Bakgrund: Tendinopati är en vanlig diagnos hos patienter inom primärvården, en av de vanligare formerna av tendinopati är epikondyalgi. Det är oklart vad som är den mest effektiva behandlingen för epikondyalgi. Studier har visat lovande resultat av enbart excentrisk träning (ET) samt som del av kombinationsbehandling. Det var därför relevant att kartlägga vilken effekt excentrisk träning har vid epikondyalgi. Syfte: Kartlägga och sammanställa aktuell forskning gällande evidensen för effekten av  ET på smärta och funktion vid epikondyalgi. Metod: En systematisk litteraturstudie. Litteratursökning genomfördes i databaserna PubMed, Cinahl, Web of Science samt Scopus. Åtta artiklar inkluderades. Dessa kvalitétsgranskades enligt PEDro, varefter den sammanvägda evidensen bedömdes enligt GRADE.  Resultat: De inkluderade studiernas kvalité enligt PEDro varierade från medelhög till hög. Begränsat vetenskapligt underlag för att ET inte minskar smärta vid lateral epikondyalgi (LE). Otillräckligt vetenskapligt underlag för att ET ökar funktion vid LE. Otillräckligt vetenskapligt underlag för en jämförelse av ET i olika former eller som del av kombinationsbehandling. Inga resultat för medial epikondyalgi framkom. Slutsats: ET har inte någon effekt på smärta vid LE. Det finns otillräcklig vetenskaplig grund för effekten på funktion vid LE. Interventionerna, i studierna som jämförde ET i olika former eller utvärderade kombinationsbehandlingar, skilde sig åt vilket gjorde att sammanvägningen av dessa resultat inte var möjlig. Vidare forskning behövs för att kunna fastställa effekterna av excentrisk träning vid epikondyalgi. / Background: Tendinopathy is a common diagnosis in primary care, a common form of tendinopathy is epicondylalgia. However, the most effective treatment for epicondylalgia is undetermined. Studies have shown promising results in regard to eccentric training (ET) as a stand-alone treatment as well as adjunct to other treatments. It is therefore relevant to map the effect of ET for patients with epicondylalgia. Objective: Map and compile current evidence on the effect of ET on pain and function for patients with epicondylalgia. Methods: A systematic review. A search was conducted in the PubMed, Cinahl, Web of Science and Scopus database. Eight articles were included. These were assessed for quality according to the PEDro scale and the evidence was assessed according to GRADE. Results: The quality of the included studies ranged from medium to high. Limited evidence showed that ET does not reduce pain for patients with lateral epicondylalgia, LE. Insufficient evidence showed that ET improves function. The evidence on the comparison of ET in different forms or in combination with other treatments was insufficient. No results emerged for medial epicondylalgia. Conclusion: ET does not reduce pain for patients with LE. There is insufficient evidence on the effect of ET on function for patients with LE. Studies comparing different forms of ET alone or in combination with other treatments have used different interventions, preventing the aggregation of results. Further research is needed to determine the effects of ET for patient with epicondylalgia.

Bakgrund: Besvär från akillessenan är ett vanligt problem hos såväl motionärer som elitidrottare och kan leda till båda smärta och funktionsförlust. Excentrisk träning är en vanlig behandlingsmetod i klinik, trots att evidensen är begränsad och motstridig. Syfte: Att kartlägga vilken evidens som finns för excentrisk träning som behandling av akillestendinopati. Metod: Systematisk litteraturstudie. Sökningen genomfördes i databasen PubMed. Studierna granskades med PEDro-skalan och den sammanlagda evidensen graderades enligt GRADEstud. Resultat: Litteratursökningen resulterade i att 7 studier med totalt 448 deltagare inkluderades. Studierna fick medelhög-hög kvalitet enligt PEDro. Evidensen för excentrisk träning vid 8-16 veckor var måttligt hög (+++) och vid 52 veckor mycket låg (+). Excentrisk träning hade en lägre effekt än hälinlägg och akupunktur mätt med VISA-A vid 8-16 veckor. Effekten av excentrisk träning mätt med VISA-A hade en likvärdig effekt som passiv stretch och tung långsam styrketräning vid 8-16 veckor. Vid 52 veckor var effekten mätt med VISA-A densamma av excentrisk träning som proloterapiinjektioner och tung långsam styrketräning. Konklusion: Excentrisk träning kan ha en effekt vid achillestendinopati. Effekten är densamma som eller lägre sett till poäng på VISA-A än andra behandlingsmetoder och skulle kunna bero på naturlig läkning över tid eller deltagandet i en studie. Evidensen för excentrisk träning graderades vid 8-16 respektive 52 veckor till måttligt hög (+++) och mycket låg (+). Detta grundar sig på studier av medelgod till hög kvalitet. / Background: Achilles tendon issues is a common problem among athletes on all levels. The problem can cause pain and loss of function. Eccentric exercise is a somewhat gold standard and often used in the clinical setting although the level of evidence is limited and conflicting. Objective: Map the evidence of eccentric exercise as a treatment for achilles tendinopathy. Method: A systematic review. The search was conducted in the Pubmed database. The included studies were analyzed using the PEDro scale and the evidence was graded using the GRADEstud. Results: The literature search identified 7 studies that were included with a total of 448 participants. The studies received a moderate-high quality on PEDro. The level of evidence at 8-16 weeks was moderate (+++) and at 52 weeks very low (+). Eccentric exercise had a lower effect than heel lifts and acupuncture measured with VISA-A. Eccentric exercise had a similar effect on VISA-A as passive stretch and heavy slow resistance. At 52 weeks the effect of eccentric exercise was the same as prolotherapy injections and heavy slow resistance. Conclusion: Eccentric exercise might have an effect as treatment for achilles tendinopathy, but the effect is the same or lower than other treatment options measured with VISA-A and might depend on the natural healing process or the participation in a study. The level of evidence for eccentric exercise was graded at 8-16 and 52 weeks respectively, as moderate (+++) and very low (+). This is based on studies of moderate to high quality.

INTRODUÇÃO: Este estudo tem como objetivo comparar os achados biomecânicos e anatomopatológicos de um modelo animal inédito de tendinopatia do tendão do calcâneo, induzido por injeções seriadas de baixa dose da enzima colagenase bacteriana, com o modelo mais comumente utilizado na literatura, induzido por injeção única de maior dose da enzima, e com os controles. A hipótese é que a utilização de injeções seriadas resultaria em alterações tendíneas mais progressivas e duradouras, similar à doença nos humanos. MÉTODOS: Quarenta e cinco (N=45) coelhos foram randomizados em três diferentes grupos de estudo (A, B e Controles). Animais do Grupo A (n=18) foram submetidos a três injeções seriadas de baixa dose de colagenase (0,1mg), em ambos os tendões do calcâneo, separadas por intervalo de duas semanas. Animais do Grupo B (n=18) foram injetados com dose única de maior dose (0,3mg). Já no Grupo Controle, animais (n=9) foram injetados bilateralmente com três doses seriadas de solução fisiológica 0,9%. Após a última injeção, foi realizada eutanásia do mesmo número de animais dos Grupos A e B (n=6), com 10 semanas (Subgrupos A1 e B1), 12 semanas (Subgrupos A2 e B2) e 16 semanas (Subgrupos A3 e B3). Todos os animais do Grupo controle foram eutanasiados após 16 semanas. Alterações anatomopatológicas, pelo escore de Bonar, e biomecânicas foram comparadas entre os grupos e dentro de cada grupo, para os diferentes momentos de eutanásia. Valores de p < 0,05 foram considerados estatisticamente significativos. RESULTADOS: Após 16 semanas, o escore anatomopatológico de Bonar foi significativamente maior para ambos os Grupos A (11,8±2,28) e B (5,6±2,51), quando comparados aos controles (2±0,76). Os valores para o grupo A também diferiram do Grupo B (p < 0,001). Para os desfechos biomecânicos, os grupos diferiram quanto à área de secção transversa do tendão (p=0,003), módulo de elasticidade (p=0,024), e tensões no limite da elasticidade (p=0,020) e na resistência máxima (p=0,022), com piores resultados encontrados nos animais do Grupo A. Na semana 12, também houve diferença entre os Grupos A e B para o escore anatomopatológico de Bonar (p=0,028) e para a tensão no limite da elasticidade(p=0,013), novamente com piores resultados no Grupo A. Já na 10a semana, foram os coelhos do Grupo B que demonstraram alterações mais pronunciadas quando comparados aos do Grupo A, com diferença significativa no Escore de Bonar (p=0,033), área de secção transversa do tendão (p=0,038), rigidez (p=0,048), módulo de elasticidade (p=0,024), força, tensão, energia e densidade de energia no limite da elasticidade (p=0,008, p=0,020, p=0,047 e p=0,0015, respectivamente) além de força e tensão no limite da resistência máxima (p=0,004 e p=0,008, respectivamente). A comparação dos desfechos dentro de cada grupo, entre os diferentes subgrupos, apresentou diferenças significativas no escore de Bonar em ambos os grupos A (p=0,012) e B (p < 0,001). Parâmetros biomecânicos não diferiram entre os subgrupos do Grupo A. Já os subgrupos do grupo B apresentaram diferenças na área de secção transversa do tendão (p=0,011), módulo de elasticidade (p=0,024), tensão no limite da elasticidade (p=0,023) e da resistência máxima (p=0,031), assim como na a densidade de energia no limite da elasticidade (p=0,017), com resultados mais pronunciados no subgrupo B1. CONCLUSÃO: O modelo animal de tendinopatia do tendão calcâneo induzida por injeções seriadas de colagenase apresentou alterações anatomopatológicas e biomecânicas mais avançadas na 16a semana, de caráter progressivo e duradouro, similar à doença dos humanos. Tal modelo experimental pode representar uma melhor opção na indução da tendinopatia do tendão do calcâneo, possibilitando a realização de estudos promissores no futuro / INTRODUCTION: This study aims to compare the biomechanical and histological findings of a new animal model of Achilles tendinopathy induced by serial low-dose injections of bacterial collagenase with the most commonly used high-dose single injection and to controls. The hypothesis of the study is that consecutive low-dose injections of collagenase would result in more progressive and long-lasting tendinopathic findings, reproducing better the disease in humans. METHODS: Forty-five (N=45) rabbits were randomly divided into three groups (A, B and Control). Animals in Group A (n=18) underwent three serial low-dose (0,1mg) injections of bacterial type I collagenase in both Achilles tendons, separated by a two-week interval. Animals in Group B (n=18) underwent bilateral single high dose injection (0,3mg) of the same enzyme. In the Control Group, animals (n=9) were injected bilaterally with three consecutive doses of saline solution, separated by a two-week interval. Following the last injection, the same number of rabbits from Groups A and B (n=6) were euthanized after 10 weeks (Subgroups A1 and B1), 12 weeks (Subgroups A2 and B2), and 16 weeks (Subgroups A3 and B3). Animals in the Control Group were all euthanized after 16 weeks. Histological findings, using the Bonar tendinopathy score, and biomechanical properties of the Achilles tendons were compared between the groups and inside each the group, in the different time-points of euthanasia. Findings at 16 weeks were considered primary outcomes. P-values < 0,05 were considered significant. RESULTS: After 16 weeks, the Bonar score was significantly increased for both Groups A (11,8±2,28) and B (5,6±2,51), when compared to controls (2±0,76). Group A has also differed from Group B (p < 0,001). Regarding biomechanical findings, groups differed in cross-sectional area of the Achilles tendon (p=0,003), Young\'s modulus (p=0,024), Yield stress (p=0,020) and ultimate tensile strength (p=0,022), with the worst results in animals from Group A. At 12 weeks, comparison between Groups A and B have shown significant differences for Bonar score (p=0,028) and Yield stress (p=0,013), again with worse results in Group A. Conversely, at 10 weeks, rabbits in Group B showed worse results when compared to Group A, with significant differences in the Bonar score (p=0,033), cross sectional area of the tendon (p=0,038), stiffness (p=0,048), Young\'s modulus (p=0,024), Yield tension (0,008), Yield stress (p=0,020), energy Yield (p=0,047), ultimate tension (p=0,004), ultimate stress (p=0,008) and yield strain energy density (p=0,015). The comparison of outcomes inside each group, in the different time-points of follow-up, demonstrated significant differences in the Bonar score for Group A (p=0,012) and Group B (p < 0,001). Regarding biomechanical properties, Group A showed no differences between the subgroups for any of the parameters evaluated. Subgroups in Group B differed for cross-sectional area of the tendon (p=0,011), Young\'s modulus (p=0,024), Yield stress (p=0,023), ultimate stress (p=0,031) and yield strain energy density (p=0,017), with worst results in the earliest follow-up (Subgroup B1). CONCLUSIONS: The animal model of Achilles tendinopathy induced by consecutive injections of collagenase showed worse histological and biomechanical properties after 16 weeks, demonstrating more progressive and long lasting tendinopathic findings, reproducing better the disease in humans. This novel experimental model can represent a better option to induce Achilles tendinopathy, allowing promising future research on the subject

INTRODUÇÃO: Este estudo tem como objetivo comparar os achados biomecânicos e anatomopatológicos de um modelo animal inédito de tendinopatia do tendão do calcâneo, induzido por injeções seriadas de baixa dose da enzima colagenase bacteriana, com o modelo mais comumente utilizado na literatura, induzido por injeção única de maior dose da enzima, e com os controles. A hipótese é que a utilização de injeções seriadas resultaria em alterações tendíneas mais progressivas e duradouras, similar à doença nos humanos. MÉTODOS: Quarenta e cinco (N=45) coelhos foram randomizados em três diferentes grupos de estudo (A, B e Controles). Animais do Grupo A (n=18) foram submetidos a três injeções seriadas de baixa dose de colagenase (0,1mg), em ambos os tendões do calcâneo, separadas por intervalo de duas semanas. Animais do Grupo B (n=18) foram injetados com dose única de maior dose (0,3mg). Já no Grupo Controle, animais (n=9) foram injetados bilateralmente com três doses seriadas de solução fisiológica 0,9%. Após a última injeção, foi realizada eutanásia do mesmo número de animais dos Grupos A e B (n=6), com 10 semanas (Subgrupos A1 e B1), 12 semanas (Subgrupos A2 e B2) e 16 semanas (Subgrupos A3 e B3). Todos os animais do Grupo controle foram eutanasiados após 16 semanas. Alterações anatomopatológicas, pelo escore de Bonar, e biomecânicas foram comparadas entre os grupos e dentro de cada grupo, para os diferentes momentos de eutanásia. Valores de p < 0,05 foram considerados estatisticamente significativos. RESULTADOS: Após 16 semanas, o escore anatomopatológico de Bonar foi significativamente maior para ambos os Grupos A (11,8±2,28) e B (5,6±2,51), quando comparados aos controles (2±0,76). Os valores para o grupo A também diferiram do Grupo B (p < 0,001). Para os desfechos biomecânicos, os grupos diferiram quanto à área de secção transversa do tendão (p=0,003), módulo de elasticidade (p=0,024), e tensões no limite da elasticidade (p=0,020) e na resistência máxima (p=0,022), com piores resultados encontrados nos animais do Grupo A. Na semana 12, também houve diferença entre os Grupos A e B para o escore anatomopatológico de Bonar (p=0,028) e para a tensão no limite da elasticidade(p=0,013), novamente com piores resultados no Grupo A. Já na 10a semana, foram os coelhos do Grupo B que demonstraram alterações mais pronunciadas quando comparados aos do Grupo A, com diferença significativa no Escore de Bonar (p=0,033), área de secção transversa do tendão (p=0,038), rigidez (p=0,048), módulo de elasticidade (p=0,024), força, tensão, energia e densidade de energia no limite da elasticidade (p=0,008, p=0,020, p=0,047 e p=0,0015, respectivamente) além de força e tensão no limite da resistência máxima (p=0,004 e p=0,008, respectivamente). A comparação dos desfechos dentro de cada grupo, entre os diferentes subgrupos, apresentou diferenças significativas no escore de Bonar em ambos os grupos A (p=0,012) e B (p < 0,001). Parâmetros biomecânicos não diferiram entre os subgrupos do Grupo A. Já os subgrupos do grupo B apresentaram diferenças na área de secção transversa do tendão (p=0,011), módulo de elasticidade (p=0,024), tensão no limite da elasticidade (p=0,023) e da resistência máxima (p=0,031), assim como na a densidade de energia no limite da elasticidade (p=0,017), com resultados mais pronunciados no subgrupo B1. CONCLUSÃO: O modelo animal de tendinopatia do tendão calcâneo induzida por injeções seriadas de colagenase apresentou alterações anatomopatológicas e biomecânicas mais avançadas na 16a semana, de caráter progressivo e duradouro, similar à doença dos humanos. Tal modelo experimental pode representar uma melhor opção na indução da tendinopatia do tendão do calcâneo, possibilitando a realização de estudos promissores no futuro / INTRODUCTION: This study aims to compare the biomechanical and histological findings of a new animal model of Achilles tendinopathy induced by serial low-dose injections of bacterial collagenase with the most commonly used high-dose single injection and to controls. The hypothesis of the study is that consecutive low-dose injections of collagenase would result in more progressive and long-lasting tendinopathic findings, reproducing better the disease in humans. METHODS: Forty-five (N=45) rabbits were randomly divided into three groups (A, B and Control). Animals in Group A (n=18) underwent three serial low-dose (0,1mg) injections of bacterial type I collagenase in both Achilles tendons, separated by a two-week interval. Animals in Group B (n=18) underwent bilateral single high dose injection (0,3mg) of the same enzyme. In the Control Group, animals (n=9) were injected bilaterally with three consecutive doses of saline solution, separated by a two-week interval. Following the last injection, the same number of rabbits from Groups A and B (n=6) were euthanized after 10 weeks (Subgroups A1 and B1), 12 weeks (Subgroups A2 and B2), and 16 weeks (Subgroups A3 and B3). Animals in the Control Group were all euthanized after 16 weeks. Histological findings, using the Bonar tendinopathy score, and biomechanical properties of the Achilles tendons were compared between the groups and inside each the group, in the different time-points of euthanasia. Findings at 16 weeks were considered primary outcomes. P-values < 0,05 were considered significant. RESULTS: After 16 weeks, the Bonar score was significantly increased for both Groups A (11,8±2,28) and B (5,6±2,51), when compared to controls (2±0,76). Group A has also differed from Group B (p < 0,001). Regarding biomechanical findings, groups differed in cross-sectional area of the Achilles tendon (p=0,003), Young\'s modulus (p=0,024), Yield stress (p=0,020) and ultimate tensile strength (p=0,022), with the worst results in animals from Group A. At 12 weeks, comparison between Groups A and B have shown significant differences for Bonar score (p=0,028) and Yield stress (p=0,013), again with worse results in Group A. Conversely, at 10 weeks, rabbits in Group B showed worse results when compared to Group A, with significant differences in the Bonar score (p=0,033), cross sectional area of the tendon (p=0,038), stiffness (p=0,048), Young\'s modulus (p=0,024), Yield tension (0,008), Yield stress (p=0,020), energy Yield (p=0,047), ultimate tension (p=0,004), ultimate stress (p=0,008) and yield strain energy density (p=0,015). The comparison of outcomes inside each group, in the different time-points of follow-up, demonstrated significant differences in the Bonar score for Group A (p=0,012) and Group B (p < 0,001). Regarding biomechanical properties, Group A showed no differences between the subgroups for any of the parameters evaluated. Subgroups in Group B differed for cross-sectional area of the tendon (p=0,011), Young\'s modulus (p=0,024), Yield stress (p=0,023), ultimate stress (p=0,031) and yield strain energy density (p=0,017), with worst results in the earliest follow-up (Subgroup B1). CONCLUSIONS: The animal model of Achilles tendinopathy induced by consecutive injections of collagenase showed worse histological and biomechanical properties after 16 weeks, demonstrating more progressive and long lasting tendinopathic findings, reproducing better the disease in humans. This novel experimental model can represent a better option to induce Achilles tendinopathy, allowing promising future research on the subject

BakgrundPatellatendinopati (PT) är förekommande hos personer som tränar rekreativt och bland elitidrottare men förekomsten bland inaktiva är okänd. Forskningen på PT har huvudsakligen varit fokuserad på de fysiska begränsningarna av tillståndet med viss framgång på utfall som smärta och funktion genom olika träningsprotokoll. Men PT tenderar att bli långvarigt och långt ifrån alla blir bra. Internationellt vetenskapligt konsensus inom tendinopati menar att det saknas kunskap om tillstånden ur ett bredare biopsykosocialt hänseende. Hittills har såvitt studieförfattarna vet, inga studier utforskat vilka erfarenheter personer med PT har av att leva med och rehabilitera besväret.SyfteAtt utforska erfarenheterna av att leva med och rehabilitera PT hos personer som rekreativt tränar/idrottar.MetodDetta är en deskriptiv intervjustudie med semi-strukturerade intervjuer där en kvalitativ induktiv ansats användes. En tematisk analys utfördes med en semantisk och induktiv inriktning. Totalt rekryterades tio deltagare.ResultatFem huvudteman identifierades ur datan: (1) Hot mot identiteten, (2) Att inte kunna leva sitt liv fullt ut, (3) En ogynnsam relation till smärta, (4) Att känna makt över sin situation återgav kontroll (5) Avgörande för rehab var att se helheten och inte bara ett knä.SlutsatsPT visar sig kunna vara ett tillstånd som innehåller ett större lidande utöver de uppenbara fysiska begränsningarna. Bland personerna som deltog framkom flertalet negativa kognitiva och emotionella erfarenheter och maladaptiva beteenden i relation till smärtan. Resultaten kan argumenteras ha en viktig klinisk innebörd. Omhändertagandet av PT bör ske personcentrerat med ett förhållningssätt förankrat i att smärta har en biopsykosocial inverkan. Av metodologiska skäl ska överförbarheten till en bredare population dock tolkas med viss försiktighet. / BackgroundPatellar tendinopathy (PT) is common within an active population, especially elite athletes, but less is known about the presence among sedentary people. Previous research has focused on the physical impairments with modest effect on outcomes like pain and function through different training protocols. Nonetheless, PT tends to be persistent and many fail to recover. Current international consensus highlights the lack of knowledge of tendinopathy through a biopsychosocial perspective. No studies have explored people with PT and their experiences with living and rehabilitating the condition.PurposeTo explore the experiences of living with and rehabilitating PT among people who exercise or do sports recreationally.MethodA descriptive interview study with semi-structured online interviews was performed. A total of 10 participants participated. A thematic analysis was performed with a semantic and inductive procedure.ResultsFive main-themes were identified from the data: (1) Threatened identity, (2) Not being able to live your life to the fullest, (3) A adverse relationship with pain, (4) To feel in charge over ones situation brought back control (5) To be seen as a whole and not just a knee was crucial to rehab.ConclusionPT has a larger impact beyond the physical impairments. Negative cognitions and emotions coupled with maladaptive behaviours in relation to the pain emerged to a considerable degree. These results could have an important clinical message, that the management of PT would benefit from being person-centred where the biopsychosocial impact of pain is acknowledged. Caution should be taken in regards to this study's transferability to a wider population due to methodological aspects.

Thesis questions: • Is the glutaminergic system altered in rotator cuff tendinopathy? • Is the glutaminergic system altered by common treatments? • Are glutaminergic changes related to pain symptoms? • What are the effects of glutamate and glutamate receptor modulation on tendon derived cells? Summary answers: • The glutaminergic system is altered in rotator cuff tendinopathy • Changes within this system are seen after common treatments • Specific glutaminergic changes are associated with the resolution of pain following shoulder surgery but do not predict the severity of pain symptoms • Glutamate has significant effects on tendon derived cells. What is known: It is known that extracellular glutamate concentrations are increased in both Achilles and patellar tendinopathy. It has also been previously shown that the glutamate receptors NMDAR1 and mGluR5 are upregulated in patellar tendinopathy. What this thesis adds: This thesis has shown for the first time that glutamate and NMDAR1 are increased in rotator cuff tendinopathy. Increases in cell proliferation, vascularity and HIF1α are seen after surgical rotator cuff repair and these features are not seen after glucocorticoid injection. There are significant differences between painful and pain-free rotator cuff tendons in terms of glutamate receptor expression (KA1, mGluR7 and mGluR2) and inflammatory cell numbers (CD45 and CD206). Exposure to 1.875mM glutamate for 72 hours results in reduced cell viability, decreased collagen (COL1A1 and COL3A1) and increased aggrecan gene expression; NMDAR antagonism with MK-801 attenuates the deleterious effect on cell viability but had no effect on the changes in matrix gene expression. Bias, confounding and other reasons for caution: The observational histological work was limited by the control tissue. Some control tissue was not age matched, while some of the pain-free control tendons were post-surgical intervention. Confounding factors include tendon structure, length of symptoms and previous treatments. Caution must be applied when discussing the in vivo implications of the in vitro work.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

This diploma thesis deals with the Achilles tendinopathy, and particularly with its etiopatogenetics. The theoretical part includes information about the Achilles tendon, tendinopathy of Achilles tendon and a summary of dysfunctions of the locomotor system. We assumed that the dysfunction of the locomotor system is the main etiopatogenetic factor of the Achilles tendinopathy, and that it results in changes of its position and loading. In the practical part we tried to reveal these dysfunctions by examination of seven patients, and to prove its main etiopatogenetic influence by a successfull therapy. The aim of the thesis was to point out the importance of the examination as well as the therapy of the locomotor systems function. Powered by TCPDF (www.tcpdf.org)

Les tendinopathies sont la première cause de maladie professionnelle en France. Elles sont devenues une préoccupation majeure de santé publique. Cependant, leurs mécanismes physiopathologiques restent encore mal définis. Au cours de cette thèse, nous nous sommes intéressés aux phases précoces de la tendinopathie engendrées par une sur-utilisation du tendon supra-épineux (tSE) de la coiffe de rotateurs de l’épaule chez le rat. Nous avons tenté de comprendre les mécanismes à l’origine de cette pathologie afin de pouvoir agir et la traiter en amont de l’apparition des symptômes.Nous montrons que le profil d’évolution moléculaire des collagènes, des protéoglycanes et des glycosaminoglycanes (GAGs) associé aux phases précoces de la sur-utilisation, témoigne d’un profond remaniement matriciel et d’une différenciation chondroïde des fibroblastes tendineux. Nous avons identifié les métalloprotéinases (MMPs) majeures et leurs inhibiteurs (TIMPs) susceptibles d’être impliqués dans ce remaniement. Nos résultats suggèrent que le mécanisme lésionnel initial et les changements matriciels observés sont dus à un processus induit par des médiateurs locaux libérés par les ténocytes et non à une réaction inflammatoire. Enfin, nous avons cherché à établir une corrélation entre les changements moléculaires observés et le degré de sévérité d’une tendinopathie diagnostiquée chez l’Homme. Nous avons montré, sur des échantillons de tendon patellaire humain une relation entre la quantité des GAGs et le score (VISA score) reflétant le degré pathologique du tendon.Cette étude nous a donc permis d’améliorer nos connaissances des phases précoces du processus d’altération du tSE. Cependant, d’importants efforts restent néanmoins à accomplir dans la caractérisation de la pathogenèse précoce notamment pour préciser le contexte biomécanique qui la génère. / Tendinopathies are the first cause of professional diseases in France. They are a major public health concern. However, their physiopathological mechanisms remain poorly understood. This project aimed at investigating the early stages of supraspinatus tendinopathy caused by overuse. Using a rat animal model, we attempted to understand the mechanisms behind this disease in order to act and treat the symptoms upstream of their onset.We have shown that the molecular changes of collagens, proteoglycans and glycosaminoglycans (GAGs) associated with the early events of overuse attest a major matrix remodeling and chondrogenic differentiation of tendon cells. We identified the main metalloproteinases (MMPs) and their inhibitors (TIMPs) that may be involved in this remodeling. Our results further suggest that the initial mechanisms linked to the observed matrix changes are due to local mediators release by tenocytes rather than an inflammatory process. Finally, we attempted to correlate molecular changes observed during overuse with the severity of the tendinopathy diagnosed in humans. We have shown a relationship between the amount of GAGs and the pathological score (VISA score) on human patellar tendons.This study improved our knowledge of the early pathological events of the supraspinatus tendon. However, more remains to be done for characterizing the early stages of tendinopathy especially to clarify the biomechanical context up-stream.

Tendinopathien der Achilles- oder Patellarsehne sind häufig in Sportarten mit zahlreichen repetitiven Belastungen im Dehnungs-Verkürzungs-Zyklus der unteren Extremität zu finden. Sowohl eine möglicherweise alterierte belastungsspezifische neuromuskuläre Antwort (NMA), als auch funktional begründete Therapiemaßnahmen mit möglichen positiven Effekten sind aktuell ungeklärt. Ziel der Arbeit war deshalb die Untersuchung der belastungsspezifischen neuromuskulären Antwort bei Athleten mit Tendinopathie der Achilles- oder Patellarsehne im Vergleich zu beschwerdefreien Athleten. Zusätzlich sollten mögliche funktionale und therapeutische Effekte eines sensomotorischen Trainings im randomisierten, kontrollierten und prospektiven Studiendesign überprüft werden. 51 Sportler mit unilateraler Tendinopathie (Achilles-/Patellarsehne n = 35/16) und 33 gesunde Sportler wurden zur Beurteilung der belastungsspezifischen neuromuskulären Antwort eingeschlossen. Zur Klärung der Effekte eines sensomotorischen Trainings im Längsschnitt konnten 26 Sportler mit Tendinopathie randomisiert zu einer Kontrollgruppe (n = 14) und einer Therapiegruppe mit sensomotorischem Training (n = 12) zugeordnet werden. Nach einer ersten biomechanischen Messung M1 (Belastungssituationen: Lauf-, Stabilisations-, Kraftbelastung) und der Erhebung der subjektiven Schmerzsymptomatik folgte eine 8-wöchige Therapiephase mit einer abschließenden Re-Test-Messung M2 identisch zu M1. Das sensomotorische Training war auf die gesamte untere Extremität ausgerichtet und wurde nach Einweisung regelmäßig kontrolliert. Die Erfassung der NMA erfolgte über die Quantifizierung der muskulären Aktivität (EMG). Zusätzlich wurde die Kinetik (z.B. Maximalkraft) belastungsspezifisch erfasst. Eine reduzierte NMA konnte für die Sportler mit Tendinopathie über veränderte EMG-Zeit- und Amplitudenmessgrößen, eine reduzierte aktive Stabilisationsfähigkeit und Maximalkraft (p < 0,05) nachgewiesen werden. In Abhängigkeit der Lokalisation (Achilles-/Patellarsehen) bzw. der Seite (Beschwerdeseite/gesunde Seite) ergaben sich keine relevanten Differenzen. Das sensomotorische Training zeigte eine Optimierung der NMA (z.B. erhöhte Maximalkraft) bei Tendinopathie der Achilles- oder Patellarsehne. Die Überprüfung der Beschwerdesymptomatik wies in allen Schmerz-Scores nach der Therapie reduzierte Werte und damit einen positiven therapeutischen Effekt gegenüber der Kontrollgruppe auf. Zusammenfassend kann eine systematisch reduzierte NMA bei Lauf-, Stabilisations- und Kraftbelastung der Sportler mit Tendinopathie nachgewiesen werden. Das sensomotorische Training ist funktional und therapeutisch als effiziente Therapiemaßnahme zu erachten. / Tendinopathies of the achilles- or patellartendon are common overuse unjuries in sports including high numbers of repetitive stretch-shortening-cycles of the lower limb. Possible alterations of the neuromuscular response (NMR) to physical stress and functionally justified therapies with potential positive effects are currently unknown. The aim of the study was therefore the analysis of the neuromuscular response in situations with physical stress in athletes with tendinopathie of the achilles or patellartendon compared to symptom free athletes. In addition, possible functional and therapeutic effects of a sensorimotor training were studied in a prospective, randomized and controlled study. 51 athletes with unilateral tendinopathy (achilles-/patellartendon n = 35/16) and 33 healthy athletes were included to assess the stress related neuromuscular response (NMR). To clarify the effects of a sensorimotor training 26 athletes with tendinopathy were randomized to a control group (n = 14) and a therapy group with sensorimotor training (n = 12). After initial biomechanical measurements M1 (situations: running, active postural stability and maximum strength test) and the collection of subjective complaints (pain) an 8-week treatment phase followed with a final re-test M2 measure identical to M1. The sensorimotor training was arranged for the entire lower extremity, and was checked after an initial briefing on a regular basis. The assessment of the NMR was quantified by muscle activity (EMG). In addition, the kinetics (e.g. maximum force) was acquired in the stabilization and maximum strength test. A reduced NMR could be proven for athletes with tendinopathy with changed EMG time and amplitude measurements, a reduced active postural stabilization ability and reduced maximum strength (p <0.05). No relevant differences could be observed in comparing localization (achilles-/patellartendon) and side (leg with complains/healthy leg). The sensorimotor training showed an optimization of NMR (e.g. increased maximum strength) for patient with tendinopathy of the achilles- or patellartendon. The examination of the complaints showed reduced values in all pain scores after therapy. The treatment had therefore positive therapeutic effects compared to the control group. In summary, a systematically reduced NMR in running, stabilization and strength tests are evident for athletes with tendinopathy. The sensorimotor training can be considered as an efficient treatment with functional and therapeutic effects.