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PENATALAKSANAAN KFR PADA

TENDINITIS

dr.Hendi IndiarsaSupervised :

dr.Tertianto Prabowo,SpKFR

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TENDON• A tendon (or sinew) is a tough band of fibrous

connective tissue that usually connects muscle to bone.

• Tendons are similar to ligaments and fasciae as they are all made of collagen .

• Except that ligaments join one bone to another bone, and fasciae connect muscles to other muscles.

• Tendons and muscles work together and can only exert a pulling force.

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Tendon

Fungsi Tendon :Mentransmisikan gaya antara

otot dan tulangStore elastic energy

To provide & maintain body structure

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Struktur Tendon

Tendon terdiri dari sel dan matrix extraseluler

(ECM)

Lokasi Tendon dibagi menjadi 3,yaitu :

Muscle tendon junction (MTJ)

Bone-tendon junction (BTJ)

Tendon Midsubstance

Pada BTJ, tdpt 4 zone yg dibagi berdasarkan

komposisi bahannya (over a distance of about 1 mm) : tendon, fibrocartilage,

mineralized fibrocartilage, tulang.

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Tendon structure Composed of

fasicles derived from smaller fibrilso Surrounded by

epitendono Separated by

endotendon

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Tendon structure• Consist of fibroblasts and collagen arranged in

parallel rows

• Contain relatively few cells and therefore has low metabolic activity

• Fibroblasts produce Type I collagen o (85% of dry weight of

tendon)

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Tendon Types• 2 types:

o Paratenon covered tendons• Rich vascular supply• Better healing potential

o Sheathed tendons• Tendon segments supplied by vinculae

and osseous insertion• Avascular areas receive nutrition via

diffusion from vascularised segments

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Tendinitis & Tenosynovitis

• Tendinitis and tenosynovitis are the painful inflamation of a tendon (Tendinitis) or a tendon sheath (Tenosynovitis).

• Tendinitis is inflamation of a tendon, the fibrous cord that attaches a muscle to a bone.

• Tenosynovitis is inflamation of the sheath of tissues that surrounds a tendon.

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Tendinitis & Tenosynovitis

• These two conditions usually occur together.• Tendons around the shoulder, elbow, wrist,

fingers, thigh, knee, or back of the heel are most commonly affected.

• Both condition be caused by injury of a particular tendon, or rarely, by an infection.

• Inflamation of the achilles tendon between the heel and the calf may be the result of a sport injury or of wearing ill-fitting shoes.

• Tenosynovitis may be associated with RA.• In some cases, the cause is unknown.

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Symptoms • Pain and/or mild swelling.• Stiffness and restricted movement in the affected

area.• Warm, red skin over the tendon.• A tender lump over the tendon.Particularly during movement in the affected area, and sometimes may feel a crackling sensation (crepitus).

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General Principles of Tendinopathy Treatment• Identify & remove negative external forces/factors• Establish stable baseline treatment• Determine tensile load starting point• Use symptoms to guide loading program• Control pain• Address use of whole kinetic chain• Employ specificity• Use maximum loading• Load progression

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Rehabilitation• Early controlled mobilisation can:

o Reduce scar adhesionso Facilitate healing by stimulating remodelling

• Excessive loading will:o Disrupt the repair tissue

• Thus optimal healing requires:o Surgical apposition and mechanical

stabilisationo Minimal soft tissue damageo Optimal mechanical environment for healing

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Tendon healing• Occurs through extrinsic and intrinsic

processes

• Divided into 3 phaseso Inflammation (Day 0-7)o Repair (Day 3-60)o Organisation and remodelling (Day 28-180)

• Under action of cytokines:o PDGF (Chemotaxis)o TGFß (Collagen type)

(Transforming growth factor β)

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Variables that influence healing

TRAUMA

Cell & Matrix damage

HEALING

Inflammation -> Repair->

Remodelling

RESULT

Restoration of original tissue

Scar

Excessive repair

Failure of healing

INJURY

Type

Intensity

Duration

PATIENT

Age

Comorbidity

Medication

TREATMENT

Apposition

Stabilisation

Loading & Motion

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Inflammation (0-7 days)

• Inflammatory cells migrate from:o Epitendinous tissues (sheath, periosteum, soft

tissues) o Epitendon and endotendon

• Defect rapidly filled with granulation tissue, haematoma and tissue debris

• Fibronectin laid down as scaffolding for collagen synthesis

• Extrinsic response outweighs intrinsic response

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Inflammation (0-7 days)

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Inflammation (0-7 days)

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Inflammation (0-7 days)

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Inflammation (0-7 days)

PDGF

PDGF

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Repair (3-60 days)• Fibroblast migrate to zone of injury and

begin to synthesise collagen by day 5

• Initially collagen type 3 produced which is laid down in a random orientation

Healing tendon

Normal tendon

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Repair (3-60 days)• During 4th week intrinsic fibroblasts

proliferate and these cells take over the healing process both synthesising and reabsorbing collageno “Tendon Callus”

• Switch to production of Type 1 Collagen which is increasingly orientated along line of force

• Vascular ingrowth via collagen/fibronectin scaffolding

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Repair (3-60 days)

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Repair (3-60 days)

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Repair (3-60 days)

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Organisation (28-180 days)

• Final stability acquired during this phase by the normal physiological use of the tendon

• Accompanied by cross linking between fibrils further increasing tendon tensile strength

• Complete regeneration never achievedo Defect remains hypercellularo Thinner collagen fibrils

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Summary• Tendon healing:

o Weakest at 7-10 dayso Regain most of original strength by 21-28 dayso Achieve maximum strength by about 6 months

• Early mobilisation: o Increases ROM but can decrease tendon repair

strength if excessive stress placed on repairo Immobilisation leads to increase tendon

substance strength at expense of ROM.

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THANK YOU