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PTP 521 Musculoskeletal Diseases and Disorders

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1 PTP 521 Musculoskeletal Diseases and Disorders
Tendons and Muscles PTP 521 Musculoskeletal Diseases and Disorders

2 Tendons Transmit force between muscles and bone
Store elastic energy when stretched Connect bone to muscle Concentrate the pull of muscle in a small area

3 Histological Composition of Tendon
Dense, parallel fibered, connective tissue Bundles of coarse collagen fibers among scattered rows of fibroblasts with elongated nuclei Endotenon: Collagen Type III Epitenon: Collagen Type I Peritenon (tenosynovium): areolar tissue becomes tendon sheath in some areas


5 Tendon Cell Composition
Behavior of tendon is determined by the amounts, types, and organization of their extracellular components Collagen (type I): 65-75% dry weight Elastin: 2 % dry weight Matrix: composed of proteoglycans – water Cell types: Tenoblasts Tenocytes

6 Tendon Bone Interface Tendon

7 Musculotendinous Junction

8 Classification System of Tendon Injury
Based on the histology of the tendon at time of elbow surgery

9 Clinical and Functional Classification -Blazina et al. 1973
4 stages: Pain after sports activity Pain at the beginning of sports activity, disappearing with warm-up and sometimes reappearing with fatigue Pain at rest and during activity Rupture of tendon

10 Classification according to Chronology of Symptoms
Acute: symptoms have been present for 0 – 6 weeks Sub-acute: symptoms present between 6-12 weeks Chronic: symptoms present longer than 3 months

11 Common Tendon Injury Terminology
Paratendinopathy: (Paratenonitis, tenosynovitis, peritendinitis, tenovaginitis) Acute tendinopathy (Tendonitis) Chronic tendinopathy (Tendinosis) Pantendinopathy (Paratnonitis with tendinosis or tendinitis)

12 Paratendinopathy Definition: Inflammation of the paratenon sheath which becomes thicker and inflammed. Clinical Manifestations: Swelling, burning, shooting pain, crepitus, dysfunction, tenderness and warmth Becomes chronic condition, can lead to adhesion of sheath to the tendon underneath Treatment: NSAID’s, corticosteroid injections,

13 Acute Tendinopathy (Tendonitis)
Pathology: minor lesion of the tendon tissue Etiology: caused by tissue fatigue the tendon is strained such that it can no longer endure tension and stress, structure begins to disrupt microscopically and inflammation, edema and pain result.

14 Extrinsic Factors: unaccustomed activity (excessive load on body)
weather (environmental conditions) training errors poor equipment

15 Chronic Tendinopathy (Tendinosis)
Pathology: degeneration within the tendon. No inflammatory response, due to atrophy from aging, microtauma and vascular trauma, overuse Clinical Manifestations Signs: palpable tendon, nodule, usually not tender to touch Symptoms: pain with active movement, prolonged stretch


17 Possible progression of Tendon injury
Inflammation : minimal or absent Gradual change of tendon tissue Pain occurs eventually and may be related to the revascularization and neural growth into the tendon Some tendons rupture without any previous signs or symptoms Zachazewski JE, Magee Dj, Quillen SW. Athletic Injuries and Rehabilitation, p 42. Philadelphia, 1996, WB Saunders.

18 Pantendinopathy: Tendinosis with Paratenonitis
Pathology: both paratendinopathy and acute or chronic tendinopathy occur, separate entities Clinical Manifestations: Signs: inflammatory signs with a palpable tendon nodule, swelling and redness Symptoms: pain

19 Healing a. Inflammatory stage: within the first 3 days after injury b. Repair stage: seen within one week, initially formed at random, fibroblasts predominate, collagen content increases through the first 4 weeks. Fibers initially are oriented perpendicular to the gap c. Remodeling stage: begins within 2 months after injury. Complete healing occurs when the tensile load strength returns.

20 Other Types of tendon injuries
Tendon Strain: can lead to rupture Same grades of strain as a ligament sprain Tendon Dislocation: Biceps Brachii Thermal injury: burn or cold Tendon Lacerations

21 Histology of Muscle Tissue
Highly specialized tissue, surrounded by basement membrane or external lamina Contractile, extensibilty, elasticity and excitability properties Three types of muscle tissue Skeletal Muscle Cardiac Muscle Smooth Muscle

22 Skeletal muscle Large, elongated, multinucleated fibers Striated
Cellular Unit: myofiber of muscle fiber Basement membrane: contains collagen, laminin, fibronectin and muscle-specific proteoglycan Striated Myofilaments Thin: Actin Thick: Myosin

23 Pathological Conditions of Musculotendinous Junction and Muscle Belly
Causes of Injury a. Contusion- direct blow b. acute strain: excessive stretching c. chronic strain: repetitive loading d. laceration

24 Contusion - key points Capillary rupture occurs and bleeding into the muscle followed by an inflammatory reaction Severity of contusion determined by degree to which it limits motion of the joint Most commonly occurs in biceps and quadriceps Injuries graded as mild, moderate or severe Take at least 24 hours to stabilize

25 Muscle Strains - Key point
Some degree of muscle fiber or tendon disruption occurs Acute and chronic strains occur when muscle or tendon lacks flexibility, strength or endurance to accommodate demands placed upon it

26 Grade I: mild or first degree
No disruption of muscle/tendon unit Symptoms Active contraction and passive stretch are painful, may have mild muscle spasm Signs Localized swelling and tenderness no loss of strength in the muscle No loss of motion in the adjacent joints No palpable defect No ecchymosis

27 Grade II: moderate or 2nd degree
Some degree of disruptions within the muscle/tendon unit. Symptoms: Tenderness to palpation Very painful with passive stretching and attempted contraction of the muscle Signs: Decreased muscle strength Decrease in ROM in joints Possible palpable discontinuity Moderate spasm echymosis

28 Grade III: severe or third degree
One or more components of the muscle/tendon unit are completely disrupted Symptoms: No change in pain with passive stretch, may be a little less painful than the grade II strain Signs: Motion in adjacent joint is severely restricted Extreme tenderness with swelling Palpable defect, bunching up of muscle tissue Possible compartment syndrome with concurrent loss of sensation and pulse distally

29 Muscle Healing Following a Strain
Injury heals with both regeneration and repair Capacity for regeneration is based on type of injury and extent of injury

30 Phases of Healing Destruction Phase:
Muscle fibers and sheaths are disrupted Gap between ends of ruptured muscle fibers due to muscle retraction Necrosis of tissue


32 Proliferation (repair) Phase
Hematoma formation Matrix formation Fibronectin and fibrin cross link to form matrix for fibroblasts Fibroblasts synthesize proteins for extracellular matrix Collagen formation Type I collagen

33 Regeneration Occurs at same time as proliferation phase
Activation of satelitte cells and myoblastic precursor cells divide, proliferate and differentiate into myotubes then into myofibers Myofibers fuse with other myofibers on other end of wound. May limit degeneration Mechanism? Scar tissue between may limit regeneration Integration of neural structures and formation of a neuromuscular junction last part of regeneration

34 Maturation Phase Regenerated muscle matures and contracts

35 Early ischemic damage Fragmentation phase Myotube Muscle fiber

36 Fibromyalgia Chronic, widespread pain and tenderness to touch
Incidence: 5-8% of population Females 9:1 over males More common than RA Etiology: theories only Stress related Genetically predisposed Sleep disturbance Dopamine abnormality Deposition disease

37 Clinical Manifestations
Symptoms Widespread pain Duration: at least three months Non-radicular pain Fatigue Nonrestorative sleep Defined number of trigger points

38 Trigger Points in Fibromyalgia
Trigger Point: tender point which becomes painful upon pressure 11/18 standardized sites Sensitivity of 88% and specificity of 81%

39 Myofascial Pain Syndrome: Trigger Points
Definition: Hyperirritable point within a taut band of skeletal muscle, Localized in muscle tissue or associated fascia Painful on compression: jump sign Evokes a characteristic referred pain pattern and autonomic phenomena

40 Classification of Trigger Points
Active: causes pain at rest Latent: clinical silent for pain, may restrict ROM and may cause weakness of the affected muscle

41 Associated Trigger Points
Develop in response to injury/other trigger points Satellite Trigger Point: develops in the zone of referred pain from another muscle Secondary Trigger Point: develops in either a synergist or antagonist of the muscle which first develops a trigger point because it is overloaded.

42 Trigger Point Signs and Symptoms
Pain referred in a specific pattern Dull aching pain, often deep, intensity varies Doesn’t follow known sclerotome, myotome or dermatomal patterns

43 Activated by acute overload, overwork, fatigue, trauma or chilling
Activated by other trigger points, visceral diseases, arthritic joints, emotional stress TP can change from latent to active

44 Examination Findings

45 Increase pain with active or passive stretching of the muscle
ROM is decrease Pain increases with resisted activity Muscle strength is decreased Palpable nodule that has “exquisite” tenderness

46 Taut, tight, tense muscle, can snap or “twang”
Local twitch response, transient, visible, palpable contraction of the muscle Lab tests, imaging tests are negative for other pathology

47 Myositis Definition: infectious, inflammatory disease of muscle Etiology: viral, bacterial, parasitic agents Incidence: 4% for parasitic agents Most common form: polymyositis (weakness in trunk muscles) and dermatomyositis (weakness plus skin rash)

48 Clinical Manifestations
Medical Diagnosis: Biopsy: Determines form of myositis EMG Lab Values Creatine kinase levels in blood indicate muscle breakdown Symptoms: Malaise Pain Tenderness Lethargy Signs: Swelling Fever

49 Immobilization Effects on Muscle
Muscle: length of time/position of immobilization Changes tend to occur at myotendinous junction Adjustment in number and length of sarcomeres, occurs within hours after immobilization

50 Muscle belly changes with immobilization
Occurs with muscle atrophy Contractile elements are lost before noncontractile elements Result is increase in connective tissue and decrease in tissue extensibility Endomysium and perimysium may also increase in thickness

51 Aging Muscle effects: decrease in number of muscle fibers – 39% by age 80 Type II are more affected than Type I fibers (probably denervation) May occur secondary to decrease in demand on the body and can be reversed to some extent with exercise Overall increase in connective tissue and collagen, greater muscle stiffness and less flexibility and strength as age.

52 Other Connective Tissue Structures
Bursa Definition: functions to reduce friction between either muscle and tendon, tendon and tendon, tendon and bone Cause of injury: inflammation from overuse, trauma from a direct injury, infection. Bursitis: inflammation occurs in areas that are close to the surface Symptoms : localized pain, tenderness over the area Signs: localized swelling outside the joint, not a joint effusion, warmth, edema, loss of motion, loss of function can occur Fat Pads Closely packed fat cells surrounded by fibrous tissue Function: act as packing around the joint Cushions the joint Assists in Joint lubrication Symptoms: increase in pain and tenderness Signs: decrease in ROM around joint, increase in warmth around the fat pad

53 References Jozsa L, Kannus P. Human Tendons: Anatomy, Physiology, and Pathology. Human Kinetics. Champaign IL Magee D, Zachazewski J, Quillen W. Scientific Foundations and Principles of Practice in Musculoskeletal Rehabilitation. Saunders. St. Louis

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