1	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
2	General methodological issues Beware! The poor quality surgical outcome studies should not influence management inappropriately There are many examples of… retrospective chart reviews uncontrolled studies data collected by surgeon studies with large loss to follow-up And what about publication bias?
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5	Methodology Score versus Outcome of Surgery
6	New surgical techniques Arthroscopic patellar tendon debridement
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8	Open and arthroscopic patellar tenotomy 4-yr follow up Retrospective study 2 surgeons One performed open The other performed arthroscopic surgery No difference in outcome between types of surgery
9	Outcome of surgery
10	Time to return to sport Paavola, 2001 Prospective 7-month outcome study of Achilles tendon surgery better results in patients without focal tendinosis (88%) than those with such a lesion (54%)
11	Time to return to sport Maffulli – numerous studies in patellar (Testa) & Achilles tendons Patellar tendon surgery has the longest rehabilitation period Achilles tendon also has long recovery period
12	Surgery
13	Complications – skin healing Paavola, UKK Finland 11% complications in the retrospective study, n=432 patients (AJSM, 2000) 19% complications in the prospective study, n= 42 patients (thesis, 2001)
14	Difficult to compare surgeries Subtle technical aspects of surgery, or of rehabilitation protocol may significantly change outcome Opening, closing of patellar defect Excision, retention, of paratenon in TA Time immobilised after surgery Strengthening protocol
15	Take home: Type of surgery Remains unclear as lack of ‘head to head’ RCTs Canadian surgeons are at the forefront of high quality RCT design and collaborative studies Suggest audit YOUR surgeon’s data as they most representative outcome for your patients
16	Presentation Outline A. Pathology B. Where is the pain coming from? C. Update – conservative Rx D. Update – surgical Rx E. 10 Practical Tips – Rx and return to sport
17	10 practice pearls
18	1. Reduce abusive load Reduce training volume &/or intensity but complete rest rarely required Activity level shouldn’t provoke tendon (clinical judgement) Remember Alfredson advocates pain in his regimen!
19	2. Unload the tendon with alternate structures Patellar tendinopathy – essential to make sure calf, foot and ankle complex are excellent primary shock absorbers Repeated ankle injury risk factor for patellar tendinopathy (clinical impression)
20	2. Unload the tendon with alternate approaches Midfoot mobilisation Orthotics for Achilles tendinopathy (McCrory 2000) Elbow brace? Treat joints that might be referring pain – Neck in epicondylalgia, neural tension
21	3. Strengthen widely… Strengthen surrounding muscles (patellar tendinopathy – strengthen the ankle and hip joint muscles) Strengthen all components necessary for sport – eccentric, fast, rapid change, endurance, landing from a height
22	4. Strengthen specifically To strengthen and hypertrophy weak muscles can take 3 months Gradually add speed program (for up to 6 months) Include sport-specific movement patterns (for up to 12 months)
23	5. Minimise electrotherapy – consider massage, stretching Electrophysical agents minimal role Massage and frictions quadriceps and calf massage some evidence for frictions (Davidson, 99) Stretching – hamstring, calf especially
24	6. Retrain motor patterns Sports injury and pain often cause altered motor patterns Assess biomechanics (whole limb, whole body, - Kibler approach) Correct as needed
25	7. Prevent recurrence First season after major tendinopathy – allow several rest days where the player does weights and nonprovocative activities Emphasise strength training for at least 12 months after return to sport
26	8. Beware in ‘successful returners’ Attend to: weakness abnormal loading patterns Ideal to do this in the off-season if at all possible
27	9. Duration of rehabilitation ? If the patient has long standing symptoms (>12 months)… They can rarely rehabilitate in less than 3 months And often require in excess of 6 months rehabilitation (respect the pathology and tendon physiology)
28	10. How to progress treatment Few reliable and quantifiable measures – imaging, etc no help Don’t use tenderness to palpation as a guide Use musculotendinous function under load as the clinical indicator to progress treatment (jumps, running etc.)
29	Le Summary
30	Le Summary