Current Topics on Tendinopathies
May 17, 2012
________________________________________________________________________
Title:
Lower Extremity Tendinopathies: Presentation, Intervention Framework and
Mechanisms behind the Intervention.
Course Description:
This course will provide a patho-anatomical, imaging, biomechanical and clinical trial
framework for a sound “evidence-based” treatment for patients with tendinopathy. We
will delineate the characteristics of patients suitable for non-surgical management from
those whom a surgical candidates. Critical intervention dose will be discussed.
Learning Objectives:
1. Analyze the biomechanical characteristics of locomotion in the presence of
tendinopathy and draw clinical inferences for evaluation and treatment.
2. Discuss the framework for non-surgical intervention of tendinopathies.
3. Discuss the possible mechanisms behind the effectiveness of eccentric loading to the
tendon.
Integrated evidence through current bibliographic reference:
Bibliography. * denotes articles of special interest.
Framework for Intervention
*Davenport TE, Kulig K, Matharu Y, Blanco CE: The EdUReP model for nonsurgical
management of tendonopathy. Physical Therapy. 85(10):1093-103, 2005.
Mechanism behind the Eccentric Intervention
*Grigg NL, Wearing SC, Smeathers JE. Eccentric calf muscle exercise produces a greater
acute reduction in Achilles tendon thickness than concentric exercise. Br J Sports Med.
2009; 43: 280-283.
*Henriksen M, Aaboe J, Bliddal H, Langberg H. Biomechanical characteristics of the
eccentric Achilles tendon exercise. J Biomech. 42(16):2702-7, 2009.
*Henriksen M, Aaboe J, Graven-Nielsen T, Bliddal H, Langberg H. Motor responses to
experimental Achilles tendon pain. Br J Sports Med. 45:393-398, 2011.
Achilles Tendinopathy
Alfredson, H: Chronic midportion Achilles tendinopathy: an update on research and
treatment. Clinics in Sports Medicine 22: 727-41, 2003.
*Arya S and Kulig K: Tendinopathy Alters Mechanical and Material Properties of the
Achilles Tendon. Journal of Applied Physiology, 108:670-5, 2010.
Alfredson H, Pietila T, Jonsson P, Lorentzon R: Heavy-load eccentric calf muscle
training for the treatment of chronic Achilles tendinosis. American Journal of
Sports Medicine 26: 360-6, 1998.
Alfredson H, Pietila T, Lorentzon R: Chronic Achilles tendinitis and calf muscle
strength. American Journal of Sports Medicine 24: 829-33, 1996.
Alfredson H, Pietila T, Ohberg L, Lorentzon R: Achilles tendinosis and calf muscle
strength. The effect of short-term immobilization after surgical treatment.
American Journal of Sports Medicine 26: 166-71, 1998.
Current Topics on Tendinopathies
May 17, 2012
________________________________________________________________________
*Baur H, Müller S, Hirschmüller A, Cassel M, Weber J, Mayer F.Comparison in
lower leg neuromuscular activity between runners with unilateral mid-portion
Achilles tendinopathy and healthy individuals. J Electromyogr
Kinesiol;21(3):499-505, 2011.
*Kulig K, Loudon JK, Popovich JM Jr., Pollard CD, Winder BR: Dancers with Achilles
tendinopathy demonstrate altered lower extremity take-off kinematics. Journal of
Orthopedic and Sports Physical Therapy, 41:606-613, 2011.
Ohberg L, Alfredson H: Effects on neovascularisation behind the good results with
eccentric training in chronic mid-portion Achilles tendinosis? Knee Surgery,
Sports Traumatology, Arthroscopy 12: 465-70, 2004.
Ohberg L, Lorentzon R, Alfredson, H: Eccentric training in patients with chronic
Achilles tendinosis: normalised tendon structure and decreased thickness at
follow up. BJSM online 38(5):597-600 38: 8-11; discussion 11, 2004.
Ohberg L, Lorentzon R, Alfredson H: Good clinical results but persisting side-to-side
differences in calf muscle strength after surgical treatment of chronic Achilles
tendinosis: a 5-year follow-up. Scand J Med Sci Sports 9(2):104-9 11: 207-12,
2001.
Williams DS, Zambardino JA, Banning VA. Transverse-plane mechanics at the knee
and tibia in runners with and without a history of achilles tendonopathy. J Orthop
Sports Phys Ther.38(12):761-7, 2008.
Posterior Tibial Tendinopathy
Alvarez RG, Marini A, Schmitt C, Saltzman CL: Stage I and II Posterior Tibial
Tendon Dysfunction Treated by a Structured Nonoperative Management Protocol:
An Orthosis and Exercise Program. Foot Ankle Int 22(3):214-9 27: 2-8, 2006.
Augustin JF, Lin SS, Berberian WS, Johnson JE: Nonoperative treatment of adult
acquired flat foot with the Arizona brace. Foot Ankle Clin 6(1):129-35, vii 8:
491-502, 2003.
Flemister S, Neville C, Houck, JR: The Relationship among Ankle, Hindfoot and
Forefoot Position and Posterior Tibialis Muscle Length. Foot and Ankle
International, Foot Ankle Int. 28(4):448-55, 2007.
*Kulig K, Popovich JM Jr., Nocetti-DeWit L, Reischl SF, Kim D: Persons with Posterior
Tibial Tendon Dysfunction have Diminished Hip Muscle Performance. Journal of
Orthopedic and Sports Physical Therapy, 41:687-694, 2011.
Kulig K, Lederhaus E, Reischl SF, Arya S, Bashford GB: Does a 10-week tendon
specific eccentric exercise program alter the degenerated tibialis posterior tendon?
Foot and Ankle International 30:877-85, 2009.
Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, Mais-Requejo S, Thordarson
DB, Smith RW: Non-operative management of tibialis posterior tendon
dysfunction using orthoses and resistive exercise: a randomized clinical trial.
Physical Therapy, 89:26-36, 2009.
Kulig K, Pomrantz AB, Burnfield JM, Reischl SF, Mais-Requejo S, Thordarson DB,
Smith RW: Non-operative management of posterior tibialis tendon dysfunction:
design of a randomized clinical trial BMC Musculoskeletal Disorders. 7:49, 2006.
Current Topics on Tendinopathies
May 17, 2012
________________________________________________________________________
Kulig K, Burnfield JM, Reischl S, Requejo SM. Blanco CE. Thordarson DB. Effect
of foot orthoses on tibialis posterior activation in persons with pes planus.
Medicine & Science in Sports & Exercise. 37:24-9, 2005.
Kulig K, Burnfield JM, Requejo SM, Sperry M, Terk M: Selective activation of
tibialis posterior: evaluation by magnetic resonance imaging. Med Sci Sports
Exerc 36: 862-7, 2004.
Neville CG, Flemister AS, Tome, J, Houck J: Comparison of Changes in Posterior
Tibialis Muscle Length Between Subjects with Posterior Tibial Tendon
Dysfunction and Healthy Controls. J Orthop Sports Phys Ther. 37(11):661-9.
2007.
Tome J, Flemister S, Nawoczenski D, Houck J: Comparison of Foot Kinematics
between Subjects with Posterior Tibial Tendon Dysfunction and Healthy
Controls. Journal of Orthopedic & Sports Physical Therapy 36: 635-644, 2006.
Patellar Tendinopathy
Visnes H, Bahr R: The evolution of eccentric training as treatment for patellar
tendinopathy (jumper's knee) - a critical review of exercise programs. Br J Sports
Med. 2007 Jan 29;
Bahr R, Fossan B, Loken S, Engebretsen L: Surgical treatment compared with
eccentric training for patellar tendinopathy (Jumper's Knee). A randomized,
controlled trial. J Bone Joint Surg Am. 88(8):1689-98, 2006.
Hoksrud A, Ohberg L, Alfredson H, Bahr R: Ultrasound-guided sclerosis of
neovessels in painful chronic patellar tendinopathy: a randomized controlled trial.
Am J Sports Med. 2006 34(11):1738-46, 2006.
Lian O, Dahl J, Ackermann PW, Frihagen F, Engebretsen L, Bahr R: Proprioceptive
and antinociceptive neuromediators in patellar tendinopathy. Am J Sports Med.
34(11):1801-8, 2006.
Sorenson SC, Arya S, Souza RB, Pollard CD, Salem GJ, Kulig K. Knee Extensor Dynamics
in the Volleyball Approach Jump: The Influence of Patellar Tendinopathy. Journal of
Orthopedic and Sports Physical Therapy, 40:568-576, 2010.
Current Topics on Tendinopathies
May 17, 2012
________________________________________________________________________
Session outline (topic and duration)
Topic
Time
Time
(minutes)
Mechanical properties of tendons and their relevance to
degeneration and potential for healing.
3:00-3:15 p.m.
45
Biomechanical characteristics of locomotion (running,
jumping, leaping), in the presence of tendinopathy and
clinical inferences for evaluation and treatment.
3:15-4:00 p.m.
45
BREAK
Proposed mechanisms behind eccentric re-loading.
4:00-4:15 p.m.
4:15-4:35 p.m.
15
20
Common and tendon specific ingredients of effective
interventions for the tendons of Achilles, Patellar and
Tibialis Posterior.
4:35-5:45 p.m.
70
Discussion, Questions and Answers
5:45-6:00 p.m
15
Current Topics on Tendinopathies
May 17, 2012
________________________________________________________________________
Kornelia Kulig, PhD, PT, FAPTA, FMAAOMPT is a Professor of Biokinesiology and
Orthopedic Surgery and a Co-Director of the Musculoskeletal Biomechanics Research
Laboratory at the University of Southern California. Her research explores tissue
morphology, biomechanics, physiology, and pathology in relation to degenerative
processes in connective tissues and accompanying muscle activation, kinematic and
kinetic movement strategies and related signs, symptoms, and loss of function. Dr. Kulig
is a member of the American Physical Therapy Association, American College of Sports
Medicine and the American and International Societies of Biomechanics. Dr. Kulig
serves as a reviewer for several biomechanical and clinical journals and servers as an
Editorial Board Member of the Journal of Orthopaedic and Sports Physical Therapy and
Physiotherapy. She is a Founding Member of the American Academy of Orthopedic
Manual Physical Therapists.
Keywords:
Tendinopathy, metabolic syndrome, extremities
Teaching and Learning Strategies:
Lecture and discussion
Instructional Level: Intermediate to Advanced