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6 Om icke operativ behandling beslutas skall patienten överväga att modifiera sin aktivitetsnivå. Undvika snabba stopp och vridningar

7 Reflex Inhibition Smärta och svullnad medför inhibition av voluntär muskelaktivitet. Mål: Minska smärta och svullnad.

8 Tidig rörelseträning? Animal studies have shown that physical training affects the characteristics of ligaments Tensile Strength Elastic Stiffness Total weight of ligamentous tissue Message: Improved biomechanical properties of the ligament-bone junction by exercise Tipton 1984

9 Motion studies: Human subjects (Woo, et al 1982) Answer: In principle, motion should start as early as possible, as it improves both the structural and mechanical properties

10 Should early motion be allowed in ACL reconstructed patients? T. Häggmark and E. Eriksson (1978 ): Early motion is possible and even beneficial after ACL surgery Answer: Yes

11 ACL Rehabilitation What motions are safe to carry out post-operatively without compromising ACL graft integrity and healing?

12 ACL strain pattern during open kinetic chain - active flexion-extension

13 Closed kinetic chain exercise - Squatting with and without Sport Cord

14 ACL Rehabilitation Study at our department showed that doing only functional exercises during ACL rehabilitation can lead to muscular weakness i.e. not regaining full strength. Conclusion: CKC should be combined with OKC (Mikkelsen, Werner ESSKA Journal 2001)

15 Rehabilitation Exercise Peak Strain Isometric quads 15 o (30 Nm) 4.4 (0.6)% 8 Squatting w/ Sport Cord 4.0 (1.7)% 8 Active flexion-extension w/ 45 N weight boot 3.8 (0.5)% 9 Lachman test (150 N; 30 o flexion) 3.7 (0.8)% 10 Squatting 3.6 (1.3)% 8 Active flexion-extension of the knee (no weight boot) 2.8 (0.8)% 18 Simultaneous quads and hams 15 o 2.8 (0.9)% 8 Isometric quads 30 o (30 Nm) 2.7 (0.5)% 18 Anterior drawer (150 N; 90 o flexion) 1.8 (0.9)% 10 Stationary Bicycling 1.7 (1.9)% 8 Isometric hams contraction (-10 Nm; 15 o flexion) 0.6 (0.9)% 8 Quads and hams co-contraction (30 o flexion) 0.4 (0.5)% 8 Passive flexion-extension of the knee 0.1 (0.9)% 10 Isometric quads contraction (30 Nm; 60 o flexion) 0.0% 8 Isometric quads contraction (30 Nm; 90 o flexion) 0.0% 18 Quads and hams co-contraction (60 o flexion) 0.0% 8 Quads and hams co-contraction (90 o flexion) 0.0% 8 Isometric hams contraction (-10 Nm; 30 o, 60 o & 90 o ) 0.0% 8 n

16 The use of FKB- a summary Biomechanics: FKB have some stabilizing effect on the knee during lower loads Proprioception: Some enhancing effects Clinical: --FKB are not needed after ACL surgery --FKB seem to be beneficial for ACL deficiency Conclusion: There is a role for FKB in the management of knee instability

17 Aggressive rehabilitation after ACL surgery - Any risks? Human Studies Aggressive early rehabilitation after surgery using the hamstring tendons had increased risk of residual laxity compared to the B-PT-B. (Muneta et al, Journ. Orthop. 22, 1998) Aggressive rehabilitation resulted in increased laxity and swelling after three months as compared to conventional rehabilitation. (Johnson, Beynnon, Renström et al. 1999)

18 Take home message Effects of inactivity and immobiliztion are devastating for recovery Early motion and loading are important for recovery of the musculo- skeletal tissues after injury A well designed goal-oriented program is the only way for a speedy and safe recovery after injury

19 Take home message ACL injuries are still the greatest problem in Orthopedic Sports Medicine!! Surgery of knee ligaments injuries is not only surgery--rehabilitation is as important!! ACL reconstruction will not restore the knee to normal!! Management of knee injuries is a team work!! Many questions remain to study to get answers!!

20 Final words: We must know what we are doing Our actions must be based on science combined with long term experience More Science is needed!

21 Riktlinjer Individuell Välfungerande team work mellan behandlande läkare, sjukgymnast och patient Funktionell styrke- och koordinationsträning Tidig rörlighetsträning

22 Patellarluxation

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26 För tunga belastningar För många upprepningar För hastiga rörelser För snabb stegring av träning För hög intensitet För kort vila mellan träningspass För ensidig träning För oregelbunden träning Bristfällig teknik För varmt / kallt Mörker Dålig utrustning Överbelastningsskador - uppstår pga av. Bristande rehabilitering av tidigare Yttre faktorer Inre faktorer skador Anatomiska felställningar Benlängdsskillnad Nedsatt balans Nedsatt koordination Muskelsvaghet Muskelobalans Nedsatt rörlighet Instabilitet i led Ungdom/hög ålder Över/undervikt

27 Träningsvärk Lindrig form av akut muskelskada Muskelsmärta som uppstår 24-48h efter ovant, ffa excentriskt muskelarbete Inflammation, ödem och ökat i.m. tryck Elektronmikroskopiskt har man påvisat rupturer i Z-banden som förbinder sarkomererna Fria radikaler frisätts och kan orsaka träningsvärken men kan även ha en fysiologisk betydelse för regeneration och adaptationen av skelettmuskeln (GM Close, Comp Biochem Physiol A Mol Integr Physiol Sep 6)

28 Senskador Tendinopathy is the combination of tendon pain, swelling and impaired performancce indicates the clinical diagnosis tendinopahy Paavola et al 2002, Maffuli et al 2002

29 Ålderns betydelse 8-18 years Muscle-tendon junction problems years Increasing incidence after years 55 år Decrease in ultimate strain and load, tensile strength, and an increase in stiffness (Banks et al 1999). The rate of degeneration with a age can be reduced by regular activity (Jozsa, Kannus 1997) Shoulder injury increasingly common with age --18%

30 Riskfaktorer extrinsic factors: - felaktig träning - underlag intrinsic factors: - malalignments - muskelsvaghet -ålder Kom ihåg! Ont om bra studier

31 Extrinsic factors It is clinically accepted that a change in load, training errors (linked to a change in load), changes in the environment, and change or faults with equipment can result in onset in tendon symptoms (Kannus, 1997). Other extrinsic factors have little evidence to support them and further research is required.

32 Proven intrinsic factors Do they need biomechanical corrections?? Intrinsic factors associated with Achilles tendinopathy are Malalignment of lower leg in 60% of Achilles disorders Increased forefoot pronation ( Nigg 2001) Increased hindfoot inversion, decreased dorsiflexion with the knee in extension and varus deformity of the forefoot (Kaufmann et al.2000) Limited mobility of the subtalar joint and rom of the ankle (Kvist 1991) Conclusion: Biomechanical abnormalities should be corrected but may not be important (Åström 1997)

33 Pathology?? Is inflammation present? No or minimal (3-5%) inflammation Arner 1959, Puddu 1976 Alfredson et al 2000, Zamora & Marini, 1988 But it is important to note that the absence of inflammatory modulators at end stage disease does not mean that they are not present in early stage disease Tendinosis is degenerative process of tendons, seen as hyaline and mucoid degeneration, lipomatous infiltration of tendon, fibrillation of collagen fibres Puddu et al 1976

34 What should these overuse tendon conditions be called? Conclusion: Tendinits is wrongly usually used for chronic tendons conditions that in reality are tendinosis This leads the athletes to underestimate the proven chronicity of the problem Maffuli, Kahn, Puddu 1998 Suggestion: Let us call these chronic painful degenerative tendon conditions for tendinopathy

35 Akut krepiterande akillestendinit (Paratenoit) Symptom/statusfynd: Smärta Svullnad Palpömhet Rodnad Krepitationer

36 Akut krepiterande akillestendinit (Paratenoit) Patogenes: Extrinsic Ändrad träningstyp och intensitet Överbelastning Barfotalöpning Intrinsic Hyperpronation Pes cavus Begränsad rörlighet i foten Varus i bakfoten Minskad dorsiflektion (Kaufmann et al.2000)

37 Akut krepiterande akillestendinit (Paratenoit) Behandling: Gips 3-4 dagar Orala NSAID Alternativt Heparin IE iv under 3-4 dagar Klackförhöjning 2-3 veckor

38 > 3 månaders duration Kronisk akillestendinit

39 Diagnos Anamnes Status Ultraljud MRT Remember: Imaging gives anatomic, not functional information Diagnosis is clinical!! Experience vital!!

40 Behandling Successivt ökad ffa excentrisk träning Sklerosering av blodkärl ESWL Akupunktur Kortison??? undvik! Sjukgymnastik Om konservativ behandling misslyckas får man överväga operation

41 Excentrisk träning Hypotes: Stärker senor genom stimulering av mekanoreceptorer i tenocyter som i sin tur producerar kollagen

42 Excentrisk träning The idea of eccentric exercise in treating tendinopathy was introduced by Curwin and Stanish in 1984 In a prospective randomized study on Achilles chronic tendinopathy verified by ultrasound eccentric training was shown to be effective (Alfredson et al 2001, 2003)

43 Effects of exercise Relative changes from rest to exercise Tendon Muscle Blood flow 3-7 fold fold Oxygen uptake 3-6 fold fold Glucose uptake 2-3 fold 5-15 fold

44 PICP (ug/l) Sick tendon * Collagen type I production after eccentric training Healthy tendon Achilles tendon pain Unilateral >3 months n=10 Elite football players 12 weeks training Before After Before After (Ellingsgaard, Langberg & Kjær. unpublished) Courtesy of Dr Kjaer

45 Acupuncture- effective? Effective through Analgesia Improvement of circulation Immunological response (KM Chan 2003)

46 Extracorporal Shock Wave Therapy (ESWT) Longitudinal studies: great --ESWT is reported effective (Rompe 1996,Ogden 2001). Comparative study (CJSM): good --It shows comparable outcome to surgery of patellar tendinopathy (Peers et al 2003) Could be indicated in insertional tendinopathy after other consevative treatment failed Be aware: More research is needed!!

47 Sclerosing therapy Material Mid-portion n=58 elite athletes n=11 injections:n=146 Distal n=18 elite athletes n=4 injections n=56 Results promising but there is reason for caution Alfredson et al Knee Surg, Sports Traumatol, Arthrosc, 2003

48 Surgery some background Remember: An incision gives a strong healing response Surgical technique is probably not very important. Observations: We do not know the physiological and biological bases for the effect of surgery. The relationship operative treatment and healing is not well understood (Jozsa, Kannus 1997).

49 Surgical management of Achilles and patellar tendinopathies There are no validated surgical protocols Technique: Needling, Coblation, Percutaneous (ultrasound guided) tenotomy, Percutaneous paratenon stripping, Open tenotomy and paratenon stripping, Tendon grafting Arthroscopic debridement (tendoscopy) is slowly taking over Surgery is not difficult technically but experience is need to decide what to do.

50 Return to sports after surgery for tendinopathy may take long time!!!! Rule of thumb for return to sport: When there is no increase of symptom Chronic injury may require 4-6 months for Achilles tendinopathy 6-12 months for patellar tendinopathy 8-14 months for rotator cuff

51 Jumper s knee (Patellarsenetendinopati) Överbelastning t t ex basketbollspelare, volleybollspelare Små rupturer Granulationsvävnad Behandling: Vila Avlastande ortos Excentrisk träning Operation

52 Morbus Osgood-Schlatter Morbus Sinding-Larsen- Johansson

53 Löparknä

54 Patello femorala smärtor, PFSS eller främre knäsmärta Orsak okänd

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56 Behandlingsstratergi PFSS Standardiserad information om knäledens funktion, symtom och behandlingsmöjligheter Ett succesivt stegrat träningsprogram En smärthanteringsmodell Dagboksanteckningar

57 Bursiter Prepatellar bursit Infrapatellar bursit Pes anserinus bursit

58 Bakercysta

59 Stressfrakturer - uppkommer vid oförmåga hos friskt ben att motstå submaximal upprepad belastning eller en plötslig ökning av belastningen

60 Stressfrakturer Vanliga lokalisationer Utmattningsbrott Vanligast i tibia 53,5% Metatarsalben 18,3% Långdistanslöpare Balettdansöser Militärer Vanligare hos kvinnor

61 Stressfraktur Symtom Belastningssmärta, definitionsmässigt utan trauma Smygande debut Med tiden tilltar smärtorna i styrka med molande värk och tiden till besvärsfrihet blir allt längre Kontinuerligt smärttillstånd

62 Klinisk undersökning Stressfraktur Lokaliserad palpationsömhet Ibland svullnad Perkussion är i regel smärtsam Stämgaffelvibrationer mot det ömmande området ger obehag eller smärta

63 Radiologisk undersökning Stressfrakturer Konventionell röntgen frakturlinje eller periostal bennybildning tidigast 3 v efter symtomdebut MRT Skelettskintigrafi Datortomografi

64 Behandling Stressfraktur Partiell avlastning Alternativ träning Ev gips, ortos Gradvis återgång till full aktivitet under 8-12 veckor Ev operation

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66 Plantarfascit Hyperpronation Backträning Pes Cavus Ömhet och smärta vid fascians ursprung

67 Plantarfascit Diagnos: Status och ev rtg Behandling: Avlastning Alternativ träning Inlägg (lokal tryckavlastning och stöd i hålfoten) Stretching Kortisoninjektion (Cave ruptur!)

68 Benhinneinflammation Behandling: Stretcha baksidan och stärk framsidan av underbenet

69 Tack för uppmärksamheten