Podcast
Questions and Answers
What is the first step in diagnosing a tendon or ligament injury?
What is the first step in diagnosing a tendon or ligament injury?
Which examination technique is specifically mentioned for evaluating dynamic function?
Which examination technique is specifically mentioned for evaluating dynamic function?
What does the 'Gold Standard' refer to in diagnostic imaging for tendon injuries?
What does the 'Gold Standard' refer to in diagnostic imaging for tendon injuries?
Which of the following factors is important when constructing a differential diagnosis for tendon and ligament lesions?
Which of the following factors is important when constructing a differential diagnosis for tendon and ligament lesions?
Signup and view all the answers
What aspect of tendon and ligament injury does not typically change with injury?
What aspect of tendon and ligament injury does not typically change with injury?
Signup and view all the answers
What is a primary goal of tendon and ligament treatment?
What is a primary goal of tendon and ligament treatment?
Signup and view all the answers
Which treatment option is considered the gold standard for eccentric loading of the affected structure?
Which treatment option is considered the gold standard for eccentric loading of the affected structure?
Signup and view all the answers
How does the severity of the lesion affect healing?
How does the severity of the lesion affect healing?
Signup and view all the answers
What role does cryotherapy play in tendon and ligament treatment?
What role does cryotherapy play in tendon and ligament treatment?
Signup and view all the answers
What is a consequence of a chronic lesion compared to an acute one?
What is a consequence of a chronic lesion compared to an acute one?
Signup and view all the answers
What is the benefit of controlled and gradually increasing exercise after tendon or ligament repair?
What is the benefit of controlled and gradually increasing exercise after tendon or ligament repair?
Signup and view all the answers
Which of the following treatments may be necessary before comfortable movement is restored?
Which of the following treatments may be necessary before comfortable movement is restored?
Signup and view all the answers
Which statement correctly describes the treatment options available for tendon and ligament injuries?
Which statement correctly describes the treatment options available for tendon and ligament injuries?
Signup and view all the answers
Which of the following options should be initiated for pain relief in the postoperative period for the horse?
Which of the following options should be initiated for pain relief in the postoperative period for the horse?
Signup and view all the answers
What is the most beneficial treatment for improving collagen synthesis in a horse's ligament?
What is the most beneficial treatment for improving collagen synthesis in a horse's ligament?
Signup and view all the answers
What is the most common hind limb soft tissue injury in large breed dogs?
What is the most common hind limb soft tissue injury in large breed dogs?
Signup and view all the answers
Which diagnostic test is needed for assessing structures commonly injured in dogs with hind limb lameness?
Which diagnostic test is needed for assessing structures commonly injured in dogs with hind limb lameness?
Signup and view all the answers
In a post-surgery case, which symptoms should be monitored for effective rehabilitation?
In a post-surgery case, which symptoms should be monitored for effective rehabilitation?
Signup and view all the answers
What is an appropriate method for reducing periligamentous thickening post-surgery in horses?
What is an appropriate method for reducing periligamentous thickening post-surgery in horses?
Signup and view all the answers
What is a primary cause of degeneration in tendons?
What is a primary cause of degeneration in tendons?
Signup and view all the answers
What aspect of healing significantly improves prognosis in horses post-surgery?
What aspect of healing significantly improves prognosis in horses post-surgery?
Signup and view all the answers
Which type of tendon lesion involves partial or complete tearing?
Which type of tendon lesion involves partial or complete tearing?
Signup and view all the answers
Which of the following may help improve the ultrasound appearance of a ligament during recovery?
Which of the following may help improve the ultrasound appearance of a ligament during recovery?
Signup and view all the answers
What is the primary composition of tendons based on dry weight?
What is the primary composition of tendons based on dry weight?
Signup and view all the answers
Which tendon lesion type is characterized by the presence of fiber flaps or tears at the periphery?
Which tendon lesion type is characterized by the presence of fiber flaps or tears at the periphery?
Signup and view all the answers
What is likely to occur as tendons mature and age?
What is likely to occur as tendons mature and age?
Signup and view all the answers
Which of the following is NOT a type of ligament lesion?
Which of the following is NOT a type of ligament lesion?
Signup and view all the answers
What is the main function of tenocytes in tendons?
What is the main function of tenocytes in tendons?
Signup and view all the answers
Which condition involves sudden overloading that exceeds the tendon's resistive strength?
Which condition involves sudden overloading that exceeds the tendon's resistive strength?
Signup and view all the answers
What is one of the initial responses of tendons to injury as observed through ultrasound?
What is one of the initial responses of tendons to injury as observed through ultrasound?
Signup and view all the answers
Which phase of healing occurs from 2 to 28 days after tendon or ligament injury?
Which phase of healing occurs from 2 to 28 days after tendon or ligament injury?
Signup and view all the answers
During tendon healing, what is one consequence of the inflammation phase?
During tendon healing, what is one consequence of the inflammation phase?
Signup and view all the answers
What is a key difference in the healing process between tendons and ligaments?
What is a key difference in the healing process between tendons and ligaments?
Signup and view all the answers
Which of the following is a pathological change seen in ageing tendons?
Which of the following is a pathological change seen in ageing tendons?
Signup and view all the answers
What type of collagen is primarily associated with myofibroblastic scar formation during remodelling?
What type of collagen is primarily associated with myofibroblastic scar formation during remodelling?
Signup and view all the answers
What effect does excess strain on tendons and ligaments primarily lead to?
What effect does excess strain on tendons and ligaments primarily lead to?
Signup and view all the answers
What is the primary goal of tenorrhaphy in tendon treatment?
What is the primary goal of tenorrhaphy in tendon treatment?
Signup and view all the answers
Which of the following is NOT a recommended characteristic of suture material for tendon repairs?
Which of the following is NOT a recommended characteristic of suture material for tendon repairs?
Signup and view all the answers
Which of the following is NOT a sign of the inflammation phase after injury?
Which of the following is NOT a sign of the inflammation phase after injury?
Signup and view all the answers
Which option is a viable material for suture in tendon procedures?
Which option is a viable material for suture in tendon procedures?
Signup and view all the answers
Which of these statements accurately describes the impact of pathological remodelling on tendons?
Which of these statements accurately describes the impact of pathological remodelling on tendons?
Signup and view all the answers
What is one significant advantage of biologic therapies in tendon treatment?
What is one significant advantage of biologic therapies in tendon treatment?
Signup and view all the answers
What does the rate of healing for tendon injuries primarily depend on?
What does the rate of healing for tendon injuries primarily depend on?
Signup and view all the answers
Which method of delivery is NOT mentioned for administering biologic therapies?
Which method of delivery is NOT mentioned for administering biologic therapies?
Signup and view all the answers
What factor is known to significantly promote collagen synthesis in healing tissues?
What factor is known to significantly promote collagen synthesis in healing tissues?
Signup and view all the answers
Which surgical technique is typically used for ligament repair?
Which surgical technique is typically used for ligament repair?
Signup and view all the answers
What is the expected tensile strength of a repaired tendon at one year post-surgery?
What is the expected tensile strength of a repaired tendon at one year post-surgery?
Signup and view all the answers
What is the purpose of prosthetics or implants in ligament surgeries?
What is the purpose of prosthetics or implants in ligament surgeries?
Signup and view all the answers
What should be avoided during the rehabilitation process for tendon treatment?
What should be avoided during the rehabilitation process for tendon treatment?
Signup and view all the answers
Study Notes
Approaches to Tendon & Ligament Disease
- Presented by Jodie Daglish, BVSC MS DACVSMR MRCVS, equine sports medicine and rehabilitation clinician
- At Newmarket Equine Hospital (NEH)
Tendons and Ligaments - Learning Objectives
- Construct a differential diagnosis list based on clinical presentations associated with tendon and ligament lesions
- Select appropriate diagnostics to confirm the lesion
- Select appropriate medical, surgical and complementary treatments of the specific lesion
- Determine appropriate prognosis for the specific lesion
How to Approach a Tendon or Ligament Injury
- Determine location and severity: the function of the structure, how this has changed with injury, constituent parts, how injury affects them, and how they heal
- Restore or improve function
Injury Diagnosis
- History: Obtain a comprehensive history
- Clinical Exam: Palpation (systematic and thorough), Dynamic exam (straight line walk and trot, circles, discipline-specific exam, flexion tests/system perturbation)
- Ancillary Tests: Diagnostic analgesia (regional nerve vs. intra-synovial blocks)
- Diagnostic Imaging: Determine the "Gold Standard"
Injury Diagnosis - Palpation Findings
- Heat
- Sensitivity to digital pressure
- Swelling or thickening (focal or diffuse)
- Loss of definition of the margins of the structure
- Reduced ROM
- +/- Synovial distension
Injury Diagnosis - Dynamic Exam Findings
- Variable severity of lameness
- Mild with desmopathy
- Moderate with tendonitis, enthesopathy
- Moderate to severe with partial to complete ligament or tendon rupture
- Positive to flexion of the affected joint
Diagnostic Imaging of Soft Tissues
- Various imaging modalities are shown (e.g., radiographs, ultrasound, MRI)
- The presentation highlights the choice of imaging based on the specific clinical presentation
Injury Diagnoses - Common Soft Tissue Injuries
- Canine Front Limb: Biceps tendon, Supraspinatus tendon, Collateral ligament of the elbow, Digital flexor tendons, Flexor carpi ulnaris
- Canine Hind Limb: Cranial cruciate ligament, Gastrocnmeius +/- Common calcaneal tendon, Digital flexor tendons
- Equine Front Limb: Superficial digital flexor tendon, Deep digital flexor tendon, ALDDFT/Inferior Check Ligament, Proximal suspensory ligament, Suspensory ligament branches
- Equine Hind Limb: Proximal suspensory ligament, Medial cranial meniscotibial ligament, Suspensory ligament branches
Injury Diagnosis - Why Injuries Occur at Predilection Sites
- Degeneration: Progressive weakening due to ECM synthesis imbalances, Mechanical overuse (micro-injuries)
- Trauma: Sudden overloading, External injury
Tendon Lesion Types
- Core lesions
- Margin tears or flaps
- Fibrillation
- Avulsions/Ruptures
- Adhesions/Contractures
Ligament Lesion Types
- Strains
- Enthesopathy
- Desmopathy (sprain)
- Avulsions (partial or complete rupture)
Normal Tendon Structure and Function
- Tenocytes (fibroblasts): Arranged linearly in parallel between collagen bundles/fibres. Improved arrangement with skeletal maturation, declines with age
- Water (66%): Contributes to the tendon's structure
- Extracellular Matrix (33%): Collagen Type I (mostly, 80% dry weight), Proteoglycans (1-5%), Elastin (2%)
- Inorganic (0.2%): Minerals contribute
Normal Tendon Structure and Function (Continued)
- Diameter varies by structure (from 1.5 nm collagen molecule to 15 mm whole tendon)
- Hierarchical arrangement of collagen. Crimp and inter-fascicular tenocytes
- Tendons transmit forces between muscle and bone (mainly tensile; highest tensile strength 17x body weight)
- Compressive regions (e.g., point of hock, sites of sesamoid bones)
- Functions: concentrate muscle forces, allow directional changes of the skeleton, energy storage (elastic modulus), proprioception (Golgi tendon organ), strength depends on the number, size, and orientation of collagen type I fibres
Normal Tendon Structure and Function - Additional Notes
- Toe region: Non-linear stretch, elimination of crimp; Linear deformation, area of curve where stiffness is determined; Yield region, irreversible lengthening of the tendon; Failure, rupture (approx. 4-10% strain)
- Protective mechanisms: Tendon sheaths (longer surface protection), Bursae (single point protection), Design to protect from shear damage, and Dictates tendon orientation
Normal Ligament Structure and Function
- Ligaments transmit forces between bone and bone: mainly tensile, structural integrity of joints
- Compared to tendon a ligament has: increased % type III collagen (lower volume collagen type 1), higher number of cells, increased PG at high compression sites
- Location: Incorporated into joint capsule (e.g., collaterals, suspensory ligament branches), Intra-synovial (e.g., Cr & Ca CXL, straight distal sesamoidean ligament)
Response of Tendons & Ligaments to Injury
- Tendons: Ultrasound enlargement, intra-tendinous oedema, hypoechoic foci, peritenon thickening, loss of myotendinous/osseous-tendon junctions, increased stiffness, reduced elasticity, reduced ROM
- Ligaments: Minimal oedema, loss of ligament definition, peri-ligamentous thickening, enthesopathy, increased stiffness, reduced/increased ROM
Pathophysiology of Tendon and Ligament Injuries
- A sliding scale from physiological modeling to failure
- Factors like degeneration, mechanical overuse, and trauma can contribute to injury
Ageing and Injury of Tendons
- Darker brown and reddish center at post-mortem due to degeneration
- Focal sites of chondroid metaplasia (high pressure sites)
- Pathological remodeling and progression to injury (tendons and ligaments)
- Predisposed sites (high-strain sites)
- Excessive stretching beyond elastic loading capacity leads to micro-damage and can cause failure
- Microdamage causes fibril breakdown, collagen disruption, loss of structural crosslinks between collagen fibres, chondroid metaplasia, and ischemia
Healing of Tendons and Ligaments
- Inflammation (24 hrs-14 days): Oedema, increased temperature, pain, loss of function
- Repair (2-28 days, peaking at 21 days): Proliferation of tenocytes, production of new ECM
- Remodelling (60+ days): Consolidation of repaired tissue and maturation, aim to minimize scar tissue formation
- Healing events: Intra-synovial and extra-synovial healing; Blood supply is key factor; acute vs. chronic lesions; dependent on duration of lesion
- Factors influencing healing: Severity of lesions, duration of lesion, poor blood supply leads to slower healing
Treatment of Tendons and Ligaments
- Goals: Resolve pain and inflammation, restore function, optimize function
- Treatment options: Many, but few used in isolation; best outcomes found with controlled and gradually increasing exercise, eccentric loading of affected structures, Gold standard (e.g., heel raises)
- Surgical Treatments: Aim to minimize adhesion formation, improve gliding function, remove contamination
- Arthroscopic/endoscopic debridement (equine), tenorrhaphy/tenodesis, open surgical repair (more typical in canine), tenorrhaphy, tenotomy.
- Material Selection for Tenorrhaphy/repair: Should be easy to pass through tissue, non-irritant, good knot security, adequate strength
- Treatment Options: Monofilament nylon, Polypropylene, Polydioxanone
- Ligament Surgical Repair (Mostly canine): Aim to restore joint stability, suture repair as for tendons, anchor through bone tunnel or suture anchor (if tissue destroyed), screw and washer for avulsions; prosthetics/implants
- Restore function = Requires Time: increasing use of biologics, mesenchymal stem cells, adipose-derived stem cells, platelet-rich plasma, autologous protein solution, exercise.
- Optimal Function: Rehabilitation, controlled exercise programs, walking, underwater treadmill, pole work, daily stretches, modalities (Laser, ECSWT, cryotherapy). Prevents adhesions
- Prevention of injury: Starting from low level exercise , gradual loading, warm-up and cool-down periods, regular stretching, hydration, rest days, appropriate nutrition, adequate support
Summary
- Thorough examination and diagnostics critical
- Tendons and ligaments need time, appropriate exercise, and often structural repair for optimal function
- Client education and cooperation are key for positive outcomes
References
- A plethora of references for tendon & ligament physiology, common diseases. Specific titles of books are provided
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Related Documents
Description
Test your knowledge on the diagnosis and treatment of tendon and ligament injuries. This quiz covers key concepts from evaluation techniques to treatment options and their effects on healing. Ideal for students and professionals in sports medicine and physical therapy.
