REHABILITATION TENDON INJURIES

TABLE 1: CRITERIA TO BE NOTED IN THE CLASSIFICATION OF TENDINOPATHIES

Criterion

Tendon affected Tissue(s) affected

Site Severity Description Eg. Achilles, patellar

Paratenon/tenosynovial sheath Tendon proper

Insertion (enthesis)

Myotendinous junction Midsubstance Insertion

Pain Function

VISA score (imaging findings – see tissue disruption)

Tissue disruption (on diagnostic ultrasound)

Aetiology Chronicity

Additional features Grade 1: <25% Grade 2: 26–50%

Grade 3: >50% (partial rupture) Rupture

See Table 2 Acute: <48 hours

Subacute: 48 hours–2 weeks Chronic

Neovascularisation Calcification:

n Primary (‘Calcific tendinitis’) n Secondary (dystrophic, seen in chronic injuries)

Impingement by bone/ osteophyte

assessment of the patient in relation to posture, asymmetries, strength, functional control and flexibility. More specific examination of the involved tendon entails inspection for swelling, bruising, deformity, muscle wasting, and palpation to identify crepitus in more acute tendinopathies, palpable gaps to suggest tears, sites of reproduction of symptoms, and bony lesions that may cause impingement. Functional assessment follows, including resisted testing, stressing the tendon in different ways to reproduce symptoms and evaluating movement patterns. Examination of equipment (eg. shoes, tennis rackets) and technique (with input from an informed coach if necessary) are also important. Imaging may be helpful, but only

to extend evaluation of the injury rather than to make the diagnosis in the absence of the clinical context, as findings can be misleading at times. As mentioned earlier, monitoring of tendon pain with specific scoring systems can be useful. For example, the VISA and VISA-A scores are used for patellar tendinopathies (1,2).

TABLE 2: INTRINSIC AND EXTRINSIC CAUSES OF TENDON INJURIES

Intrinsic factors

Biomechanical: anatomical and/or functional malalignment

Muscle imbalance Poor technique Hypermobility Hypomobility Poor vascular supply

Disease (eg. seronegative spondyloarthropathies, diabetes)

Fatigued muscles (altered movement patterns)

www.sportEX.net Extrinsic factors

Equipment (eg. poor heel counter causing Achilles tendinitis)

Training patterns (sudden increase in intensity/volume)

Surface (eg. running on uneven surface)

Environment (eg. extremes of temperature)

Immobilisation (tissue atrophy, weakness)

Local steroid injection (mechanical disruption,

reduced collagen synthesis) Non-steroidal anti-

inflammatory drugs (NSAIDs) (can mask injury)

MANAGEMENT OF TENDON INJURIES Musculoskeletal conditioning Management of any tendon injury commences with making an accurate diagnosis and identifying and correcting the underlying causes. Many injuries occur due to training errors (‘too much, too soon’), biomechanical issues, muscle imbalances, weaknesses and asymmetries, lack of good core control and technique errors – or a combination of some of these. These issues must be addressed as a priority. Isolated paratenon complaints often occur as a result of poor biomechanics and sudden excessive overload. The core component of treatment is rehabilitation to address the above factors. Strengthening the muscle tendon unit in a functional way is very important. The literature strongly supports the use of eccentric training programmes as the most effective way to strengthen tendons. This applies to not only mild but also severe tendinopathies, and not only to midsubstance injuries but also to insertional tendinopathies (3,4).

Pain management Some phases of such progressive

strengthening programmes involve a degree of tendon pain. In such situations, the focus should be ensuring pain control in order to allow essential rehabilitation to proceed. Pain management can involve simple modalities of ice post-rehabilitation, analgesics including paracetamol, and other medications. Non-steroidal anti-inflammatory drugs (NSAIDs) are indicated in acute tendinopathies (eg. tenosynovitis), but in chronic central tendinopathies NSAIDs do not have any advantage over basic analgesics. If an NSAID is considered appropriate, then a topical preparation has the advantage of a high degree of tendon penetration in relatively superficial tendons (eg. Achilles tendon, patellar tendon, common extensor tendon of elbow), without the degree of side effects seen with systemic preparations. Other medications used for pain management in chronic tendinopathies include topical glyceryl trinitrate (GTN) patches, which may provide pain relief through nitric oxide release or simply through the vascular supply. In severe chronic tendinopathies, neuropathic pain is often present; strong anti- neuropathic pain medications such as tricyclic agents or gabapentin may be indicated.

Therapeutic ultrasound is the most common electrical modality used in tendon injuries and may induce thermal and non-thermal physical effects in tissues. When therapeutic ultrasound is applied for thermal effects, non- thermal effects also occur but, through alteration of the dose parameters, non- thermal effects can be achieved in the absence of thermal effects. Reported thermal effects of ultrasound upon tissue include increased blood flow, reduction in muscle spasm, increased extensibility of collagen fibres, and a pro-inflammatory response. It is estimated that thermal effects occur with elevation of tissue temperature to 40–45°C for at least 5 minutes. Excessive thermal effects, seen in particular with higher ultrasound intensities, may damage the tissue. The use of ultrasound in subacute or chronic conditions aims to relieve pain and spasm and to increase tissue extensibility in the 10 minutes after heating, before the tissue cools. This may be used in combination with stretching exercises to achieve optimal tissue length.

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