1. Various physical therapies in TENDINOPATHY Jakub Jeníček

2. 2 Objectives Definition of the clinical condition and diagnostics Basics of patophysiology Most common types of tendinopathy Goals of treatment Various treatment approaches – from conventional up to advanced ones

3. 3 Tendinopathy – definition and diagnostics primary disorder of the tendons – common, often chronic, difficult treatment diagnosis is in most clinical  activity-related pain, pain at rest  decreased function, ADL  stiffness of the tendon  localized swelling  palpable crepitations  muscle tone imbalances

4. 4 Tendinopathy – pathogenesis repetitive or excessive mechanical overloading and subsequent activation of noxious mechanisms tendon loses its reparative capacity inflammation and degeneration work together in the pathogenic cascade confusion in terminology – tendinitis / tendinosis / tendinopathy

5. 5 Tendinopathy – most common types certain tendons are especially susceptible to degenerative pathology:  rotator cuff in the shoulder  forearm extensor tendons (tennis elbow)  forearm flexor tendons (golfer´s elbow)  patella tendon (jumper´s knee)  Achilles tendon  small feet muscles tendon

6. 6 Tendinopathy – epidemiology most commonly diagnosed musculoskeletal disorders (Forde et al., 2005):  tendinopathies (19%)  discopathies (18%)  shoulder bursopathies (15%)  carpal tunnel syndrome (12%)  sum of all other disorders (36%) high lifetime prevalence in sportsmen  tennis (40%!), volleyball (20%)  squash, basketball, soccer, running, jumping, cycling

7. 7 Tendinopathy – therapeutic intervention in many cases remains uneffective – especially when treatment is only analgesic or anti-inflammatory monotherapy! choice of adequate therapy:  phase of disorder - acute / chronic - more inflammatory / degenerative nature  goals of treatment...

8. 8 Tendinopathy – Goals of treatment analgesia reducing inflammation elimination of the swelling tendon structure recovery (elasticity) muscle normotonia, trigger points elimination detection of primary causes of the disorder:  muscle imbalance in segment, hypertonia  incorrect movement stereotypes  overloading activities, ergonomics  other individual factors

9. 9 Tendinopathy – range of treatments Conventional treatment Non-steroidal anti-inflammatory drugs, corticosteroids Biomechanical alterations – braces, taping, Kinesio-taping Cryotherapy, Rest Manual therapy techniques Therapeutic ultrasound Electrotherapy, Iontophoresis Advanced treatment Low-intensity laser therapy Shockwave therapy Stem-cell or gene therapy Platelet-rich plasma Sclerosant injections numerous different types of treatment in literature poor evidence base – mostly empirical findings from clinicians

10. 10 Tendinopathy – treatment in acute stage predominance of inflammation pain, swelling, redness, crepitations typically occurs after prolonged stereotypical work (e.g. screwing) treatment  rest, cryotherapy  orthotics – supportive braces, Kinesio-taping  drugs – NSAId, antiphlogistics, corticosteroids injections  manual therapy techniques  analgesic physical modalities – electrotherapy – TENS, DD, interferential currents  myorelaxant physical modalities – ultrasound or combined therapy ultrasound + electro distinguish acute x chronic tendinopathy!

11. 11 Tendinopathy – clinical suggestions most effective combination of physical modalities for patient with acute tendinopathy: analgesia  electrotherapy – DD currents – sequence of DF (1 min.) + CP (5 min.) x LP (6 min.), polarity reverse in the middle myorelaxation  ultrasound – subaqual application from the distance of 10 cm (1 MHz, 1 W/cm 2, 20% duty factor)  combined therapy (electro + ultrasound) for trigger points – 1 cm 2 ultrasound head (3MHz, 0,5 W/cm 2, 50% duty factor) + large electrode (TENS, f 100 Hz, motor treshold intensity)

12. 12 Tendinopathy – treatment in chronic stage predominance of degeneration pain, structural changes in tendon, stiffness, dysfunction typically occurs after long-term overloading and microtraumatization (incorrect sport load, work position) treatment  manual therapy techniques  physical modalities to modify the structure and promote healing of affected tendon:  laser therapy (anti-inflammatory, analgesic, biostimulation)  shockwave therapy (analgesic, reparative)

13. 13 Tendinopathy – clinical suggestions most effective combination of physical modalities for patient with chronic (degenerative) tendinopathy: analgesia and biostimulation, reparation  laser therapy – focused with laser probe 1.dose 20 J/cm 2, continuous frequency do deliver energy to the tissue 2.dose 10 J/cm 2, pulsed frequency to modulate desired effect structure modification and healing  shockwave therapy – optimum 2 bar in pathologic spot, 2000 pulses with frequency 10 - 15 Hz

14. 14 Thank you for your attention!