Patrick S. Pabian, PT, presents "Rehabilitation Considers of Lower Extremity Tendinopathy" at the 2013 9th Annual Cutting Edge Concepts in Orthopaedics & Sports Medicine Seminar presented by Orlando Orthopaedic Center Foundation.

1. Rehabilitation Considerations
of Lower Extremity
Tendinopathy
Patrick S. Pabian PT, DPT, SCS, OCS, CSCS
University of Central Florida

2. LE Tendinopathy
• Objectives for Treatment
– Multifaceted / Comprehensive Examination
– Rehabilitation Science
– Stewards of the Research for Best Practice
– Integration of Care

3. Predisposing Factors
• Extrinsic • Intrinsic
Training Errors Malalignment
Surfaces Leg Length Discrepancy
Shoes Muscle Imbalance
Equipment Muscle Weakness
Environment Muscle Flexibility
Psychological Factors Gender. Size, Body comp
Nutrition Other
(metabolic, genetic, endoc
rine)
Brukner & Kahn. Clinical Sports Medicine. 2012.

4. • Examination & Treatment of LE Tendinopathy
“Whole” “Part” “Whole”

5. Rehabilitation Science
• Goals:
– Improve understanding of injury
– Identify influence of our treatment

6. Lorenz & Reiman. IJSPT 2011.

7. Alternate Classification - Continuum
• Reactive Tendinopathy
– Tensile / compressive overload (acute)
– Repair proteins, proteoglycans prominent (water in
matrix)
• Tendon Dysrepair
– Myofibroblasts present
– Disorganization starting: collagen separation
• Degenerative Tendinopathy
– Absent cell nuclei, little collagen
– Heterogeneous signal on MRI, US
Cook & Purdam. Br J Sports Med. 2009.

8. Normal vs. Excessive Loading
Normal Tendinopathy
• Tendon cells spindle • Rounded nuclei, fewer
shaped tenocytes
• Minimal ground • Increased ground
substance substance
• Linear, tight bundled • Disrupted collagen
collagen • Ingrowth of
• Minimal intratendinous intratendinous nerves
nerves • Prominent vessels
• Minimal vascularity
Brukman & Kahn. Clinical Sports Medicine. 2012

9. Treatment Focus: “Part”
Modalities? Exercise? Rest? Activity Modification? How
long conservative?
• Do any of these reverse the aforementioned processes
/ biological characteristics of tendinopathy?

10. Mechanotransduction
Process by which “mechanical loading” creates
a cellular response
1. Mechanical trigger (mechanocoupling)
– Can be in just isolated region
– Shear or compression
2. Cell to cell communication
– “signaling proteins” (Ca and inositol triphosphate)
3. Effector cell response
– Tissue repair & remodeling
Kahn & Scott. Br J Sports Med. 2008

11. Mechanotransduction
Up-regulation of Insulin growth factor (IGH-I)
= cellular proliferation & matrix remodeling
within tendon
= increase rate of collagen synthesis
**Best Facilitated through Eccentric Exercise**
Landberg. Scand J Med sci Sports. 2007.

12. Eccentric vs. Concentric Exercise
• Patella Tendinitis
– Pain, satisfaction, return to sport, future care
• Johnssen et al. Br J Sports Med 2005.
• Achilles Tendinitis
– 82% vs. 36% return to prior activity
• Mafi et al. Knee Surg sports Traumatol Arthrosc 2001.
– Decreased intratendinous signal (3 mo. and 4 yr)
• Gardin et al. Skeletal radiol. 2010.

13. Prescription of Eccentric Exercise
• Original source:
Alfredson’s Heel-Drop Protocol for
Achilles Tendinopathy
• 180/day
• Overload theory
• Pain
• Add resistance / weight
(up to 50kg)
Alfredsen et al. Am J Sports Med 1998
Fahlstrom et al. Knee Surg sports Taumatol Arthrosc. 2003
Roos et al. Scand J Med Sci Sports 2004.

14. Training Program Effectiveness
12 week eccentric training program
6x15, BID, 7d/wk
26 patients
Mean 50 y/o with pain 17 months
Results:
1. Significant reduction in cross sectional size of tendon
2. 19 of the 26 had normal return of structural integrity
based on US examination.
Ohberg, Leretzon, Alfredsen. Br J Sports Med. 2004

15. Research on Effectiveness (RCT)
• Eccentric vs. Concentric
– ECC = higher recovery, ROM, less pain
• Silbernagle et al. 2001
• Low Level Laser + ECC vs. Placebo + ECC
– LLLT showed tendency for improve at wk 4 but not
week 12
• Stergioulas et al. 2008
• PRP + ECC vs. Placebo + ECC
– No benefit at 6,12,24 weeks
• De Vos et al. 2010

16. Research on Effectiveness (RCT)
• ECC + Night splint vs. ECC alone
– ECC alone better at 6,12,24,53 weeks
• Roos et all 2004.
• ECC + Low-energy shockwave vs. ECC alone
– ECC + SWT better at 4 months but no diff 1 yr.
• Rompe et al. 2009.
• Surgical treatment vs. ECC
– No difference at 12 weeks. Surgical took twice as long to
RTP.
• Alfredson et al. 1998.

17. Connect the Whole
Proximal Distal
• Landing Strategies
– Forefoot Landing reduces vertical ground reaction
forces by 25%
– Only 40% of landing energy transmitted proximally
***Gastroc / Soleus Strength essential***
Cook et al. Scan J Med Sci Sports. 2000.

18. Integration of Care
• “Connect the whole”
• Address all Intrinsic & Extrinsic factors with
appropriate personnel
– ATC, Strength Coach, etc.

19. Keep the Focus
• Multifaceted / Comprehensive Examination
• Rehabilitation Science
• Stewards of the Research for Best Practice
• Integration of Care

20. • Thank You!!