Tendon and Ligament Injuries

What is an orthopaedic injury?
A fracture without deformity
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What is a muscle?
Contains contractile filaments which change the size of the muscle, therefore producing muscular force
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What is a tendon?
Connects muscle to bone. It has to withstand tensions as it transfer the muscle force to the bone to initiate movement
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What is a ligament?
Connects bone to bone. Maintains joint stability
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What is cartilage?
Firm, whitish and flexible tissue in the articulating surface of joints
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How many UK military suffer from lower limb tendinopathy?
1.4%
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What sports is patella tendinopathy more prevalent?
volleyball, handball, basketball
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What is the function of a tendon?
It connects the two ends of a muscle to bone. Edge closer to body is the origin and the edge further away is called the insertion.
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What is a musculotendinous unit/junction
A muscle and tendon together
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What is a popeye sign?
When the biceps tendon ruptures and the biceps compresses looking like popeye
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Describe the structure of a Tendon?
Soft connective tissues, hierachy of highly aligned collagen composed of fibrils, fascicles, fibres, to form a strong tissue in the body to initialise motion of joints and stabilise joints when muscles contract.
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What is an acute rupture and its effect?
Acute rupture is due to repirition and overuse, eccentric activities, and quick cutting motions that involve rapid acceleration.deceleration. Upset mobility/stability balance and result in abnormal loading -> damages soft tissue
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What % does chronic tendinopathy account for of all sports injuries?
30-50% of all injuries related to sport
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What % does achillies tendinopathy account for in running injuries?
7-11% of all running injuries
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What % of people over 60 experience rotator cuff tears?
more than 30% -> bad posture increases the risk of injury
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What are symptoms for tendinopathy?
insidious onset - mechanical injury (difficult to recall exact moment of injury), specific site of pain, pain walking and first mobilising in the morning, pain commencing activity, eases in 'warm up', pain after activity, pain with direct palpation
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What are intrinsic causal factors of tendinopathy?
Gait, heavy heel strike, double heel lift, motor patterning (e.g. over use hamstrings, under use of glute), posture alignment (rounded shoulders), age, BMI, Previous injury
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What are extrinsic causative factors of tendinopathy?
Training errors (volume, intensity, energy storage activities like plyo's), footwear, exercise, medication (fluoroquinolones, steroid)
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Draw the tendinopathy continuum model (Purdham and Cook 2009)
.
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What is important to remember when considering the continuum model?
Not all tendinopathy is the same and you can be in different areas of the continuum.
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What is reactive tendinopathy?
non-inflammatory response secondary to acite tensile or compressive overload -> 'too much too soon'
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What happens in reactive tendinopathy?
Increase in proteoglycans which attract water, increase in ground substance - tenocyte proliferation. source of pain could be pressure from fluid or response to tenocytes (not actually known) - once flared may remain for days
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What is dysrepair Tendinopathy?
Matrix disorganisation and collagen seperation.
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What happens in dysrepair tendinopathy?
Increased thickening due to foci of collagen breakdown and increased ground substance formation. Neo-vascularisation - upregulation of VEGF (promotes growth of blood vessels). Source of pain is not known
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What is there difference between healthy tendon tissue and dysrepair tissue under the microscope?
Healthy tissue you can't see blook flow through it, as dysrepair happens, you can see dopplar blood flow
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What is degenerative tendinopathy?
Significant collagen matrix disorganisation -> focus of holes within tendon, increase Type III collagen, apoptosis = tenocyte death (cell death). Source of pain = hypoxia (increased lactate, less O2), neural, centralisation
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What is hypoechoicarea?
Effectively a black whole in tendon where a blood vessel grows in hole and thickens area.
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What is an eccentric contraction?
Contracting and lengthening a muscle
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Defining reactive phase (age, loading, prevalence, pain, palpation, response to load)
15-25, suddent increase, e.g. new recruits, pain very acute and immediate on loading, palpation may notice fusiform selling, sensitive to load irritable.
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Defining Dysrepair phase (age, loading, prevalence, pain, palpation, response to load)
20-35, overload, common, pain typical tendon pattern, may note fusiform swelling, less irritable response to load
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Defining Degenerative phase (age, loading, prevalence, pain, palpation, response to load)
30+, prolonged history, common, typical tendon pattern pain, palpation nodular, grumbling flare ups in response to load
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Defining reactive on degenerate phase (age, loading, prevalence, pain, palpation, response to load)
30+, Pain = very acute, immediate on loading, palpation = fusiform swelling, sensitive to load
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Give an example of reactive on degenerate
e.g. a middle-ages person deciding to take up squash again, but remembers the reason they gave it up in the first place was due to tendinopathy.
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What are the 5 stages of rehabilitation
1) Address pain, 2) address ROM, 3) address contractile deficits, 4) address movement patterns, 5) re-inforce movement patterns
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What is the key to managing tendinopathy?
Progressive load to reduce pain and restore function
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Name 3 outcome measures?
VAS (Visual analogie scale), NRS (Numerical pain rating), FAA (functional activity assessment - military occupation score)
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What are NRS and VAS?
Measurement scales of pain (e.g. 1-10, 1-100, were are you on the scale?)
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How many stages are there to progressive loading?
4
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Describe stage 1 of progressive loading
Isometrics (low load) allows early addressing of contractile deficits, stimulates collagen synthesis, reduction of pain, reduced cortical inhibition. Avoid compressive element, work within tolerance of pain. hold 30-60 secs x 4, 5 times a day
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Describe stage 2 of progressive loading
Concentric/eccentric (medium load) addresses contractile deficits, slow + controlled through range (may avoid compressive load), open and closed kinetic chain if poss. Stage 1 isometrics on stage 2 days off.
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Describe stage 3 of progressive load
Heavy loading through range = isotonic loading into compressive range, heavy slow resistance for PTs, HSR and Eccentrics for Achilles
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Describe the imporvements on young male volleyball players from HSR training
Improved symptoms and function, reduced tendon width, increased collagen fibril density.
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How many weeks should eccentric training of stage 3 last?
Traditionally 12 weeks progressive load, but may be more effective as a combined programme.
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Describe stage 4 of progressive load
Energy storage loading = minimal pain during/after high load tests, when single leg strength is equivalent (limb symmetry test, relative strength index), may avoid compressive range
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How do all 4 stages fit together in a programme?
Gradually progress through them all. E.g. week 1-2 just stage 1, week 3-4 vary stage 1 and 2 on different days. Week 6-9 mostly stage 2 and 3 but rest days of stage 1. Continue to build gradually.
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What 5 things are important to consider with progressive load?
1) Biomechanics (proximal control, posture), 2) flexibility, 3) associated injury, 4) lumbar spine, 5) neural mobility
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What follows stage 4 in rehab?
Returning to running/jogging by walking/jogging on high load days but continue to monitor pain. Continue load management.
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To conclude, what are the 3 treatments that target non-inflammatory mechanisms in tendinopathy?
1) Heavy slow resistance, 2) Eccentric loading, 3) Shockwave (ESWT)
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If conservative management fails, what 5 other treatments are possible?
Corticosteroid injections, platelet rich plasma, dectrose, polidocanol, and high volume injections.
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What are corticosteroid injections?
injections around the tendon for short term relief (weeks) but no long term improvement.
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What is platelet rich plasma treatment?
Blood injections into tendon. Research shows promising results but low quality research but not sufficient evidence of benefits
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What is dectrose?
requires repeat injections into tendon but not tested against control and theoretical risk infection/rupture
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What is Polidocanol?
Requires repeated injetions into neovessels around tendon. RCT evidence in patella
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What are high volume injections?
injections to seperate and destroy neovessels around tendon, case series but no RCT.
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What is the function of a ligament?
connects bone to bone across a joint. Called articular ligaments. Limit mobility, prevent unwanted movements, provide joint stability.
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Describe the concistency of ligaments?
They are viscoelastic - they strain when under tension, and return to origional shape when tension is removed.
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How does the speed of a strain effect the ligament?
If it is strained slowly, they are lengthened. If they are strained rapidly, they would break.
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What is the Beighton Score?
Test for hypermobility. 1 point for hands touching floor, then 1 points for each limb with thumb, little finger, elbow and knee tests. 4/9 or more = hypermobile.
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What is the relationship between hypermobility and injuries?
There is an association but one does not cause the other!
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Describe the structure of a ligament
soft connective tissues, heirachy of highly aligned collagen composed of fibrils, fascicles, fibres, to form a strong tissue in the body. (similar to tendon). Fibroblasts are nearly parallel in ligament stabilising joint. (not as parallel as tendon!)
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Ligament acute sprains: describe a grade 1
Grade 1 = ligament being sprained and stretched but is still competent and able to stabilise a joint
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Ligament acute sprains: describe a grade 2
ligament is partially torn but still able to stabilise a joint to an extent. Healing is possible and promising
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Ligament acute sprains: describe a grade 3
ligament is competely torn and is unable to stabilise a joint
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What are the 3 most common ligament injuries in sport?
1) Anterior talofibular ligament (ATFL) at ankle, 2) Anterior cruciate ligament (ACL) at knee, 3) Medial/lateral collateral knee ligaments at knee
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What is O'Donoghue's Triad?
('unhappy triad') = 1) tibial collateral ligament tear, 2) medial meniscus tear, 3) anterior cruciate ligament tear
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What is a likely cause of the unhappy triad?
Valgus tackle/stress from the side. (knee-in toe-out)
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What is the acute management of ligament sprain?
ATFL/ACL inuries require same day clinicial review, need x-ray if unable to weightbear, fractures will need orthopaedic opinion, ACL rupture managed with surgery 3 weeks after injury
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What is a key element of rehab?
Muscle strengthening = the musculotendinous unit also provides joint stability and so training surrounding muscles in order to compensate the inferior stability of torn ligament.
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What other aspects of muscles are trained in rehab?
Proprioception and muscle reaction
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What is usually used in reconstruction surgery of ligaments?
Tendon grafts as it has similar properties and some tendons would regenerate over time. (e.g. hamstring tendon for ACL)
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What is tissue engineering?
A lot of research is investigating the possibility to regenerate ligaments with stem cell therapy. Tests still biological cellular level and in animals, no human trials yet.
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Other cards in this set

Card 2

Front

What is a muscle?

Back

Contains contractile filaments which change the size of the muscle, therefore producing muscular force

Card 3

Front

What is a tendon?

Back

Preview of the front of card 3

Card 4

Front

What is a ligament?

Back

Preview of the front of card 4

Card 5

Front

What is cartilage?

Back

Preview of the front of card 5
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