Entesopatier T6. The enthesis organ

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Stefan Falk
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1 Entesopatier T6 The enthesis organ Sena, ligament, kapsel (kollagen, trådbrosk) Bursa (synovial vävnad) Fettkudde (innervation) Ben (hävarm, osteofyt) 1

2 Entesopatier (senor, ligament, kapslar) Achilles-sena Patellar-sena Supraspinatus-sena Ext. Carpi Rad. Brev. (Lat. epikondylalgia) Runners knee tractus iliotib. Biceps brachii Biceps femoris Achillodyni FTA-ligament ACL MCL Entesopatier (senor, ligament, kapslar) Plantara fascian 2

epikondylalgia) Runners knee tractus iliotib.

3 Achilles tendon (T) is directly continuous with the plantar fascia (PF) the calcaneus (C) the heel fat pad (HP) extends upwards behind the tendon and that its fibrous septa are connected to it (arrows). The enthesis organ of the adult Achilles tendon (T). The enthesis fibrocartilage (EF) sesamoid fibrocartilage (SF) periosteal fibrocartilage (PF) the superior tuberosity (ST) the retrocalcaneal bursa (RB) Kager s fat pad (KP) the heel fat pad (HP) 3

The enthesis organ of the adult Achilles tendon (T).

4 FIG. 6. The anatomy of the collateral ligaments (CLs) of the IP joints of the hand. Each CL is a relatively large structure which extends from the proximal (PP) to the intermediate phalanx (IP), and is bounded by the volar plate (VP) on the volar surface. This latter structure is closely related to the flexor tendons (FT) and their sheaths (FS). The sturdy CLs prevent abduction and adduction of the IP joints to allow for more precision grasp and grip manoeuvres. The size and functional stresses on this joint make it especially prone to microdamage. McGonagle et al, Reumatol 2008 FIG. 5. Collateral ligament (CL) attachments in the small synovial joints of the hand. (A) A simplified view of the CL showing it attaching to the bone just beyond the articular cartilages (AC). (B) A more accurate representation of the position of its attachment sites i.e. it shows that one end of the ligament (the PP end) is attached in a pit (P) further away from the joint itself so that the bone and ligament can interact in the intervening region. This illustrates the close functional interdependence between the ligament and the immediately adjacent bone. Both are part of the enthesis organ. (C) An enlargement of the CL enthesis at the pit showing the differentiation of the cartilage into the enthesis fibrocartilage (EF), periosteal fibrocartilage (PF) and the synovial fibrocartilage (SF). This shows how the enthesis organ, including the sesamoid fibrocartilage that may line ligaments adjacent to insertions, is also intimately linked with the synovium and these structures form an SEC (PP: proximal phalanx; DP: distal phalanx). 4

This latter structure is closely related to the flexor tendons (FT) and their sheaths (FS).

5 Excentrisk träning Sklerosering Akupunktur Steroidinjektion Entesopatier Behandling Normal tendon Early inflammation Failed healing response Battery L et al, 2011 Sports Med Arthrosc Rev Tendon pain Normal tendon Kahn & Cook, 2006 Acute inflammatory tendinitis - Poly-nuclear leucocytes - SP Chronic non-inflammatory tendinosis - Collagen degeneration - Disorganizad tissues - Fibrosis - Neovascularization - Glutamate - NGF - BDNF Reactive tendinopathy McCreesh K & Lewis J, 2013 Int. J. Exp. Path Tendon disrepair - Degenerative tendinopathy 5

Poly-nuclear leucocytes - SP Chronic non-inflammatory tendinosis - Collagen degeneration - Disorganizad tissues - Fibrosis -

6 Abates M et al, 2009, Arthritis Research & Therapy Maayke N et al, 2011, Knee Surg Sports Traumatol Arthrosc 6

7 Varför fungerar excentrisk träning? 1. Ökad stiffness i senan (Pousson-90) 2. Förbättrad muskelstyrka (Alfredson -98) 3. Traumatisk effekt på nerv/kärlinväxt (Öhberg-04) 4. Excentriskträning stimulerar till en normaliserad senstruktur (Öhberg-04) 5. Ökad kollagensyntes -bättre hållfasthet (Langberg -07) 6. Förlängning av muskel-sen-enheten (Mathieu -08) 7. Oscillerande kraft vid excentrisk belastning ger bättre remodullering via mechanotherapy likheter med ben tillväxt (Rees-08) 8. Excentrisk belastning minskar senans cross-section area (CSA), sker ej vid koncentrisk belastning (Griggs-09) Per Jonsson, Thesis 2010 Umeå Tendinopathy- is a generic term for conditions characterized by: - tendon pain and soreness, - increased proteoglycan content, - collagen disorganization, - cellular changes, - neural and vascular ingrowths. Despite the extent of the problem even basic information on the etiopathogenesis of tendinopathy is lacking and therefore, the existing treatment and prevention strategies have somewhat limited effects. Although overuse is often involved in the development of tendinopathy, tendinopathy is occasionally seen in sedentary subjects, and an interesting association with increased abdominal fat distribution/dyslipidemia has recently been documented (Gaida et al., 2009). So the question is if we need to differentiate between loading-induced conditions and metabolic-induced conditions. Kongsgaard & Langberg Scand J Med Sci Sports

Oscillerande kraft vid excentrisk belastning ger bättre remodullering via mechanotherapy likheter med ben tillväxt (Rees-08) 8.

8 Olika inflammatoriska reaktioner Bakomliggande orsak Mek.belastning Celldöd Hypoxi Metabol dysfunktion Kärlskada Vävnadstyp (kärlrik eller inte) Muskel Sena Brosk Ben Synovial vävnad Återhämtningsförmåga Ålder Dyslipidemi Hyperglykemi Sömn Tobak Avslutande av inflammation: Resolviner Serhan C & Savill J, 2005 NATURE IMMUNOLOGY Pedersen, BK Brain Behavior and Immunity,

Sena Brosk Ben Synovial vävnad Återhämtningsförmåga Ålder Dyslipidemi Hyperglykemi Sömn Tobak

Kan inte ligga på knä, utan att det gör ont. Stötöm under knät.

9 Evidens Entesopatier - akupunktur Axelsmärta Armbågssmärta Vad är detta? Smärta under knät i samband med träning och efter. Kan inte ligga på knä, utan att det gör ont. Stötöm under knät. Upplever en liten uppdrivning under knät. Osgood-Schlatters sjukdom Springpojks sjukan 9

10 Vad är detta? Smärta i hälen vid ansträngning Svårighet att ta på skon, för det gör ont i hälen. Vilovärk i hälen efter ansträngning Mb Haglund Haglunds sjukdom Apofyser Mb Schlatter Mb Sinding-Larsen, Johansson Little league elbow Tuber ossis ischii SIAS 10

11 Osteochondroser Specifika Mb Sinding-Larsen-Johansson Mb Osgood-Schlatter 11

12 Anterior knäsmärta Diff. diagnoser Vanliga Patellar tendinopati (Jumpers knee) Patellofemoralt smärtsyndrom (Främre knäsmärta) Anterior knäsmärta Diff. diagnoser Vanliga Mindre vanliga Patellofemoralt smärtsyndrom (Främre knäsmärta) Patellar tendinopati (Jumpers knee) Knädistorsion Patellar luxation Meniskskada Ligamentsskada Specifika Mb Sinding-Larsen-Johansson Mb Osgood-Schlatter Stressfraktur i tibia Plica syndrom Prepatellär bursit Infrapatellär bursit Q-ceps tendinopati Fat pad impingement Kondrala skador Popliteustendinit Bicepstendinit Tractus iliotib. tendinit Flaggor Refererad smärta (höft) Osteochondritis dissecans Perthes sjd Tumör (osteosarkom) 12

Ligamentsskada Specifika Mb Sinding-Larsen-Johansson Mb Osgood-Schlatter Stressfraktur i tibia Plica syndrom Prepatellär bursit Infrapatellär bursit Q-ceps

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