On October 7, The “Barça Sports Medicine Conference” took place during the “Sports Science Week”. An event organised by Barça Innovation Hub (BiHUB), the innovation platform of FC Barcelona. The main tendon specialists in the world of sports participated in the event in which they were able to show the latest scientific evidence about pathophysiology, pain clinic and prevention, intervention and rehabilitation protocols in tendon injuries. The launch of the FC Barcelona Tendon Injury Guide was announced for 2020, which will include the knowledge and experience of 35 collaborators from 11 countries, in order to gather a unique vision and comprehensive approach of tendon injuries.
Description of the pathology and pain.
The first part of the day was dedicated to the global analysis of the injury. Dr. Jill Cook, physiotherapist and research teacher at La Trobe University, explained how the tendon can have a paradoxical response to the loading, as it can induce an adaptation but it can also be an important factor in the pathology/pain of the tendon. Furthermore, she confirmed that “we have come very far in its study but we still have a long way to go regarding its pathology and pain comprehension as well as understanding everything we don’t know such as the genetics, the co-morbidities or the risk factors”.
Dr. Markus Walden, orthopaedic surgeon and researcher at Football Research Group, presented epidemiological studies that show how teams have an average of 4 tendon injuries per season, being the Achilles tendinopathy the most frequent among professional football players. He also analysed different risk factors and described that its indecency rate increases especially during pre-season in older players and in countries with cold weather. This could be because of a hard ground playing surface.
As for Dr. Sean Docking, researcher at La Trobe University, he emphasised the importance of taking into account the cognitive bias in the diagnosis. The researcher explained how the use of images in some cases can have a negative effect in regard to the final resolution of the injury, as the patient can develop symptoms linked to it.
The presentation of Dr. Ebonie Rio, also a researcher at La Trobe University, focused on the tendon injury pain model, pointing out misconceptions that can damage the patient’s recovery. She exposed the effects that pain has on the brain and the importance of language and exercise in the rehabilitation program.
In order to finish this first approach to the tendon, Dr. Carles Pedret, a specialist in sports medicine and ultrasound diagnosis, analysed how the use of image can help manage the evolution of an injury, highlighting the ultrasound as the best image method for the tendon and the magnetic resonance for its differential diagnosis. However, he confirmed that “even though structural changes can be analysed using images, we still don’t know what they mean exactly”. In the same vein, Dr. Sandra Mechó emphasised that “images allow us to visualize morphological changes but we can’t get to distinguish between degenerative or adaptive changes.”
Tendon injury interventions.
The second part of the day started with Henning Langberg, physiotherapist and professor at the Faculty of Health and Medical Sciences at Copenhagen University, who emphasised the need to also focus on the muscle and not only on the tendon as the muscular health seems to be critical for tendinopathy. In addition, he affirmed that “in the future, tendon rehabilitation should be personalised based on data”.
As for Dr. Jeremy Loenneke, from the Health and Exercise Science Department at the Mississippi University. He analysed the possibilities of blood-flow restriction (BFR) in the management of injuries and the modulation of workload as “it has proven to be a safe technique and it can increase muscle mass and strength with low load/intensity works”. Despite the opportunities that arise from it, more studies are going to be needed since the analysed evidence so far shows how the tendon doesn’t seem to adapt to the low loadings with BFR, unlike the muscle.
The presentation of Dr. Tero A H Järvinen, from the Medicine and Health Technologies Faculty at Tampere University, analysed a key aspect in the pathophysiology of tendon injuries, the hypoxia, meaning, the oxygen reduction in the injured tissue. He emphasised that “oxygen is necessary for the regeneration of the tissue”, and its drop increases the creation of non-functional vascular structure (neovascularisation), further worsening the problem. Therefore, the use of corticosteroids is not justified since it doesn’t address the pathology and the degeneration, within the tendon.
Along the same line, Dr. Hans Tol, doctor at the Amsterdam Academic Centre of Sports Medicine, encouraged the audience “to say no to the use of steroid injections” in tendon injuries, adding that another treatment such as “PRP is not only painful and expensive but it also doesn’t work”. He concluded saying that “loading is key and wonderful but it is not wonderful for all athletes”. Likewise, Dr. Lorenzo Masci, sports medicine and exercise consultant based in ISEH, defended that exercise therapy should be first in treatment, affirming that, at the same time; intratendinous surgery could cause severe tendon damages.
Practical cases of rehabilitation
The first example of tendon injury management was introduced by Dr. Dylan Morrissey, physiotherapist and researcher at Queen Mary University of London, illustrating a successful treatment of Achilles intratendinous rupture. He also emphasised the need to improve the imaging technique because despite being useful for monitoring the injury, improvement of its resolution is still needed.
The next case was presented by Dr. Maurizio Fanchini, responsible for the strength and conditioning department at AS Roma, who explained the treatment of a 39-year-old player with an Achilles tendon rupture with a multi-factorial approach. On the other hand, he emphasised the importance of monitoring training load, both internal and external, so as to control the player’s ability at the time of training and competing.
As for Dr. Hans Zwerver, professor at Groningen University, he also pointed out the significance of exercise in patellar tendinopathy management. Likewise, he stated that surgery is not a quick solution for tendinopathy, besides its results are unpredictable in many cases.
Dr. Andreas Serner, physiotherapist and researcher in Aspetar, talked about adductor tendinopathy, which he affirmed: “it has an uncertain diagnosis”. He insisted on the importance of previously controlling the player’s strength levels to anticipate injuries in this area as “his strength is reduced before the symptoms appear”. Likewise, he emphasised the importance of applying a progressive loading for its rehabilitation.
Lastly, prevention and evaluation models were presented. Dr. Robert-Jan de Vos, from the Medical Centre at Erasmus University, talked about the main risk factors of Achilles tendinopathy, pointing out having previously suffered a lower limb tendinopathy. Similarly, he spoke about the diagnosis of hamstring tendinopathy and about the absence of rehabilitation protocols clinically proven in patients with this injury. On the other hand, Dr. Seth O’Neill, professor at Leicester University, highlighted the importance of diagnosis at the time of addressing the Achilles tendon rehabilitation, as well as the need of valuing the muscle-tendon merger and the loadings that it has to usually withstand. Moreover, he emphasised actions that should be avoided in its treatment.
Dr. Andreas Ivarsson, chief of the Arsenal psychology department and professor at Halmstad University, detailed how stress and the responses that it causes are variables that can increase the risk of injury. On this basis, he expressed that “the monitoring of players’ stress levels along with psychological techniques can be integrated into preventive injury schemes within a team or a club and so help reduce injury risk”. Finally, Daniel Florit, one of FC Barcelona’s first team doctors, gave an overview analysis of tendon injuries in professional team sports at FC Barcelona. He mentioned that injuries in the patellar tendon are the most frequent, followed by the Achilles tendon ones. In addition, he specified that the incidence of these injuries is greater in indoor sports (e.g. basketball, hockey skates and indoor football). Based on this data, Javier Ruiz, strength and conditioning coach at FC Barcelona, affirmed that “the data collected during these two seasons is very valuable to us as it provides qualified information that allows us to make conclusions which help us identify risk factors and develop a more specific work proposal”.
The Barça Innovation Hub team