Abdul Ghafoor Sajjad Assistant

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Professor RCRS (RIU)
SPORTS PHYSICAL THERAPY
LECTURE NO 05

Dr Abdul Ghafoor
Assistant Professor
RCRS,RIU
PART 3
PATHOPHYSIOLOGY OF MUSCULOSKELETAL
INJURIES
Chapter 4. Pathophysiology Of Skeletal Muscle
Injuries
Chapter 5. Tendons
Chapter 6. Pathophysiology Of Ligament Injuries
Chapter 7. Pathophysiology Of Skeletal Injuries
Chapter 8. Peripheral Nerve Injuries
Abdul Ghafoor Sajjad Assistant
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Professor RCRS (RIU)
 CHAPTER NO 05

PATHOPHYSIOLOGY OF TENDONS
INJURIES
 This chapter will outline the tendon
physiology from a molecular level to gross
tissue level and how this relates to its function
and its subsequent mechanical properties.

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Professor RCRS (RIU)
 BASIC TENDON ANATOMY AND PHYSIOLOGY

• Tendon consists of tendon cells (fibroblasts)

that lie in longitudinal rows and are elongated
cells extending within the tendon structure
and communicate via gap junctions within the
three-dimensional space of the tendon.
• Also there is the extracellular matrix (ECM)
that forms the scaffold for the tendon and
which consists of a range of collagens (I, II, III,
V, VI, IX and XI), proteoglycans and water.
Abdul Ghafoor Sajjad Assistant
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Professor RCRS (RIU)
BASIC TENDON ANATOMY AND PHYSIOLOGY

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Professor RCRS (RIU)
 Functional aspects of tendon
• The tensile properties of tendon allow for its
capacity to resist rupture under normal
loading conditions.
• The tendon response to loading in terms of
strain (percentage change of length from rest)
and stress (force per unit area).

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Professor RCRS (RIU)
 Functional aspects of tendon
• As tendons are also elastic they tend to
stretch when muscle contraction takes place.
If, for example, the external load is very
heavy, then as the muscle contracts the
tendon may stretch initially, the action of the
tendon here could be thought of as similar to
a spring being stretched and energy stored.

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Professor RCRS (RIU)
Tendon injury and its management
• A damaged tendon will likely reduce the
capacity for transfer of forces via the muscle
to the bone.
• Injury to the tendon can be characterised as
acute resulting in either a catastrophic rupture
or a less major tear of the tendon tissue.

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Professor RCRS (RIU)
 TERM DESCRIPTION
1 Tendinitis or tendonitis Inflammation of the
tendon
2 Tendinosis Asymptomatic tendon
3 Tendinopathy Generic description for
tendon
4 Paratenonitis Inflammation of the
paratenon
5 Peritendinitis Inflammation of the
peritendon
6 Spontaneous tendon rupture Tendon rupture without
any
7 Partial rupture Incomplete tendon tear
8 Enthesopathy Tendon-bone junction
disorders

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Professor RCRS (RIU)
 Tendon injury and its management
Acute tendon injury
• This can be perhaps best described as either
complete rupture of the tendinous structure
or partial rupture.
• The tendons mostly seen to be suffering
rupture are those bearing higher functional
loads, such as the Achilles and Patellar
tendons

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Professor RCRS (RIU)
 Tendon injury and its management
Acute tendon injury
Causes
• Acute tendon injuries may be predominantly
caused by extrinsic factors
• A sudden, large force or torque applied through
the tendon, perhaps at an oblique angle could
result in a partial or complete tear.
(Incorrect or accidental placement of the limbs,
abnormal surface conditions, neural control mechanism
failure, inappropriate muscle balance.)
•
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Professor RCRS (RIU)
 Tendon injury and its management
Acute tendon injury
Causes
• It has been reported that males present with
tendon injuries more often than females.
• Certain classes of drugs, including antibiotics
(flouroquinolines) and corticosteroids, can
affect the collagen tissue directly. (Sode et al.
2007).
(Increased activation of metalloproteinase, a
regulator of collagen degradation)
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Professor RCRS (RIU)
 Tendon injury and its management
Chronic Tendon Injury
CAUSES
• Overuse injuries can be described as chronic
tendon injuries and fall into the description
for tendinopathies.
• Tensile overload, Tenocyte related collagen
synthesis disruption, Tendon load induced
ischemia, Neural sprouting, and Histological
adaptive compressive responses.

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Professor RCRS (RIU)
Tendon injury and its management
• Clinical diagnosis of tendinopathies involves
manual and visual elements. Pain may or may
not be present, but changes to the tendon
may include swelling, crepitus, tenderness.

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Professor RCRS (RIU)
Tendon injury and its management
• Tendon healing I slow due to
– lower metabolic rate
– the limited blood supply to the tendon tissue
TREATMENT
• Surgery may be advantageous, providing
better functional capacity over non-operative
options (Schepsis et al. 2002);
• The use of a “cascade membrane” to knit the
tendon and accelerate healing. (thin layer of
autologous fibre saturated in platelets)
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Professor RCRS (RIU)
Tendon injury and its management
TREATMENT
• After surgery the patient was immobilised for
a period of four weeks.
• Conservative and non-surgical, treatment
options include: Rest, ice, massage therapy,
eccentric exercise, NSAIDS, ultrasound
therapy, electrotherapy, taping, sclerosing
injections (Polidocanol) , blood injection, and
glyceryl trinitrate patches.

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Professor RCRS (RIU)
Tendon injury and its management
Achilles Tendon Disorders

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Professor RCRS (RIU)
Tendon injury and its management
Achilles Tendon Disorders

Anatomy ???

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Professor RCRS (RIU)
Tendon injury and its management
Achilles Tendon Disorders

Physiology ???

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Professor RCRS (RIU)
Tendon injury and its management
Achilles Tendon Disorders

Biomechanics ???

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Professor RCRS (RIU)
 Tendon injury and its management
Achilles Tendon Disorders
Biomechanics
• Gastrocnemius-soleus-Achilles complex
– Spans 3 joints
• Flex knee
• Plantar flex tibiotalar joint
• Supinate subtalar joint
• Up to 10 times body weight through tendon
when running

Abdul Ghafoor Sajjad Assistant

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Professor RCRS (RIU)
 Tendon injury and its management
Achilles Tendon Disorders
• Pathophysiology
– Repetitive
microtrauma in a
relatively hypovascular
area.
– Reparative process
unable to keep up
– May be on the
background of a
degenerative tendon

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Professor RCRS (RIU)
 Tendon injury and its management
Achilles Tendon Disorders
• 75% of sports-related ruptures happen in
patients between 30-40 years of age.
• Most ruptures occur in watershed area 4cm
proximal to the calcaneal insertion.
• Mechanism
• Eccentric loading (running backwards in
tennis)
• Sudden unexpected dorsiflexion of ankle
• Direct blow or laceration
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Professor RCRS (RIU)
Tendon injury and its management
Achilles Tendon Disorders
POSITIVE THOMPSON TEST

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Professor RCRS (RIU)
Tendon injury and its management
Achilles Tendon Disorders
Ultrasound MRI

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Professor RCRS (RIU)
 Tendon injury and its management
Achilles Tendon Disorders
Management Goals
• Restore musculotendinous length and tension.
• Optimize gastro-soleous strength and function
• Avoid ankle stiffness

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Professor RCRS (RIU)
Tendon injury and its management
Conservative Management
Cast in Plantarflexion cast with
2 wks plantarflexion q 2 wks

4 weeks

Start physio for ROM Allow progressive weight-

exercises bearing in removable cast

2- 4 weeks

Start a strengthening Remove cast and walk with

program shoe lift. Start with 2cm x 1
month, then 1cm x1 month
then D/C
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Professor RCRS (RIU)
Tendon injury and its management
Achilles Tendon Disorders

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Professor RCRS (RIU)
Achilles Tendon Disorders
Physiotherapy

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Professor RCRS (RIU)
Achilles Tendon Disorders
Physiotherapy

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Professor RCRS (RIU)
Achilles Tendon Disorders
Physiotherapy

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Professor RCRS (RIU)
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