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Is compressive load a factor in the development of tendinopathy?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Nov 23, 2011.

  1. NewsBot

    NewsBot The Admin that posts the news.


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    Is compressive load a factor in the development of tendinopathy?
    JL Cook, C Purdam
    Br J Sports Med doi:10.1136/bjsports-2011-090414
  2. This have got me thinking I very much would like to look at this paper in full text.

    Could be a very important paper. We tend to discuss Tensile force or strain in the tendon, but if compression also has a negative effect on tendon fibres it may change some of the treatment programs.

    Maybe another zone type concept

    Zones of optimal tensile tendon load. ZOOTTL (?) Anyway enough of my ramble and maybe it is just me who had not considered Compression of a tendon as a negative factor only considered the positive spring like energy return factors - can anyone help with a full text ? Please

    ps found these 1 by the same authors and another discusses compression re tendinopathy

    Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy


    Compression etiology in tendinopathy

    also found this which discussed a Physiologic window some maybe Tendon Physiologic window is better than ZOOTTL ie TPW - but also discussed tendinosis:confused: Anyway

    The interface of mechanical loading and biological variables as they pertain to the development of tendinosis

    and a power point by Jill Cook


    ps just skimmed the papers......

    interesting ideas...............
  3. For the last decade I have become increasingly convinced that the combination of both tension and compression loads acting on any soft tissue structural component of the foot and lower extremity will more likely predispose that structure, whether it be a tendon or ligament, to becoming injured. Some of the most common pathologies that we see in the foot, such as proximal plantar fasciitis and plantar plate injuries, are likely due to a combination of both compression and tension forces acting on that structure. It is for this reason that I always design my treatments to reduce both external compression forces and internal tension forces on these injured soft tissue structures in order to produce optimal treatment results in patients with these pathologies.

    Good article.

    Thanks Ian.:drinks
  4. toomoon

    toomoon Well-Known Member

    [ Some of the most common pathologies that we see in the foot, such as proximal plantar fasciitis and plantar plate injuries, are likely due to a combination of both compression and tension forces acting on that structure.

    Usual quality stuff from the Aussie researchers! Very interesting in relation to CPHP.. it now seems very likely that compression is at least as likely to be the problem as tension. And the reason may be that excessive or prolonged compression effects the EDR (energy dissapation ratio) of the plantar fat pad which in turn increases the transient loading profiles on the underlying tissue and interrupts the sensory component of the plantar fascial enthesis and its ability to self regulate these loads. Net result: plantar heel pad unable to dissapate impulsive loads due to the compression problem + fascial enthesial thickening = symptomatology. May be time to rethink rigid orthotic therapy for CPHP.. or at the very least, pay attention to the Kirby model of management.... not that I say this often...:D
  5. Bruce Williams

    Bruce Williams Well-Known Member

    Ok, but how are there compressive loads at the Achilles? Plantar heel I get, otherwise, not so much.
  6. toomoon

    toomoon Well-Known Member

    direct form the paper
    "Almekinders et al 1 were the fi rst to consider compression,
    or a differential in tensile loads, as a concept
    for overload of tendons. They suggested that
    strains at the Achilles tendon insertion were not
    uniform and proposed that the joint side of the tendon
    was exposed to less tensile load (stress shielded)
    and may be subjected to compressive loads. 2 This
    somewhat complex model of differential strains
    in a tendon has withstood some scrutiny, but the
    clinical applications have been limited"

    So you need to think about what happens on each side of the tendon.. o one side it is in tension.. on the other it is compressed (stress shielded)...hope this helps!

  7. I was thinking about this earlier, Bruce. Ostensibly when the calf muscle contracts it acts to vary the stiffness of the muscle-tendon unit such that the muscle tendon unit has a variable amount of compressive stiffness under loading. When the muscle-tendon unit is very compliant, i.e. low muscular tone it will act more like a rope under compressive loading, yet when there is greater muscular tone (especially isometric/ eccentric contraction), the muscle-tendon unit will act more like a stone column (have high stiffness). So the question becomes (and I think this was your point) how much muscular tone is there in the muscle-tendon unit at heel strike, i.e. when it will be under compressive loading? Over to the EMG data.

    Not had chance to read the paper yet, perhaps it answers this question.

    EDIT: reading Simon and Mike Webers response perhaps I need to read the paper as I was considering longitudinal compression. My point regarding muscular tone not withstanding, since if we are talking bending with tension on one side and compression on the other, this will come into play. Anyway, enough.
  8. Bruce I´m just working my mind around this and might be wrong

    but as tension increases in the tendon then tendon will compress against the enthesis

    due to the rounded shape of the calc as the tension of the Achilles increases , the Achilles will compress just proximal to the boney insertion point.

    does that help ?
  9. ie like this the blue point close to the bone will compress as the tension increases on the other half of the tendon

    EDIT : maybe Im not quite right in the links I posted on the 1st post Jill makes this point in her power point - increased tension in a spring causes thinning in the midtendon, therefore internal compression

    Attached Files:

  10. Bruce Williams

    Bruce Williams Well-Known Member

    Ok, thanks to Mike and the Simon's on this, I appreciate your takes. Mike's really hit home the most with me. I will try to think of insertion forces as compressive forces from now on as that seems to make sense to me.

    My take on achilles tendinopathy issues has always been that the ankle stops rotating or dorsiflexing for the most part. I would imagine that the less tendon loading as Simon talked about above, means minimal DFion of the Ankle joint, the more compression at the achilles insertion.

    It seems that maybe we are all wading into this cold pool slowly and together. It only gets worse as the water creeps higher though! :santa2:
  11. Further to this point of compression

    we will have internal and external compression forces acting on the tendon

    the bold section reminded me of this paper Muscle-tendon interaction and elastic energy usage in human walking

  12. Kent

    Kent Active Member

    See post number 9 in this thread where I discuss the compressive load at the Achilles insertion - Prediction of the success for treatment of insertional Achilles tendinosis

    What you've drawn there Mike is pretty much what I draw when demonstrating this to my patients so that they can understand what I mean by compression. I use this to illustrate why I ask them to cease all calf stretching and never to walk barefoot or in flat shoes (only walk in shoes with a heel lift).
  13. efuller

    efuller MVP

    Mike, you should label the arrows. Also, the compression arrow should be much smaller. The tension in the tendon is upward. As the tendon wraps around the curve of the bone the direction of pull is changed slightly. The compression force will be equal to the sine of the angle change times the tension force in the tendon. The angle is small so the compression force will be a small fraction of the tendon tension force.

  14. Thanks Eric was a quick drawing to try and show concept - not that it would have been different if I had of thought about for an hour.

    I do wonder if there should be a short term long term re Triceps Surea stretching in the long term we may want the muscle group to be longer to reduce tension when under load and therefore compression - if in fact stretching can cause elongation of the muscle group and then again stretching would in fact mean the symptoms return ?
  15. At the Achilles tendon insertion, I believe a much more common problem, and something not mentioned in the paper by Cook adn Purdam, is retrocalcaneal bursitis, rather than a true enthesopathy of the Achilles tendon insertion. Using my hypothesis that I should get better therapeutic results if I reduce both the tension and compression force acting on the structure that is injured, for patients with retrocalcaneal bursitis, I will not only have them use a shoe with a higher heel height differential but will have them, when at all possible, start walking in an open-back shoe (no heel counter).

    For runners with retrocalcaneal bursitis, I now standardly have my patients take an older pair of running shoes and cut a hole in the posterior heel counter of the shoe so that their inflamed retrocalcaneal bursa no longer is subjected to a compression force from the shoe. This "hole-in-the-heel shoe technique" has worked wonders for many of my runner-patients with retrocalcaneal bursitis.
  16. Hi Kevin,

    I agree that Bursitis at the insertion of the Achilles would be more likely was having the exact thought this morning, even posted a MR paper re retrocalcaneal bursitis on the Anatomy & injury - Pictorial essays thread.

    and I was thinking that treatment would be along the same lines mechanically but different medically ( NSAIDS etc)

    mechanically - reduce the tension in the Achilles tendon and reduce the internal and external compression forces acting on the area.

    Medically - ice NSAIDS, Corticosteroid injection only for retrocalcaneal bursitis

    you could also argue that the swollen bursa maybe a causative factor in increasing the compressions force in enthesopathy of the Achilles tendon insertion.
  17. musmed

    musmed Active Member

    Dear Team
    I have some problems understanding why a tendon should have compression applied to it.
    IF a tendon is cut it always retracts, just ask any hand surgeon how large a problem there is in finding the thumb flexors.
    secondly, the Achilles tendon cannot compress against the calcaneal bone due to the presence of the retrocalcaneal bursa.
    Paul Conneely
  18. NewsBot

    NewsBot The Admin that posts the news.

    Insertional Achilles tendinopathy associated with altered transverse compressive and axial tensile strain during ankle dorsiflexion.
    Chimenti RL et al
    J Orthop Res. 2016 Jun 16. doi: 10.1002/jor.23338
  19. Pod on sea

    Pod on sea Active Member

    Standing calf stretches are routinely prescribed for rehab, however they surely increase compression on an inflamed retrocalcaneal bursa? Any thoughts, Kevin?

  20. Doing a standing gastrocnemius-soleus stretch a few times a day will compress the retrocalcaneal bursa but may, by stretching the gastroc-soleus-Achilles tendon complex, reduce the cumulative compression forces on the bursa that occur during the individual's daily weightbearing activities.
  21. NewsBot

    NewsBot The Admin that posts the news.

    Ultrasound strain mapping of Achilles tendon compressive strain patterns during dorsiflexion.
    Chimenti RL et al
    J Biomech. 2016 Jan 4;49(1):39-44. doi: 10.1016/j.jbiomech.2015.11.008
  22. Anyone able to send me the full paper.

    Super interesting

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