Henning Langberg: Professor at the Institute of Health University of Copenhagen, Copenhagen, Denmark

Copyright Henning Langberg – Email: [email protected]

Henning Langberg Professor, DMSc, PhD, Pt, SSPT, ISSPT

Ins$tute of Public Health – University of Copenhagen, Denmark

From basic science to rehab of tendinopathy What have we learned?


PREVALANCE


WHAT HAPPENS IN TENDONS WITH EXERCISES?

(Kahn 2009)


Collagen Turnover

(Magnusson Langberg, Nature Rev Rheum, 6: 262-68, 2010)


Collagen synthesis in tendon and exercise load

(Magnusson Langberg, Nature Rev Rheum, 6: 262-68, 2010)

0.05

0.10

Col

lage

n

synt

hesi

s (%

/hou

r)

Cumulative loading (BW) Rest 10

0 1000 10,000 100,000

36 km run

1-h kicking Strength training


Effect of 1-‐hour kicking on patella tendon collagen expression

(Dideriksen 2013)


Carbon in atmosphere Carbon-‐12 99% Carbon-‐13 1% Carbon-‐14 small frac$on

14C level measured with accelerator mass spectrometry (AMS)

(Heinemeier et al., FASEB J, 27: 2074-‐9, 2013)

Sampling

High turnover

No turnover e.g. Time of birth

Increase in atmospheric 14C due to tesFng of nuclear bombs in 1955-‐63


(Heinemeier et al, FASEB J, 27: 2074-‐9,2013)

Bomb pulse

RelaFvely good fit of 14C levels in Achilles tendon samples with 0-‐17 year moving average curve

Bomb pulse -‐ moving average (0-‐17 years)

Achilles tendon autopsy samples (18-‐55 yrs)

Tendon core only limited renewal a\er growth

(18 y)

In contrast, (14)C levels in muscle indicated con$nuous turnover


The effect of habitual unilateral high load on patella tendon properties

Knee

exten

sor M

VC (N

m)

0

150

200

250

300weak sidestrong side

**

Couppé et al, JAP 2008

Patella

r tendo

n CSA

(mm

2 )

0

80

100

120

140

160

180 strong sideweak side

proximal middle distal

**

*

22 %

20 % 28 %

Knee ext. force

Tendon area


Training induce tendon growth

and increased stiffness

Deformation

Force

Strength

Stiffness Injury resistant


WHY THEN TENDINOPATHY?


M. plantaris

Muscle-tendon overload

(0,2,4,8,16 days) in rat

(Olesen, 2006) Overload & Sham on Day 8

TENDON

MUSCLE


PATHOLOGY What is going on in the injured tendons?


SUMMERY OF PATHOLOGY

Increased thickness In-‐growth of vessels In-‐growth of nerve endings Pain Reduced func$on

Patology of tendons


Symptoms of overuse in rat Achilles tendon


Tendinopathy Healthy

(Pinge et al 2013)


Tendon biopsies


Structural changes

(Healthy tendon area)


(Healthy tendon area)

(Injured tendon area)

Structural changes


Fibril area distribution

0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 11000 12000 13000 14000-10

0102030405060708090

100110120130140

Tendinotic tendonHealthy tendon

**

*

Area fractions nm2

Num

ber

of fi

brils

in th

efr

actio

n

(Injured tendon area) (Healthy tendon area)

Fibril area distribution

Tendinopathy Healthy

(Pingel BMC 2012)

More small collagen fibrills


Does exercise cause inflamma$on in tendinopathy?

Healthy

Achilles Tendinopathy

(Pingel et al, 2013)


WHAT HAPPENS WITH AGING?


(Døssing 2010)

Effect of rhGH on collagen turnover


(Boesen, Langberg 2013)

Age and GH – role of growth factors


!

Effect of GH during immob and rehab


(Boesen, Langberg 2013)

Effect of GH during immob and rehab


Model for Tendinopathy and healing based on clinical experiences

Thanks to Dr. Gil Rodas (FC Barcelona)


HOW TO REHABILITATE TENDONS?


Tendon ”overuse” a major clinical problem

Non-operative treatments •  Rest – decreased activity •  Orthodics •  Eccentric exercise training •  Massage + controlled motion •  Cryotherapy – heat therapy •  El-stimulation •  Laser – Ultrasound – Shock wave •  NSAID (local, systemic) •  Corticosteroid injection •  Low-dose heparin •  Topical nitroglycerine •  Platelet rich autolog inj. (PRP) •  Calf’s blood injection •  Sclerosant injection

Operative treatments


PREVENTION


ProphylacFc Training in AsymptomaFc Soccer Players With Ultrasonographic AbnormaliFes in Achilles and Patellar Tendons The Danish Super League Study

•  Prophylac$c eccentric training and stretching reduces risk of developing UL abnormali$es in the patellar tendons

•  No posiFve effects on the risk of injury

•  In asymptoma$c UL abnormal patellar tendons, prophylacFc eccentric training and stretching increased the injury risk

•  No effect on the Achilles tendons

(Fredberg, Bolvig, Andersen; Am J Sports Med 2008 36:451)


Thanks to Dr. G

il Rodas (FC

Barcelona)


HOW CAN THE PRESENTED EVIDENCE HELPED CLINICIANS IN THE MANAGEMENT OF TENDINOPATHIES ??


Case 1

•  A young talented player with symptoms in the patella tendon (on and off pain during warm up or a\er training, beger during ac$vity) during the preseason training

•  What to do? –  con$nue training? –  adjust training? –  add treatment?


Case 2

•  A very important player during season experience increasing symptoms (pain and s$ffness in the morning) in the Patellar Tendon weeks before an important match

•  What to do ??


Case 3

•  One of you players experiences sudden unset of pain in the Inser$onal Achilles tendon during training but only during high loading.

•  What to do ?


Prepare athletes to sport??

-  Peak forces -  Plyometric loading -  Contraction velocity -  Muscular fatigue -  Rotation = shear forces


More quesFons than answers

•  Tendons can adapt to loading

•  Tendons adapt slower than muscle

•  The core of the tendon may heal differently from the outside

•  All tendons are not alike, no treatment fits all

•  We need to cover the gap between rehab and return to sport

Henning Langberg: Professor at the Institute of Health University of Copenhagen, Copenhagen, Denmark

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