Upgrade to remove ads
Only $35.99/year

Principles of management of overuse/chronic injuries

Terms in this set (22)

Principles of management - phases
What are examples of Intrinsic and Extrinsic risk factors
Intrinsic
- age
- gender
- Hx of previous injury
- biomechanics
- aerobic fitness
- limb dominance
- flexibility and strength
- foot morphology

Extrinisc
- skill level
- Shoe types
- playing surface
- equipment
- use of tape/brace
- training errors
- level of competition
What are the classificaion of chronic injuries by characterisations (phases)
Phase 1
- pain during exercise
- pain can go with warming up
- can be present for a short time later

Phase 2
- pain during exercise that doesnt subside
- present later
- not interferring with ADLs

Phase 3
- Pain starting to limit physical activity in ADLs

Phase 4
- pain interfering with ADL, consistent symptoms
What is the management of phase 1 and 2 injuries
Treat and train while deloading tissue

Advice and education
- Modify activity

Therapeutic exercise
- Muscle conditioning
- neuromuscular control
- flexibility/ROM
- Cardiovascualr fitness

EPA
- pain relief and healing

Manual therpay
- Massage
- joint mobilisation

External physical devices
- orthotics
- taping

Predisposing factors
What is the management of Phase 3 and 4 conditions
Cease activity that produce/aggravates pain/injury

Attend to pain as a priority

Deload tissue to relieve pain and encourage normal function
- Advice and education
- Therapeutic exercises
- EPA
- Manual therapy
What are factors contributing to training errors
- Excessive volume
- Too high of a training intensity
- Rapid increases in volume/intensity
- Inadequate rest
- Too much too soon
Describe the use of orthotics/orthoses
Applied to correct alignment or deformity

As a mode of prevention
- tibial stress fractures
- posterior tibial stress syndrome in military
- lower limb overuse condition
- no significant differences between custom of prefabcricated orthotics

As a mode of treatment
- plantar fascia; reduce pain and improve function
- PFP; help pronating risk factor to reduce pain and stiffness

Comfort is the msot important factor
What conditions fall under the term tendinopathy
Tendinosis = degeneration

Tendinitis = inflammation

Paratendonitis = inflammation of synovial sheath
Describe tendinopathy
Overuse injury
- Running and jumping
- Better jumpers often develop PT
- Repetitive loading
- Excessive training volume and frequency

Altered biomechanics
- Muscle weakness/imbalance
- Altered absorption fo loading forces
- Decreased ankle DF, quads and hamstring ability
- FPI

Intrinsic risk factors
- males
- body composition (diabetes type 2)

Special note
- Bilateral tendinopathies common even when unilateral load or common for unaffected side to begin to show symptoms
Describe the corticospinal changes that occur during a tendinopathy
Not sure what comes first the tendinopathy or the CS changes but there are changes in CS inhibition and excitation to muscles in patients with tendinopathy and may be a protective adaptation

May be due to phasic (dramatic increase or decrease) exercise regimes so far

May influence recurrence
Information received from a tendinopathy patient interview
Pain after exercise or more frequently the following morning

Painful with movement but can overcome pain once it warms up

Pain returns as body cools down

Able to continue training in early stages however this effects the healing process
Physical examination of a tendinopathy
Local tenderness and/or thickening
- thickening is an attempt of self healing

Frank swelling and crepitus
- crepitus is usually a sign of tensosynovitis
What are the three stages of tendinopathy
Reactive tendinopathy

Tendon dysrepair

Degenerative tendinopathy
Describe reactive tendinopathy
Non-inflammatory proliferative response

Occurs with acute tensile or compressive loading generally from an unaccustomed amount of physical activity chronically overloading it or a direct blow to the tendon

Reduces strength and increases stiffness

Initial changes in ground substance
- fast acting changes (few minutes)
- increase protein production
- matrix change due to increased amount of water bound to PGs
- some longitudinal separation of collagen
- no change in neurovascular structures
- increase cell numbers, increased cell rounding and increased ground susbtance

Imaging for diagnosis
- MRI/US to identify increased diameter and/or hypochogencity between collagen

Can revert back to normal if overload is reduced sufficiently
Describe tendon dysrepair
Attempt at healing

Greater matrix breakdown
- Increase cell numbers
- Increase protein production (PGs and collagen)
- Increased PGs leads to the separation of collagen and disorganised matrix
- Some increase in vascularity and neuronal ingrowth

Imaging
- MRI/US
- discontinuity of collagen fascicle
- hypoechogenicty
- increased vascularity on power doppler

Clinical nature
- same as reactive tendinopathy
- chronic overload
- spectrum of ages and load environment
- increase cell numbers and loss of collagen
- increased number of vessels

Thicker and more swollen

Some reversibility is possible with load management
Describe degenerative tendinopathy
Further progression of matrix and cell changes
- cell death causing acellularity
- matrix disorder causing breakdown
- filled with vessels

End stage meaning there is little capacity for reversibility

Imaging
- MRI/US
- vascular changes extensive - many or large vessels on doppler
- hypoechoic regions (black regions) due to no collagen
- increase tendon size

Clinical presentation
- older people or young elite athletes
- one or more focal nodular areas
- history of repeated bouts of tendon pain
Deciding on a stage of tendinopathy
Two distinct groups
- reactive/early dysrepair
- late dysrepair/degenerative

Based on clinical imaging and presentation

Pain and radiological findings not always linked
- may present normally and have severe pain (vice versa)
- pain is induced by load meaning it is load dependent
- pain localised to tendon or enthesis (insertion)
What are the aims of tendinopathy treatment
Effecting change in tendon structure pathology

Restore corticospinal control of M-T complex

Consider the patient and the influence of pain and reduce it
Describe the treatment for the reactive/early dysrepair phase
Reduction of load
- tendons allowed to adapt
- cells become less reactive and resume normal structure
- pain reduction
- change intensity, duration and frequency
- provide external devices
- avoid plyometric exercises and maintain repetitive activities with little energy storage and release (cycling)


Adapt tendon to increased load
- increase load without increasing symptoms
- address strength, power and endurance
- Evidence to suggest that skilled training and metronome pace resistance exercises are better than self paced to restore CS control

Maintenance of program
- maintain until full function restored and beyond
- adjust load demands as necessary
- minimum 3 months but typically 6-12

Can perform manual therapy
Describe the treatment for the late dysrepair/degenerative tendinopathy
Focus on load modification
- Lower limb biomecanical issues (ankle mobility, muscle length)
- Training and technique factors (volume and technique)
- Kinetic chain (coordination, strength and endurance)
- Restore CS control of muscles

Treatments that stimulate cell activity, increase protein production and restructure include;
- exercise
- frictions
- extracorporeal shock wave therapy
- therapeutic ultrasound
- pharmacotherapies
Describe the effects of eccentric exercises in the treatment of late dysrepaire/degeneration
Heavy slow resistance training particularly effective for tendon structure and pain
- increase collagen production
- decrease tendon vessels
- improve tendon structure
- pain relief in 4-6 weeks

Can however be painful causing poor adhesion to exercise
Describe the effects of isometric exercises in the treatment of late dysrepair/degeneration
Isometric contractions used to reduce pain without a reduction in muscle strength

Isometrics could be used pre-sport for pain relief without producing fatigue

Metronome timing for CS effects

Isotonic exercise effective for tendon rehabilitation, not appropriate prior to activity
Sets with similar terms