1. RCT in eccentric exercise.
From theory to practice: a tendinopathy pathway
Dr Dylan Morrissey
Consultant Physiotherapist and Senior Clinical Lecturer
d.morrissey@qmul.ac.uk
N Webborn, V Rowe, S Hemmings, S Chaudhry, HRC Screen, N Padhiar, T Crisp, JB King, P Malliaras, O Chan,
N Maffulli, JD Perry, C Waugh, H Abdulhussein, S Morton, S Mani-Babu, H Langberg, A Chauhan

2. • How do you conservatively manage
tendinopathy now?
• Is your approach evidence-based?
• What do you think it might be in two years?

3. Dr Dylan Morrissey

4. What is the most important element of your
management pathway?
Progressive loading – mechanotransduction
Does it work quickly or is it too slow?
‘Recent literature concerning the rehabilitation of tendinopathy
confirms that the most important treatment modality is
appropriate loading.’
Scott A, et al. Br J Sports Med 2013;47:536–544. doi:10.1136/bjsports-2013-092329

6. Tendon loading:
clinical reasoning
Young
Very active
Reasonable strength
High load demands
Middle aged
recreational
Moderate strength
Lower load demands
Stress shielded?
Older
sedentary
Weak
Co-morbidities
Stress shielded++
P
Endurance then load then speed
A
Isometrics
Isometrics?
Isometrics?
I Eccentrics
Con-ecc
Eccentrics
Con-ecc
Con-ecc
N Power
Strength-endurance

7. • A young talented player
• on and off pain during warm
up or after training, better
during activity
– Grade 3- out of 5
• Pre-season training
• what to do?
Case 1

8. Tendon loading:
clinical reasoning
Younger
active
Reasonable strength
High load demands
Middle aged
recreational
Reasonable strength
Lower load demands
Older
sedentary
Weak
intrinsic factors+++
e.g. adiposity, menopause
P
Endurance then load then speed
A
Isometrics
Isometrics?
Isometrics?
I Eccentrics
Con-ecc
Eccentrics
Con-ecc
Con-ecc
N Power
Strength-endurance

9. • A very important player during season,
increasing symptoms (pain and stiffness
in the morning) in the Patellar Tendon
weeks before an important match
• What to do ??
Case 2

10. Tendon loading: clinical reasoning
Activity
specific
rehabilitation
Tendon
loading for
tendon
health
ADL
Time
under
tension

11. Balancing ‘tendon loading for tendon health’
with activity–specific rehab and ADL
Tendon
healing
Day
AM
PM
Other activity
that loads
tendon
Mon
✓
✓
Gym (core and UL)
Tue
✓
✸
Train pm
Wed
✓
✓
Thurs
✓
✸
Gym with tendon load
Fri
✸
✓
Train am
Sat
✸
✓
Shopping +++
Sun
✓
✸
train

12. Tendon ecc and con loading –
mechanisms ?
• Tendon
Stress,
strain,
force,
s0ffness
Perturba0on
/vibra0on
Vibration at 1*BW
Vibration at 1*BW + 15kg

13. Where do the (good) vibrations come
from?
Adaptation may be muscle-driven, as well as tenocyte mechanotransduction

14. Top ‘tickets to treatment’
(tendon loading)
• And think about
prevention
ostic
iagn on
D
pici
sus
SWT
R
lume
h vo n
Hig ctio
inje

15. Aim = rapid return to sport / activity with minimal
intervention OLD PATHWAY
Time Diagnostic 2
0
suspicion
4
6
8
10
12
14
16
18
20
22
24 weeks

16. Shockwave Therapy
Study or Subgroup
Control/Alternative
Mean
Total
Mean
SD
Total
22
50.3
36.3
27
SD
Std. Mean Difference
IV, Fixed, 95% CI
Std. Mean Difference
IV, Fixed, 95% CI
RSWT as a ‘ticket to treatment’
2.2.1 Mid-Portion or Insertional Tendinopathy
2.2.2 3 Month VAS
0.20 Costa 2005 SW v P
34.5
34.2
-0.95
0.96
22
-0.24
0.24
27
-1.05 [-1.65, -0.45]
-1.55
35
22
4.23
20
27
-0.21 [-0.77, 0.36]
-88
10
24
-81
16
24
-0.52 [-1.09, 0.06]
4.4
0.9
34
7.1
0.9
34
-2.97 [-3.67, -2.27]
2.9
1.2
34
6.5
0.6
34
-3.75 [-4.56, -2.95]
0.10 Rompe 2007 SW v Ec
4
2.2
25
3.6
2.3
25
0.17 [-0.38, 0.73]
0.10 Rompe 2007 SW v Wait
4
2.2
25
5.9
1.8
25
-0.93 [-1.52, -0.34]
2.1
1.1
34
2.9
1.8
34
-0.53 [-1.01, -0.05]
0.10 Rompe 2007 SW v Ec
-70.4
16.3
25
-75.6
18.7
25
0.29 [-0.27, 0.85]
0.10 Rompe 2007 SW v Wait
-70.4
16.3
25
-55
12.9
25
-1.03 [-1.62, -0.44]
0.10 Rompe 2009 EcSW V Ec
-86.5
16
34
-73
19
34
-0.76 [-1.25, -0.27]
4.2
2.4
35
8.2
1.1
33
-2.10 [-2.70, -1.50]
2.9
2.1
35
7.2
1.3
33
-2.42 [-3.05, -1.78]
3
2.3
25
5
2.3
25
-0.86 [-1.44, -0.27]
-79.4
10.4
25
-63.4
10
25
-1.54 [-2.18, -0.91]
2.2.3 FIL
0.20 Costa 2005 SW v P
-0.44 [-1.01, 0.13]
(tendon loading)
2.2.4 EQol
Systematic
Review
Submitted
0.20 Costa 2005 SW v P
2.2.5 AOFAS
Var Rasmussen 2008 SW v P
2.2.6 Mid-Portion Tendinopathy
2.2.7 1 Month VAS
0.21 Furia 2008 SW v Cons
2.2.8 3 Month VAS
ASSERT
trial
0.21 Furia 2008 SW v Cons
2.2.9 4 Month VAS
0.10 Rompe 2009 EcSW V Ec
SWT
R
2.2.10 VISA-A
2.2.11 Insertional Tendinopathy
2.2.12 1 Month VAS
0.21 Furia 2006 SW v Cons
2.2.13 3 Month VAS
0.21 Furia 2006 SW v Cons
2.2.14 4 Month VAS
0.12 Rompe 2008 SW v Ec
2.2.15 VISA-A
0.12 Rompe 2008 SW v Ec
-4
-2
0
2
Favours Shockwave Therapy Favours Control/Alt
4

17. Acute effects of ESWT on tendon interleukins.
Waugh C, Morrissey D, Maffulli N, Screen H – unpublished data
Percentage Baseline
(%)
IL-6
Concentration (% Pre)
1000000
100000
10000
1000
100
10
1
IL-8
Concentration (% Pre)
1000000
100000
10000
1000
100
10
1

18. IL-6
Concentration (pg/ml)
1000000
100000
10000
1000
100
10
1
Concentration (pg/ml)
1000000
100000
10000
1000
100
10
1
IL-8

19. • One of your players
experiences sudden onset
of pain in the Insertional
Achilles tendon during
training but only during
high loading.
• What to do ?
Case 3

20. Diagnostic suspicion as a ‘ticket to
treatment’ (tendon loading)
• Intra Tendinous tears
•
(Morton, Chan, Morrissey et al 2013 BJSM in
review )
• N = 37, 5% of 740 Achilles scanned over
48 months.
• Younger, more athletic, sudden increase
pain, 92% co-existing TAopathy, impact
related pain.
ostic
iagn on
D
pici
sus

21. Diagnostic suspicion as a ‘ticket to
treatment’ (tendon loading)
• Fascia crura tears
(Webborn, Chan, Morrissey BASEM
2013)
• N = 12 (+35) Younger, more
athletic, sudden increase pain,
most co-existing TAopathy,
impact related pain.
ostic
iagn on
D
pici
sus

22. • One of your players
experiences sudden onset
of pain in the Insertional
Achilles tendon during
training but only during
high loading.
• What to do ?
– Image
– ?prolotherapy
– Immobilise
– Graduated rehab
Case 3

23. Tendon tear and loading: clinical
reasoning: elite rugby league
Early
0-2 weeks
Reduced strength
Low load demands
Late
4-6
Respect pain at all stages
Reasonable strength
Moderate load demands
Strength normalised
High load demands
Endurance then strength then power and impact. Running last
Build numbers then load then speed in later stages
Isometrics / ADL
Con-ecc
Build endurance
Loaded con-ecc
Strength > power
Power work
Run focus

24. Power and running training: tendon tear
SO – late stage from ~5-7 weeks
Initial
late
Mderate power demands
Middle late
Full
training
High power demands
Interaction between tendon rehab and sports specificity
Initial running: building
distance then speed
From jogging to run Fast starts, Max speed,
With slow starts
spikes etc. Possibly after
period of partial weight
bearing sprints – eg
aqua / alter-G

25. Usual post tear progression – SO 3
•
From Wednesday, twice per day each day: ALL 3s up 3s
down
1. Day 1: Double leg WB calf raises 4 sets by 8 reps 3s
up 3s down (to the floor) twice daily for a day
2. 4 by 12 for a day
3. Day 3: Progress to single leg 4 sets by 8 reps for a day
4. 4 by 12 for a day
5. Day 5: Progress to over step 2 legs 4 by 8 for a day
6. 4 by 12 for a day
7. Day 7: Progress to one leg 1 day over step 4 sets by 8
reps
8. 4 by 12 for a day
• Progress to adding load: 10 kg per week to 50%
bodyweight • Relative tendon rest days in between strong loading
sessions

26. HVIGI as a ‘ticket to treatment’
(tendon loading)
• Do not get too excited!
• ~50ml ( saline + LA +
steroid)
• Image-guided
– Deep to tendon
– Adjacent to primary area
of neo-vascularisation
Reduces pain AND Allows
lume
h vo n
loading
Hig
tio
injec
WORKS REALLY WELL – see
Anders Boesen presentation!

27. How put it all together?
Dr Dylan Morrissey

28. AMENDED PATHWAY
Time 0
2
4
Prevention a
research
priority
6
8
10
12
14
16
18
20
22
24 weeks

29. Risk
factors
–
TA
(n
=
421)
Age-­‐
and
weight-­‐
matched
analysis
Highly
significantly
associated
(p<0.01)
Significantly
associated
(p<0.05)
Not
associated
Male
gender,
scia0ca,
low
arched
feet,
contracep0ve
use,
post-­‐menopausal
status,
diabetes,
smoking
and
hypercholesterolaemia
Hamstring
and
calf
strain,
ankle
sprain,
back
pain
and
0ght
hamstring
muscles
Tight
calf
muscles
and
hypertension

30. Join in!
http://patellartendinopathyquestionnaire.blogspot.com/
http://www.achillestendinopathyquestionnaire.blogspot.co.uk/
@DrDylanM

31. Now ... Going forward
• What is your conservative management
paradigm now?
• Is it evidence-based?
• What do you think it might be in two years?

32. In summary
• A simple inter-disciplinary care pathway
• Good evidence for success of different
elements
• Developing evidence about mechanisms
• Key points
– Progressive load management
– Diagnostic suspicion
– Tickets to treatment
– Combined treatments

33. It is all about teamwork

34. Thank you
Sports and Exercise Medicine MSc
Treatment for difficult to help patients
17th Annual Scientific Meeting
September 2014
@DrDylanM
d.morrissey@qmul.ac.uk