Achilles tendinopathy
03/04/16
Diacor UrheilulääkeAede 2016
Achilles tendinopathy - physiotherapy Peter Halén Sports Physiotherapist (Cert.) OMT 01 - 02.04.2016 Finnish Sports Physiotherapists AssociaAon FSPA
Many ques8ons remain… Our understanding of chronic tendinopathy is inadequate and this lends itself to debate. While our models of chronic tendinopathy are helpful they are all incomplete and all have unanswered quesAons…
1
03/04/16
• Achilles tendon is reported for the take- off in gymnasAcs at higher than 9000 N (Brueggemann, 1985) > 15 x BW • Transfer of angular momentum to linear momentum during the take- off • DirecAon change of center of mass path of >45° during the 120 milliseconds ground contact.
IOC Handbook of Sports Medicine and Science, Gymnas8cs; Dennis J. Caine, Keith Russell, Liesbeth Lim; Wiley&Blackwell 2012
Tendinopathy
• Achilles tendon injury can occur in the mid-tendon. • However, most tendon pathology and pain arise tendon aRachment to bone.
J L Cook, C R Purdam; Br J Sports Med 2009;43:409-416.doi10.1136/bjsm.2008.051193 Is tendon pathology a conAnuum? A pathology model to explain the clinical presentaAon of load-induced tendinopathy
2
03/04/16
Tendinopathy • Contradictory evidence exists on the substances responsible for pain generaAon, the source of these substances and the pathways of transmission to the central nervous system.
J L Cook, C R Purdam; The challenge of managing tendinopathy in compeAng athletes BJSM Online First, published on May 10, 2013 as 10.1136/bjsports-2012-092078
Isometric / pain management • Isometric • Reduced pain and corAcal inhibiAon • 4-5 x 45 sec x 5 7 daily • Use throughout rehab for pain
E.Rio, Isometric exercise induces analgesia… BJSM 2014
3
03/04/16
Know pain, know gain… How much pain is ok?
Thomee R, 1997 A Comprensive treatment approach for patellofemoral pain synndrome in young athletes, Phys Ther Dec;77(12):169-703
Acceptable Care Unacceptable • HURT does not equal HARM! • Monitor the 24 hour response! Adam Meakins, Rotator Cuff Tendinopathy Rehab, Shoulder Pain Virtual Conference, September, 2015
Symptoms • Tendon pain is well localized • Referal beyond the tendon seldom, only if associated with a bursa or fat pad. • Tendon pain is provoked by loading / short latency. • Pain experienced when load is applied and aba8ng quickly on removal of the provocaAon (eg, hopping). • Further, it is unusual for a tendon to trigger pain without load or to be painful at night or at rest. J L Cook, C R Purdam; The challenge of managing tendinopathy in compeAng athletes BJSM Online First, published on May 10, 2013 as 10.1136/bjsports-2012-092078
4
03/04/16
Cook JL, Purdam CR. Is tendon pathology a conAnuum? A pathology model to explain the clinical presentaAon of load-induced tendinopathy. Br J Sports Med 2009;43:409–16.
5
03/04/16
Example of overloads on the Achilles tendon Type of overload
Example
Single high-intensity session
Repeated uphill running
Increased frequency of training
High-load training more than five Ames a week
Different drills
Rapid introducAon of plyometric training
High loads when faAgued
Sprints at the end of training
Change in footwear
Shoes that provide less support, or sAff soles, shoes that mandate a forefoot strike or have a lower heel wedge
Change in surface
Running in sok-sand, running on uneven surfaces
Training with muscle sAffness
Training sessions following heavy-weight session
J L Cook, C R Purdam; The challenge of managing tendinopathy in compeAng athletes, BJSM Online First, published on May 10, 2013 as 10.1136/ bjsports-2012-092078
EvaluaAon / assessment • VISA-A
– Victorian InsAtute of Sports Assessment – Achilles quesAonnaire
Br J Sports Med 2001;35:335-341
J.M.Robinson, J.L.Cook, C.Purdam, P.J.VisenAni, J.Ross, N. Maffulli, J.E.Taunton, K.M.Khan
The VISA-A quesAonnaire: a valid and reliable index of the clinical severity of Achilles Tendinopathy
• VISA-A-F
– The Finnish version
• Clinical assessment • FuncAonal tesAng
6
03/04/16
DifferenAal diagnosis • InserAonal tendinopathy: • MidporAon tendinopathy: – Bursa – Paratenon – Haglund – Fat pad – Plantaris – TracAon spur – Sural nerve – Severe’s – Rupture / parAal rupture – Soleus
Risk factors • Intrinsic:
Previous injury Increasing age Gender GeneAc predisposiAon Muscle weakness Tendon structure Increased BMI and/or adiposity • Diabetes • MedicaAon – steroids • • • • • • •
• Extrinsic: • • • •
“Training errors” Cold weather training Footwear Training surface
• Lower extremity biomechanics
7
03/04/16
8
03/04/16
What are the new findings? We found that customised foot orthoses provide no benefit for reducing pain and improving funcAon in people with mid-porAon Achilles tendinopathy Customised foot orthoses are not recommended for mid-porAon Achilles tendinopathy in the seong of paAents undertaking prescribed eccentric exercises.
9
03/04/16
NRFS papern was associated with greater Achilles strain and strain rate, and this translated to increase stress (force per square cm). Peak strain and stress reduced when they ran at 5% above their preferred cadence, regardless of foot strike. Clinical interpretaAon: the authors suggest that using a RFS strategy and increasing cadence may be useful strategies to manage or prevent Achilles tendinopathy. This is a case of shiking stress versus reducing stress
Phys Med Rehabil Clin N Am. 2016 Feb;27(1):237-317. doi: 10.1016/j.pmr. 2015.08.005.
Malalignment Syndrome in Runners Schamberger W.
Division of Physical Medicine and RehabilitaAon, Faculty of Medicine, University of BC, Vancouver, Canada
More than 80% of runners are out of alignment. An awareness of pelvic malalignment and the the malalignment syndrome is essenAal to allow one to provide proper care of a runner. The validity of any research into the biomechanics of running should be quesAoned if the study has failed to look at whether pelvic malalignment was present...
10
03/04/16
Running
• Average 4-500N • Per stride = 6 x BW • Peak 9000 N = 12 x BW
Achilles tendon loading / 10 km run • Average Ame 50 min • Average cadence of 150 • 150 x 50 = 7500 steps • 7500/2 = 3750 steps per leg • Achilles load = 4500N per step x 3750 steps = 16,875,000N
• 1,685 Million kg per leg
Seth O´Neill, Lower Limb Tendinopathy Virtual Conference 2015
11
03/04/16
S ol e u s c on t ap p r r. 5 0% ibutes verA of cal s upp total ort forc e
Seth O´Neill, Lower Limb Tendinopathy Virtual Conference 2015
Rotated Structure of Achilles Tendon
12
03/04/16
Soleus apachment
Stage 1 Isometrics to reduce pain Indica8ons
Pain
• ReacAve • ReacAve on degen
Implementa8on Build up 45 seconds x 5 2-3 x a day “Painkiller” 2 mins rest important
Jill Cook; Structure, funcAon and pain in tendinopathy at PrevenAon – Mission Possible; Young Athlete ToleraAng the Tendon Challenge, FSPA Congress, Helsinki 2016
13
03/04/16
Stage 2: Strength (isotonic) Indica8ons
Implementa8on
Considera8ons
Pain is stable on morning test Pain is sepled from peak
4 x 6-8 Slow Heavy Single leg
• Avoid compressive loads • Avoid speed • Encourage evening to avoid calf faAgue during day
Examples - weighted calf raises (conc / ecc), seated calf raise • KineAc chain – Address deficits
• Add funcAonal exercises – Once weights are good
– Add endurance Jill Cook; Structure, funcAon and pain in tendinopathy at PrevenAon – Mission Possible; Young Athlete ToleraAng the Tendon Challenge, FSPA Congress, Helsinki 2016
Stage 3: Energy storage Indica8ons
Implementa8on
Considera8ons
Pain is stable on morning test (may not be zero) Symmetry in mm bulk? This may takes a long Ame Good strength eg 25 raises single leg, 1.5 x BW on leg press, addressed deficits
Every 2-3 days & assess response Must keep strength going Consider as much a neural reprogramming as muscle/ tendon funcAon
Add / change one thing at a Ame Break up absorpAon and propulsion phase early, add these together later in phase 3.
• Faster stairs, split squats, skipping Jill Cook; Structure, funcAon and pain in tendinopathy at PrevenAon – Mission Possible; Young Athlete ToleraAng the Tendon Challenge, FSPA Congress, Helsinki 2016
14
03/04/16
Stage 4: Sports specific / elasAc funcAon Indica8ons
Implementa8on
Considera8ons
Pain stable on morning test (may not be zero) Good strength eg 25 raises single leg, 1.5 x BW on leg press, Addressed deficits Dealing with power
Every 2-3 days & assess response Must keep strength going
Add / change one thing at a Ame Don’t add load & speed together May mix Phase 3 and 4 exs Consider tendon capacity
• DuraAon, frequency, change direcAon, speed Jill Cook; Structure, funcAon and pain in tendinopathy at PrevenAon – Mission Possible; Young Athlete ToleraAng the Tendon Challenge, FSPA Congress, Helsinki 2016
Gsm. 0500 522 561 Puh. (02) 437 1311 Fax (02) 438 0112 Email: [email protected].fi
15
03/04/16
Training bout
Strength
Training Bout 2
Training Bout 3
Go to failure…
OpAmal training
Time
• Level and intensity of the training • Individual physiology Adam Meakins, Rotator Cuff Tendinopathy Rehab, Shoulder Pain Virtual Conference, September, 2015
The wheel of tendons Guru juice 3%
InjecAons 5% MedicaAon 10%
Electrotherapy 1%
Taping / bracing 5%
Load capacity / load tolerance 70% of short- / long term recovery
Massage 5%
Ice 1%
Jill Cook; Structure, funcAon and pain in tendinopathy at PrevenAon – Mission Possible; Young Athlete ToleraAng the Tendon Challenge, FSPA Congress, Helsinki 2016
16
03/04/16
Take home • Tendon hate rest! • Tendon fail because of load – not pain! • In front of a tendon there is bone and behind a muscle! • If you do not load a tendon – it forgets it is a tendon! • Treat the person not a tendon!
17
Diacor UrheilulääkeAede 2016
Achilles tendinopathy - physiotherapy Peter Halén Sports Physiotherapist (Cert.) OMT 01 - 02.04.2016 Finnish Sports Physiotherapists AssociaAon FSPA
Many ques8ons remain… Our understanding of chronic tendinopathy is inadequate and this lends itself to debate. While our models of chronic tendinopathy are helpful they are all incomplete and all have unanswered quesAons…
1
03/04/16
• Achilles tendon is reported for the take- off in gymnasAcs at higher than 9000 N (Brueggemann, 1985) > 15 x BW • Transfer of angular momentum to linear momentum during the take- off • DirecAon change of center of mass path of >45° during the 120 milliseconds ground contact.
IOC Handbook of Sports Medicine and Science, Gymnas8cs; Dennis J. Caine, Keith Russell, Liesbeth Lim; Wiley&Blackwell 2012
Tendinopathy
• Achilles tendon injury can occur in the mid-tendon. • However, most tendon pathology and pain arise tendon aRachment to bone.
J L Cook, C R Purdam; Br J Sports Med 2009;43:409-416.doi10.1136/bjsm.2008.051193 Is tendon pathology a conAnuum? A pathology model to explain the clinical presentaAon of load-induced tendinopathy
2
03/04/16
Tendinopathy • Contradictory evidence exists on the substances responsible for pain generaAon, the source of these substances and the pathways of transmission to the central nervous system.
J L Cook, C R Purdam; The challenge of managing tendinopathy in compeAng athletes BJSM Online First, published on May 10, 2013 as 10.1136/bjsports-2012-092078
Isometric / pain management • Isometric • Reduced pain and corAcal inhibiAon • 4-5 x 45 sec x 5 7 daily • Use throughout rehab for pain
E.Rio, Isometric exercise induces analgesia… BJSM 2014
3
03/04/16
Know pain, know gain… How much pain is ok?
Thomee R, 1997 A Comprensive treatment approach for patellofemoral pain synndrome in young athletes, Phys Ther Dec;77(12):169-703
Acceptable Care Unacceptable • HURT does not equal HARM! • Monitor the 24 hour response! Adam Meakins, Rotator Cuff Tendinopathy Rehab, Shoulder Pain Virtual Conference, September, 2015
Symptoms • Tendon pain is well localized • Referal beyond the tendon seldom, only if associated with a bursa or fat pad. • Tendon pain is provoked by loading / short latency. • Pain experienced when load is applied and aba8ng quickly on removal of the provocaAon (eg, hopping). • Further, it is unusual for a tendon to trigger pain without load or to be painful at night or at rest. J L Cook, C R Purdam; The challenge of managing tendinopathy in compeAng athletes BJSM Online First, published on May 10, 2013 as 10.1136/bjsports-2012-092078
4
03/04/16
Cook JL, Purdam CR. Is tendon pathology a conAnuum? A pathology model to explain the clinical presentaAon of load-induced tendinopathy. Br J Sports Med 2009;43:409–16.
5
03/04/16
Example of overloads on the Achilles tendon Type of overload
Example
Single high-intensity session
Repeated uphill running
Increased frequency of training
High-load training more than five Ames a week
Different drills
Rapid introducAon of plyometric training
High loads when faAgued
Sprints at the end of training
Change in footwear
Shoes that provide less support, or sAff soles, shoes that mandate a forefoot strike or have a lower heel wedge
Change in surface
Running in sok-sand, running on uneven surfaces
Training with muscle sAffness
Training sessions following heavy-weight session
J L Cook, C R Purdam; The challenge of managing tendinopathy in compeAng athletes, BJSM Online First, published on May 10, 2013 as 10.1136/ bjsports-2012-092078
EvaluaAon / assessment • VISA-A
– Victorian InsAtute of Sports Assessment – Achilles quesAonnaire
Br J Sports Med 2001;35:335-341
J.M.Robinson, J.L.Cook, C.Purdam, P.J.VisenAni, J.Ross, N. Maffulli, J.E.Taunton, K.M.Khan
The VISA-A quesAonnaire: a valid and reliable index of the clinical severity of Achilles Tendinopathy
• VISA-A-F
– The Finnish version
• Clinical assessment • FuncAonal tesAng
6
03/04/16
DifferenAal diagnosis • InserAonal tendinopathy: • MidporAon tendinopathy: – Bursa – Paratenon – Haglund – Fat pad – Plantaris – TracAon spur – Sural nerve – Severe’s – Rupture / parAal rupture – Soleus
Risk factors • Intrinsic:
Previous injury Increasing age Gender GeneAc predisposiAon Muscle weakness Tendon structure Increased BMI and/or adiposity • Diabetes • MedicaAon – steroids • • • • • • •
• Extrinsic: • • • •
“Training errors” Cold weather training Footwear Training surface
• Lower extremity biomechanics
7
03/04/16
8
03/04/16
What are the new findings? We found that customised foot orthoses provide no benefit for reducing pain and improving funcAon in people with mid-porAon Achilles tendinopathy Customised foot orthoses are not recommended for mid-porAon Achilles tendinopathy in the seong of paAents undertaking prescribed eccentric exercises.
9
03/04/16
NRFS papern was associated with greater Achilles strain and strain rate, and this translated to increase stress (force per square cm). Peak strain and stress reduced when they ran at 5% above their preferred cadence, regardless of foot strike. Clinical interpretaAon: the authors suggest that using a RFS strategy and increasing cadence may be useful strategies to manage or prevent Achilles tendinopathy. This is a case of shiking stress versus reducing stress
Phys Med Rehabil Clin N Am. 2016 Feb;27(1):237-317. doi: 10.1016/j.pmr. 2015.08.005.
Malalignment Syndrome in Runners Schamberger W.
Division of Physical Medicine and RehabilitaAon, Faculty of Medicine, University of BC, Vancouver, Canada
More than 80% of runners are out of alignment. An awareness of pelvic malalignment and the the malalignment syndrome is essenAal to allow one to provide proper care of a runner. The validity of any research into the biomechanics of running should be quesAoned if the study has failed to look at whether pelvic malalignment was present...
10
03/04/16
Running
• Average 4-500N • Per stride = 6 x BW • Peak 9000 N = 12 x BW
Achilles tendon loading / 10 km run • Average Ame 50 min • Average cadence of 150 • 150 x 50 = 7500 steps • 7500/2 = 3750 steps per leg • Achilles load = 4500N per step x 3750 steps = 16,875,000N
• 1,685 Million kg per leg
Seth O´Neill, Lower Limb Tendinopathy Virtual Conference 2015
11
03/04/16
S ol e u s c on t ap p r r. 5 0% ibutes verA of cal s upp total ort forc e
Seth O´Neill, Lower Limb Tendinopathy Virtual Conference 2015
Rotated Structure of Achilles Tendon
12
03/04/16
Soleus apachment
Stage 1 Isometrics to reduce pain Indica8ons
Pain
• ReacAve • ReacAve on degen
Implementa8on Build up 45 seconds x 5 2-3 x a day “Painkiller” 2 mins rest important
Jill Cook; Structure, funcAon and pain in tendinopathy at PrevenAon – Mission Possible; Young Athlete ToleraAng the Tendon Challenge, FSPA Congress, Helsinki 2016
13
03/04/16
Stage 2: Strength (isotonic) Indica8ons
Implementa8on
Considera8ons
Pain is stable on morning test Pain is sepled from peak
4 x 6-8 Slow Heavy Single leg
• Avoid compressive loads • Avoid speed • Encourage evening to avoid calf faAgue during day
Examples - weighted calf raises (conc / ecc), seated calf raise • KineAc chain – Address deficits
• Add funcAonal exercises – Once weights are good
– Add endurance Jill Cook; Structure, funcAon and pain in tendinopathy at PrevenAon – Mission Possible; Young Athlete ToleraAng the Tendon Challenge, FSPA Congress, Helsinki 2016
Stage 3: Energy storage Indica8ons
Implementa8on
Considera8ons
Pain is stable on morning test (may not be zero) Symmetry in mm bulk? This may takes a long Ame Good strength eg 25 raises single leg, 1.5 x BW on leg press, addressed deficits
Every 2-3 days & assess response Must keep strength going Consider as much a neural reprogramming as muscle/ tendon funcAon
Add / change one thing at a Ame Break up absorpAon and propulsion phase early, add these together later in phase 3.
• Faster stairs, split squats, skipping Jill Cook; Structure, funcAon and pain in tendinopathy at PrevenAon – Mission Possible; Young Athlete ToleraAng the Tendon Challenge, FSPA Congress, Helsinki 2016
14
03/04/16
Stage 4: Sports specific / elasAc funcAon Indica8ons
Implementa8on
Considera8ons
Pain stable on morning test (may not be zero) Good strength eg 25 raises single leg, 1.5 x BW on leg press, Addressed deficits Dealing with power
Every 2-3 days & assess response Must keep strength going
Add / change one thing at a Ame Don’t add load & speed together May mix Phase 3 and 4 exs Consider tendon capacity
• DuraAon, frequency, change direcAon, speed Jill Cook; Structure, funcAon and pain in tendinopathy at PrevenAon – Mission Possible; Young Athlete ToleraAng the Tendon Challenge, FSPA Congress, Helsinki 2016
Gsm. 0500 522 561 Puh. (02) 437 1311 Fax (02) 438 0112 Email: [email protected].fi
15
03/04/16
Training bout
Strength
Training Bout 2
Training Bout 3
Go to failure…
OpAmal training
Time
• Level and intensity of the training • Individual physiology Adam Meakins, Rotator Cuff Tendinopathy Rehab, Shoulder Pain Virtual Conference, September, 2015
The wheel of tendons Guru juice 3%
InjecAons 5% MedicaAon 10%
Electrotherapy 1%
Taping / bracing 5%
Load capacity / load tolerance 70% of short- / long term recovery
Massage 5%
Ice 1%
Jill Cook; Structure, funcAon and pain in tendinopathy at PrevenAon – Mission Possible; Young Athlete ToleraAng the Tendon Challenge, FSPA Congress, Helsinki 2016
16
03/04/16
Take home • Tendon hate rest! • Tendon fail because of load – not pain! • In front of a tendon there is bone and behind a muscle! • If you do not load a tendon – it forgets it is a tendon! • Treat the person not a tendon!
17
