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76 Cards in this Set
- Front
- Back
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5 categories of low back pain
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UNCOMPLICATED LOW BACK PAIN - nonradiating with no structural damage or defect
UNCOMPLICATED SCIATICA- radiating back pain that does not extend below knee MAJOR NEUROLOGIC DYSFUNCTION - loss of motor function or continence MAJOR MECHANICAL PROBLEM - spinal fracture or instability INFECTION/NEOPLASM |
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Potential anatomic pain generators
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- Myofascial tissues
- Facet (zygapophyseal joints) - Discs - Nerves - Ligaments - Bony structures |
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_ % recover by 6 weeks
_ % recover by 12 weeks from lower back pain |
60-70
80-90 |
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Nonorganic low back pain can be divided into categories
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- Psychosomatic spinal pain (tension syndrome-fibrositis, or muscle tension generated physiologically by anxiety)
-Psychogenic spinal pain (somatization of anxiety into neck or back pain with no physiologic changes as in conversion reaction) - Psychogenic modification of organic spinal pain ( an emotional reaction that modifies appreciation of organic pain) - Situational spinal pain (litigation reaction, consious overconcern or exaggeration) |
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Metabolic disorders can contribute to neuropathy, fracture, muscle tension or associated depression/anxiety - what are they
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Electrolyte disorders, diabetes, thyroid, renal and liver disease
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Goal of diagnosis in people with lower back pain is _
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Define anatomic pain generators as soon as possible recognizing that this is not always possible
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Important historical factors in evaluation of patients with low back pain
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Mechanism of onset
Location of symptoms Duration of pain Character of pain Neurologic Constitutional Behavioral Medical illness Prior surgery/back pain Lifestyle/trauma Legal/disability issues Pharmacologic Systems review |
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Red flags
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Symptoms or physical findings suggestive of potentially serious cause for pain that requires immediate evaluation. Examples include history of progressive physical deficit, fever, pain at rest or at morning awakening without relief, distal numbness or weakness or loss of bowel or bladder control with saddle anesthesia
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High impact trauma is risk factor for _
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Serious fractures and misalignements
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Weight loss, fatigue, insomnia and night pain can indicate _
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Malignancy with metastases to bones or chronic infection such as osteomyelitis
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Spinal ostemyelitis can present with _
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Back pain, fever, night sweats
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In young people with lower back pain what should you consider
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Ankylosing spondylitis, spondylosis and spondylolisthesis
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Yellow flags
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Denote adverse prognostic indications
Examples - depressive symptoms, work related injuries still in ligation, signs and symptoms not consistent with pain severity, and behaviors incogruent with underlying anatomic and physiologic principles Yellow flags signal potential need for more complex and intensive treatment and/or earlier specialist referral. Emotional stress can be contributing to pain or its perception. When yellow flags are present physicians should be concerned with deviations from normal course of illness |
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Signs of drug addiction or diversion in patients seeking pain medications
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- History of known substance abuse
- Visits to multiple physicians - Requests for specific medications - Lost prescriptions - Multiple failed therapies - Inconsistent responses to dosage changes or patient resistance to switching to approximately equipotent opioid |
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Palpation of lower back can reveal _
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Crepitus suggestive of fracture (often with severe point tenderness over bone), instability, myositis, myofascial trigger points or visceral organ tenderness
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Pain on upper body flexion or rotation indicates what
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Facet arthropathy or other structural problesm
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Rectal exam with assesment of lower back pain can help find what
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Prostatitis, sacral pathology or colon cancer
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Waddell signs for nonorganic pain
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Indicate nonorganic pathogenesis of back pain
- Include superficial nonanatomic tenderness - Pain from simulation maneuvers that should not elicit pain - Distraction maneuvers that should elicit pain but do not - Regional disturbances not consistent with known patterns of pain - Over reaction during examination Greater number of signs present indicate greater likelihood that nonorganic cause of back pain is present, but do not definitively rule out organic cause |
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Why do you want to minimize unnecessary imaging studies
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Diagnosis can be confused by high incidence of radiographic abnormalities in asymptomatic persons
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Majority of asymptomatic abnormalities on MRI
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Bulges and protrusions but not extrusions
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Imaging studies should be ordered in patients with _
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Progressive neurologic deficits, failure to improve, history of trauma and those at elevated risk for malignancy and infections
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What is the best initial test for multiple myeloma given that many patients will have normal bone scan
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Serum or urine protein electrophoresis
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Which signs would be indicative of infection as cause of lower back pain
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Fever, elevated ESR and CRP, leukocytosis
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What is the most sensitive and specific test for identifying spinal infection
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MRI
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What should be initial drug therapy in patients with low back pain
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Acetaminophen, NSAID or COX 2 inhibitor. Muscle relaxants can be used if muscle spasm present (SEDATIVE!), short-acting opioids for moderate to severe pain. Long acting opioids when other treatment modalities have been inadequate (if not responsive to opioid - discontinue it)
Adjuvant tricyclic antidepressants and anticonvulsants in patients with underlying depression or neuropathic component to pain Epidural corticosteroid injections for radiculopathy |
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Physical modalities for treatment of lower back pain
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- Stretching, ice, heat
- Massage - Bed rest should be avoided except possibly first 24 hours, patients should be encouraged to return to work and their usual activities as soon as possible Potentially beneficial therapies - exercise rehabilitation programs, electrical muscle stimulation, work hardening programs and acupuncture |
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Interventional pain management of lower back pain
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- Diagnostic facet and nerve blocks
- Therapeutic rhizotomies and nerve ablations - Selective joint injections - Epidural injections - Intradiscal distraction therapy and spinal endoscopy - Epidural steroids have been shown effective for pain with a significant inflammatory component including nerve irritation or impingement |
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Confounding factor in evaluation and management of lower back pain
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"Yellow flags"
- Belief that back pain is harmful or potentially severely disabling - Fear-avoidance behavior and reduced activity levels - Tendency to depressed mood and withdrawal from social interaction - Expectation of passive treatment rather then belief that active participation will help - Other factors that may interfere with recovery - anxiety, depression, unresolved occupational issues, prior disability claims) AFFECTIVE DISORDERS ARE VERY COMMON CONFOUNDING FACTORS IN PATIENTS WITH CHRONIC PAIN - Pseudoaddiction - patient behvior pattern often caused by undertreatment of pain, patient initially seems to be drug seeking but normal behavior returns with appropriate pain management |
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Most appropriate diagnostic approach to lower back pain
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Look for specific biomechanical causes and identify potential anatomic pain generators when possible
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Pain that is inconsistent with known patterns of disease represents _ and requires _
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Yellow flag
Re-evaluation |
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Tendons connect _ to _
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Muscle to bone
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How do tendons contribute to joint movement
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Allow transmission of forces generated by muscle to bone
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Healthy tendons are _
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White in color and have fibroelastic structure
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Cells of tendons
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90-95% - tenoblasts (immature, spindle shaped, high metabolic activity) and tenocytes (mature, elongated, low metabolic activity)
5-10% - chondrocytes, synovial cells of tendon sheath, vascular cells (capillary endothelial cells and smooth muscle cells of arterioles) |
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Oxygen consumption of tendon is _ then muscle
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Lower (7.5 times)
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What is essential for tendon to carry loads and maintain tension for long periods reducing risk for ischemia or necrosis
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Low metabolic rate and anaerobic capacity
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Tendon is 30% _ and 70% _
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30% dry mass - collagen type I + elastin
70% water |
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Ground substance of ECM surrounding collagen and tenocytes composed of _
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- PROTEOGLYCANS - strongly hydrophilic, enable rapid diffusion of water soluble molecules and migration of cells
- ADHESIVE GLYCOPROTEINS - fibronectin and thrombospondin - repair and regeneration - TENASCIN C - abundant in tendon body, functions as elastic protein, expression regulated by mechanical strain and is upregulated in tendinopathy, plays role in collagen fiber allignment and orientation |
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Fine loose connective tissue sheath containing vascular, lymphatic and nerve supply to tendon, covers whole tendon
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EPITENON
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Thin reticular network of CT investing each tendon fiber
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ENDOTENON
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Superficially epitenon is surrounded by _
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PARATENON
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Synovial tendon sheaths are found in which areas
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-Areas subjected to increased mechanical stress - tendons of feet and hands where efficient lubrication is required
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Weakest point of tendon muscle unit
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Myotendinous junction
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Osteotendoinous junctions is composed of 4 zones - name them - explain
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Dense tendon zone
Fibrocartilage Mineralized fibrocartilage Bone Specialized structure prebents collagen or fiber bending, fraying, shear or failure |
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Tendons receive their blood supply from 3 major sources - ?
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Intrinsic systems at myotendinous junctions and osteotendinous junctions and extrinsic system through paratenon or synovial sheath
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Blood supply from osteotendinous junction is _
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Sparse and is limited to insertion zone of tendon
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Tendon vascularity is compromised at _
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Junctional zones and sites of torsion, friction or compression
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Tendon innervation originates from _
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Cutaneous, muscular and peritendinous nerve trunks
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Most nerve fibers enter body of tendon - T/F
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FALSE - most nerve fibers do not actually enter main body of tendon but terminate as nerve endings on surface
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Nerve endings of myelinated fibers function as _
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Mechanoreceptors - GOLGI TENDON ORGANS - most numerous at insertions of tendons to muscle - detect changes in pressure or tension
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Unmyelinated nerve endings serve as _
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NOCICEPTORS - sense and transmit pain
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Biomechanics of tendon
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Transmit force from muscle to bone and act as buffer by absorbing external forces to limit muscle damage, exhibit high mechanical strength, good flexibility and optimal level of elasticity
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If strain remains less then 4% tendon behaves _
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In elastic fashion and returns to original length when unloaded
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Microscopic faliure of tendon occurs at _
Macroscopic failure occurs at _ |
Strain exceeding 4%
8-10% of strain |
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Tendons are at highest risk for rupture if _
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tension is applied quickly and obliquely and the highest forces are seen during eccentric muscle contraction
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_ mechanism has been reported in up to 90% of sports related Achilles tendon ruptures
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Acceleration- decceleration
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Most common histological finding in spontaneous tendon rupture
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Degenerative tendinopathy
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_ play causative role in 2/3 of Achilles tendon disorders
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Intrinsic factors such as allignment and biomechanical faults
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_ has been linked with increased prevalence of Achilles tendinopathy
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Hyperponation of foot
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Main pathological stimulus for degeneration of Achilles tendon
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Excessive loading of tendons during vigorous physical trainng
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Tendons response to repetitive overload by _
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Inflammation of sheath, degeneration of body or both
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Repair mechanism in tendon is carried by _
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Tenocytes - maintain balance between ECM production and degradation
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What is the main theory of tendinopathy
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Ischemia - occurs when tendon is under max tensile load. On relaxation reperfusion occurs, generating oxygen free radicals, can cause tendon damage resulting in tendinopathy (increased peroxiredoxin - enzyme that protects from oxidative stress). Hypoxia alone result in degradation
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Cytokines can be mediators of tendinopathy - T/F
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TRUE - prolonged mechanical stimuli induce production of cytokines and inflammatory prostaglandins which may be mediators of tendinopathy
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Which drugs induce IL1 mediated MMP3 release and is associated with tendon rupture
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Ciprofloxacin
Fluoroquinolones inhibit tenocyte metabolism reducing cell proliferation and collagen and matrix synthesis - induction of tendinopathy |
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MMP's
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Proteolytic enzymes - ability to degrade components of ECM and to facilitate tissue remodeling
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What induces release of MMP's
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Cytokines
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Tendinopathy vs tendinitis/tendinosis
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Tendinopathy - generic descriptor of clinical conditions in and around tendons arising from overuse - tendinitis, tendinosis used only after histopathological examination
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Histological examination of tendinopathy shows _
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Disordered, haphazard healing with absense of inflammatory cells, poor healing response, noninflammatory intratendinous collagen degradation, fiber disorientation and thinning, hypercellularity, scattered vascular ingrowth and increased interfibrillar glycosaminoglycans
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_ degeneration often found in _
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Achilles tendon
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Tendinosis is _
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Failure of cell matrix to adapt to variety of stresses as result of imbalance between matrix synthesis and degeneration
- Tendon thickening - diffuse, fusiform or nodular - Grey-brown and amorphous appearance - Clinically silent, only manifestation - rupture |
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What can trigger acute inflammatory response in tendon weakening it and predisposing it to rupture
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Collagen degradation and tenocyte necrosis
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What generates pain in tendinopathy
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Chemical irritants and neurotransmitters (high concentration of glutamate, substance P)
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Tendon healing occurs in three overlapping phases - what are they
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- Initial inflammatory phase - erythrocytes and inflammatory cells (neutrophils) enter site of injury, in first 24 hours monocytes and macrophages predominate and phagocytosis of necrotic materials occurs, vasoactive and chemotactic factors are released, angiogenesis initiated, stimulation of tenocyte prolideration and recruitment of more inflammatory cells, tenocytes gradually migrate to wound and type III collagen is synthesized
- Proliferative phase - synthesis of type III collagen peaks, starts after few days and lasts for few weeks, high water and GAG content - Remodeling phase- after 6 weeks, decreased cellularity and decreased collagen and GAG - can be divided into consolidation and maturation phase. Consolidation phase begins at 6 weeks and continues up to 10 weeks - repair tissue changes from cellular to fibrous, tenocyte metabolism high and tenocytes and collagen fibers become aligned in direction of stress, high proportion of collagen I synthesis. Maturation stage - after 10 weeks - gradual change of fibrous tissue to scar like tissue over the course of 1 year |
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Mechanisms of tendon healing
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Intrinsically by proliferation of epitenon and endotenon tenocytes
Extrinsically - by invasion of cells from surrounding sheath and synovium |
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Which healing is better
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Intrinsic - better biomechanics and less complications (extrinsic - scar tissue forms adhesions and prevents gliding)
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