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Various physical therapies in TENDINOPATHY. Jakub Jeníček. Objectives. Definition of the clinical condition and diagnostics Basics of patophysiology Most common types of tendinopathy Goals of treatment
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Various physical therapies inTENDINOPATHY Jakub Jeníček
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
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
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
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
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
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...
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
Tendinopathy – range oftreatments • 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
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!
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/cm2, 20% duty factor) • combined therapy (electro + ultrasound) for trigger points – 1 cm2 ultrasound head (3MHz, 0,5 W/cm2, 50% duty factor)+ large electrode (TENS, f 100 Hz, motor treshold intensity)
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)
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 • dose 20 J/cm2, continuous frequency do deliver energy to the tissue • dose 10 J/cm2, pulsed frequency to modulate desired effect • structure modification and healing • shockwavetherapy– optimum 2 bar in pathologic spot, 2000 pulses with frequency 10 - 15 Hz