology Theories cont Neurally-based –Substance P in tendinopathy sites Pain neurotranmitter –Chronic tendon overuse could lead to disproportionate neural facilitation to promote mast cell activity Mast cells increase local blood flow and fibroblast production

5. Factors Extrinsic –Excessive or frequent load application –Inappropriate equipment or footwear –Training error –occupation Intrinsic –Age –Gender –Pathomechanics –Genetic or acquired systemic diseases Diabetes, marfans

6. Examples Increase hill running in speed, distance, incline Execution errors- hitting a tennis backhand late Shoes too tight Turf vs wood vs concrete Too short computer desk = carpal tunnel Excessive pronation Weak rotator cuff Inappropriate equipment Structure abnormalities or muscle imbalance

7. ***An increased work load of 10-15% a week is usually safe*** Biceps tendon site of tendinopathy is at transverse ligament due to being compressed against bone

8. How do we help? Take a thorough history –List all possible factors- to prevent reoccurrence, address and change each factor –Aside from the athlete, who can we ask? Where is the tendon in the healing process? –Hard to tell –Less aggressive better –Trial and error Respect pain and swelling

9. Athlete complains of Achilles pain while walking to class –Very little exercise Athlete complains of Achilles pain only while running –Can tolerate exercise

10. Classifications of Tendinopathy Class Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 IntensityMildMildModerateModerateSevereSevere PainNone W/ extreme exertion, stops when activity stops W/ extreme exertion, stops 1-2 hrs post W/ mod activity, stops 4-6 hrs post Rapid inc w/ any exertion up to 24 hrs post W/ ADL Performance limitation NoneNone No change in normal workout, limits extreme Unable w/ normal workout Unable any sport or activity Difficulty with ADL

11. Eccentrics Promote tendon health Reduce S&S by reversing neovascularization (Proliferation of blood vessels in tissue not normally containing them. )

12. Treatment Phases Classification CV and uninvolved Pain control Eccentric Exercise ROM exercise Strength and endurance Agility Sport specific, functional 5,6XX 3,4XXXX 2,3XXXXX 2,3XXXXXX 1,2XXXXXXX

13. Eccentric Exercises Vary speed Start slow and inc every 2 days until fast speed achieved by end of week –Greater the speed, greater the force –Gradually overload and inc strength output and tendon’s tolerance improves Best results occur when pt has little to no pain after 1 st set

15. https://www.youtube.com/watch?v=vJGJJ OA1Me0 https://www.youtube.com/watch?v=vJGJJ OA1Me0 https://www.youtube.com/watch?v=rb5axf V5UfU

16. Indications for Joint Replacement Also called “arthroplasty” Arthritis –May try injections prior –Debridement –Last resort for <70YO Won’t cement for <70yo

17. Overview of Rehab Hip –Begin rehab the day following Sx –Isometrics –SLR, heel slide, Short arc quad –Limitations in ROM Knee –CPM –May have 3-5 day stay in hospital –If Pt. will be sedentary, 100 degrees flexion is goal 120-130 if active –Aquatic exercises –May return to activity 4-6 month post (depends on doctor)

18. Hip/Knee/Shoulder replacement rehabilitation in a nutshell Refer