Lecture 4 - Muscle Tendon Disorders Intervention

Inflammatory Stage (1-7 days)
Inflammatory Stage (7-10 days)

Proliferative Stage Early (2-4 weeks)

Proliferative Stage Late (4-6 weeks)
Remodeling (6wks to 1 year)

Pain, swelling, potential redness to bruising, increased heat
goal - protect

pain with active ROM
may still have minor swelling but no increased heat
safe to move tissue
Goal - pain mediation and tissue repair

mobility may still be limited by pain
no pain at rest
willingness to move
goal - optimize tissue repair - motor learning
reduce abberrant movement

pain free movement for the most part
Goal - tissue repair and remodeling

pain free movement with relatively good control but limited tolerance to increase activity
Goal - return to prior activity - functional goals of PT

no less than 12 weeks of active intervention

targeted to patient goals/activities
Include active task oriented exercise
ST control
Address key impairments
symptom management

Optimize patient education, pain, tissue condition and recovery, expectations and outcomes
minimize pain
improve movement coordination
improve strength
restore UE function

minimize physical stress
modify activity
monitor impairments

provide mild-moderate physical stress
address specific impairments
restore basic level functional activity

provide moderate-high physical stress
address specific impairments
restore high demand functional activity

ROM abnormalities
Joint hypomobility or Hypomobility
Muscle Stiffness/Length deficits
Altered Movement strategies

Muscle imabalance/weakness ST
Muscle imbalance/weakness RTC
Muscle imbalances/weakness intrinsic and extrinsic finger muscles

Relatively normal ROM
Altered muscle performance and balance within the UE, ST, RTC
Poor endurance ST/Trunk muscles

Education
Exercise
Manual Therapy

on disease process and pain
Pain science and expectations
reframing thoughts, beliefs, and misconceptions around tissue injury and pain
role of active movement and exercise in tendon health
addressing any risk factors that may increase risk for prolonged recovery or re-injury: Sleep and Diet/Nutrition

usually 5 is fine, need to work with patient to see how far int red zone you can push
As long as pain goes down after exercise and sleep, it's fine to load that much

individual tailored tendon loading programs including: isometric, isotonic, eccentric, heavy slow resistance, plyometrics

address impairments in joint or muscle mobility in combination with exercise
Restore mobility and Reduce pain

sustained holds or oscillations at the tissue barrier to enhance and improve movement
Requires time under tension (1-3 min) -> #creep!

joint manipulation and mulligan's mobilization

high velocity low amplitude thrust techniques

sustained lateral glides with active gripping

effective but not on their own

as early as possible

Goal: restore optimal joint and muscle length/movement
- Manual Therapy to GH joint Grade III (stretch the joint capsule)
- Manual Stretch Pec major/minor at the shoulder or other stiff soft tissue
Promote optimal stress to Tendon with exercise
- enhance ST muscle activation control
- Regain load tolerance in RTC tendons

deload early with asssisted motion not resisted prime movement
intermittent low load contraction isometric onctractions
short level eccentric contractions
progressive resistance exercise as tolerated

Activate RTC safely
Enhance ST endurance and stability
Reload the RTC

Manual Stretching: Pec minor/major
Joint Mobilization: Caudal/Dorsal Glide, Thoracic Spine manipulation/mobilization

Pulley assisted flexion
Pulley assisted abduction
Closed grip pull downs
Pulley assisted Rotation
Gentle Elbow Flexion
Prone Shoulder extension
Dosage: low load and high reps - 3 sets 30-40 reps with 5-6 exercise in treatment session

Goal - Restore optimal joint position sense and control of movement
If joint position awareness problem Address! Stability exercise
Closed chain exercise for trunk and shoulder girdle, balance muscle performance around the shoulder
Promote optimal stress to Tendon with exercise
Enhance ST muscle activation control
Regain load tolerance in RTC tendons

deloaded intermittent low contraction, short level eccentric contraction
may need emphasis on ST control and arm position

closed chain exercise: early in ther ex program
engage RTC: gets RTC to work without doing much

Control of GH movement
Controlled Mobility -> ST endurance, RTC endurance

Goal - restore tissue tolerance to load
Manual Therapy - Thoracic Spine/First Rib
Postural Control and endurance activites/lower kinetic chain/ trunk
Promote optimal stress to tendon with exercise
Enhance ST muscle activation control
Regain load tolerance in RTC tendons

deloaded early assisted motion not resisted prime movement
intermitted low load contraction
isometric contractions
short level eccentric contractions
progressive resistance as tolerated

Symptom Modulation
Mobility
Loading
Return to Function

Tendon remodeling exercise that includes high volume low load
Combination of isometric, eccentric, concentric exercise
Upper quadrant strengthening that includes ST and RTC

20-30 sec, 3-5 reps taught to patient to perform daily multiple times

eccentric contraction greater than concentric contraction

3 sets of 30 reps with rest between each rep to rest and stress are equal

tendon remodeling exercise that includes high volume low load
Combination of isometric, eccentric and concentric exercise
Motor control and grip retraining activities (control of movement + modulation of force)

reducing compensatory muscle firing
isometric painfree contractions wrist and hand
retrain grip force reduction, all or none concept
fine motor skills enhancing intrinsic muscle contractions in hand

high volume, low load
emphasis on quality movement
3 sets of 20-30 as long as form good and painfree

Isometric Loading Max Grip or hold 45 sec, 3-5 sets
Active elbow flexion 3/30 with rest between each rep, grip/weight released every repetition
Assisted wrist extension, eccentric lower with 1-3 sets of as many as tolerated up to 30
Assisted supination with eccentric lower 1#3