Notes

Slide Show

Outline

1	After receiving the invitation to Tremblant !
2	Les tendinopathies – Karim Khan, MD, PhD, Dip Sport Med (CASM)
3	Allan McGavin Sports Medicine (UBC)
4	Les tendinopathies
5	Commanditaire
6	Thank you – to Tim & Marilyn
7	Presentation Outline A. Pathology – 2 minutes B. Where is the pain coming from? – 0 min C. Update – conservative Rx – 12 mins D. Update – surgical Rx – 10 mins E. Practical tips – Rx & return to sport -10 min
8	Presentation Outline A. Pathology
9	Light microscopy – tendon disarray
10	No evidence of ‘classical’ inflammatory cells in human overuse tendon injuries Light microscope or electron microscope Biochemistry (PGE 2 absent in lateral elbow, patellar, Achilles tendons) Alfredson 1999, 2000, 2001 – in vivo microdialysis
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12	[PGE2] by microdialysis Same in tendinosis & normal tendon
13	That’s OK with chronic problems -- but what about when symptoms have only been present for a few days ?
14	Potential deleterious effect of NSAID on the healing process following Achilles tendon injury. David Marsolais, Claude Côté & Jérôme Frenette Laval University, Quebec City
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16	Short-term painful ‘tendinitis’ may not need not to precede overuse tendinosis
17	Les tendinopathies
18	Presentation Outline A. Pathology B. Where is the pain coming from? C. Update – conservative Rx D. Update – surgical Rx E. Practical tips – Rx and return to sport
19	Where is the pain coming from ?
20	Presentation Outline A. Pathology B. Where is the pain coming from? C. Update – conservative Rx D. Update – surgical Rx E. Practical tips – Rx and return to sport
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22	Hakan Alfredson, 98-02 Prospective controlled trial (n=119, 103 resolved) Eccentric heel drop program, twice daily
23	Many more drops effective, painful ! 3 sets of 15; 7 days/week Rx for 12 weeks, twice a day Pain expected, only stop if disabling Progress when pain free (backpack / weights)
24	Mafi, Lorentzon, Alfredson, KSSTA, 2001 Randomized controlled trial Eccentric training (n=22) vs concentric training (n=22) Daily for 12 weeks 82% success rate in eccentric group 36% success rate in concentric group (p<002). VAS from 69 to 12
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26	Per Holmich, 1999 (Adductor) Randomized, controlled, blinded observers
27	Per Holmich, 1999 (Adductor) Randomized, controlled, blinded observers Adductor strengthening program (eccentric & concentric) vs. electrotherapy 8-12 week program Outcome: Return to sport without pain
28	Electrotherapy only helped 12% of patients
29	Lateral epicondylalgia - 2001 RCT, n=38 Eccentric vs stretching 3 sets of 5 reps with dumbell Exercises intended to be pain free
30	Lateral epicondylalgia 71% vs 39% completely recovered @ 12 mths (p = 0.09) increase in grip strength (p < 0.05) Further 129 with eccentric Rx – 66% good & excellent results 4 surgically treated
31	How does eccentric training work?
32	Possible mechanisms Reduce inflammation Cause new damage to stimulate inflammation Tear nerve fibres – thus, causing a denervation Wring out blood (like a sponge) Wring out noxious biochemicals Stimulate collagen repair locally or via the cell nucleus
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36	Shock wave therapy Tennis elbow, plantar fasciitis Rompe 1996 – main advocate – benefits in lateral elbow pain Krischek ’99 – not beneficial in medial elbow tendinopathy UBC – Canadian data – no improvement in lateral elbow pain (Worker’s Compensation patients)
37	Les tendinopathies