2.8 Overuse Tendinopathies & Regenerative Medicine

ABPMR Physical Medicine and Rehabilitation Board Exam Study Guide Exam

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1 Chapter 1: Introduction & Exam Overview

1.1 ABPMR Part I Exam Overview & Format 1.2 Board Review Strategy & Content Blueprint Breakdown

2 Chapter 2: Musculoskeletal Medicine

2.1 Shoulder & Upper Extremity Diagnostics 2.2 Knee, Hip & Lower Extremity Conditions 2.3 Spine Pathology, Radiculopathy & Myelopathy 2.4 Inflammatory Arthritis, Tendinopathies & Concussion 2.5 Bone Health, Osteoporosis & Metabolic Bone Disease 2.6 Thoracic Outlet Syndrome & Peripheral Nerve Entrapment 2.7 Fracture Rehabilitation & Immobilization Complications 2.8 Overuse Tendinopathies & Regenerative Medicine 2.9 Gait Analysis & Abnormal Gait Patterns

3 Chapter 3: Spinal Cord Injury Rehabilitation

3.1 ASIA Examination & Impairment Scale 3.2 Spinal Cord Injury Syndromes 3.3 Autonomic Dysreflexia & Acute Complications 3.4 Neurogenic Bladder, Bowel & Secondary Complications

4 Chapter 4: Stroke & Neuromuscular Rehabilitation

4.1 Stroke Vascular Syndromes & Acute Assessment 4.2 Stroke Motor Recovery & Hemiplegic Complications 4.3 Spasticity Assessment & Multimodal Management 4.4 ALS, GBS, CIDP & Neuromuscular Disease Rehab 4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation 4.6 Parkinsonism, Movement Disorders & Functional Neurologic Disorder

5 Chapter 5: Electrodiagnostics (EMG/NCS)

5.1 Nerve Conduction Studies Principles & Physics 5.2 Needle Electromyography & MUAP Analysis 5.3 Mononeuropathies & Radiculopathy Patterns 5.4 Neuromuscular Junction Disorders & Myopathies

6 Chapter 6: Traumatic Brain Injury

6.1 TBI Severity Classification, Glasgow Coma Scale, and Pathophysiology 6.2 Rancho Los Amigos Levels of Cognitive Functioning and Disability Rating Scale 6.3 Neurobehavioral Sequelae and Agitation Management 6.4 Concussion Evaluation, Vestibular-Ocular Dysfunction, and Return-to-Play/Work Protocols

7 Chapter 7: Chronic Pain & Interventional Spine

7.1 Fluoroscopic Spine Interventions 7.2 Opioid Stewardship & Controlled Substance Compliance 7.3 Complex Regional Pain Syndrome, Fibromyalgia & Myofascial Pain 7.4 Spinal Cord Stimulation & Intrathecal Therapy

8 Chapter 8: Amputee Rehabilitation & Prosthetics

8.1 Amputation Surgical Levels & Medicare K-Levels 8.2 Socket Designs & Suspension Systems 8.3 Prosthetic Feet & Microprocessor Knee Mechanisms 8.4 Post-Amputation Care, Residual Limb & Phantom Pain

9 Chapter 9: Pediatric Rehabilitation

9.1 Cerebral Palsy Classification & GMFCS 9.2 Spina Bifida & Myelomeningocele Management 9.3 Muscular Dystrophies & Neuromuscular Disease in Children 9.4 Pediatric Brachial Plexopathy & Congenital Disorders

10 Chapter 10: Prosthetics, Orthotics & Assistive Technology

10.1 Lower Limb Orthoses — AFOs & KAFOs 10.2 Spinal & Upper Extremity Orthoses 10.3 Upper Limb Prosthetics — Body-Powered vs Myoelectric 10.4 Wheelchairs, Seating Systems & Pressure Mapping

11 Chapter 11: Medical Rehabilitation & Outcomes

11.1 Dysphagia Assessment & Management 11.2 Neurogenic Bladder & Bowel Management 11.3 Pressure Injuries & Wound Management 11.4 Outcome Measures & Medical Complications 11.5 Cancer Rehabilitation & Oncologic Rehabilitation 11.6 Burns, Endocrine/Metabolic & Medical Complications Rehabilitation

12 Chapter 12: Cardiopulmonary Rehabilitation

12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents 12.2 Pulmonary Rehabilitation & COPD Management

13 Chapter 13: Foundational Rehabilitation Concepts

13.1 Kinesiology, Biomechanics & Functional Anatomy 13.2 Rehabilitation Pharmacology & Medication Management 13.3 Research Methodology, Biostatistics & Evidence-Based Practice 13.4 Nutrition, Metabolism & Energy Expenditure in Rehabilitation 13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

2.8 Overuse Tendinopathies & Regenerative Medicine

Key Takeaways Explain This Topic AI

Tendinopathy is now preferred over 'tendinitis' because chronic overuse tendons show degenerative (tendinosis) changes with minimal inflammation; the failed-healing response includes neovascularization, collagen disorganization, and tenocyte apoptosis.

Eccentric loading exercise (e.g., Alfredson protocol for Achilles tendinopathy) has the strongest evidence for treating tendinopathy; relative rest, activity modification, and progressive loading form the rehabilitative core.

Corticosteroid injections provide short-term relief (weeks) for lateral epicondylitis and rotator cuff tendinopathy but do not improve long-term outcomes and may weaken tendon; repeated injections are discouraged.

Regenerative biologics—platelet-rich plasma (PRP) and autologous tenocyte/STEM cell preparations—aim to stimulate healing but have variable evidence and remain investigational for many indications; PRP is best supported for lateral epicondylitis and patellar tendinopathy.

Last updated: July 2026

Overuse Tendinopathies & Regenerative Medicine

Tendinopathy is a Domain D staple and a "treatments" topic under Domain A (modalities, regenerative medicine). The shift from inflammatory "tendinitis" to degenerative "tendinosis" frames modern management around load management and collagen remodeling rather than anti-inflammatory suppression alone.

Tendinosis Pathophysiology Repeated Microtrauma ──► Failed Healing Response ──► Collagen Disorganization
│ + Neovascularization
│ + Tenocyte Apoptosis
└──── Tendinosis (Degenerative, Minimal Inflammation)

Chronic overuse tendons show collagen fibril disorganization, neovascularization (often painful, with ingrowth of nociceptors alongside vessels), increased glycosaminoglycans, and tenocyte apoptosis—not the robust inflammatory infiltrate implied by "tendinitis." This explains why anti-inflammatory monotherapy underperforms and why loading therapy succeeds.

High-Yield Tendinopathies

Condition Site Key Findings First-Line Rehab

Lateral epicondylitis ECRB origin at lateral epicondyle Pain with resisted wrist extension (Cozen), grip Eccentric wrist extensor loading, brace

Medial epicondylitis Common flexor origin Pain with resisted wrist flexion/pronation Eccentric flexor-pronator loading

Rotator cuff tendinopathy Supraspinatus Painful arc, Neer/Hawkins, empty can Scapular stabilization, RTC eccentric

Achilles tendinopathy Midportion/insertional Painful arc within tendon (not across joint), tender mid-substance Alfredson eccentric protocol

Patellar tendinopathy Inferior patellar pole Pain with single-leg decline squat, jumping Eccentric decline-board squats

Gluteus medius/minimus Greater trochanter Lateral hip pain, pain with resisted hip abduction Hip abductor eccentric strengthening

Eccentric Loading & the Alfredson Protocol

Eccentric exercise—lengthening contraction under load—is the most evidence-supported intervention. The Alfredson Achilles protocol uses two exercises (knee straight and bent) performed as 3x15 twice daily for 12 weeks, progressing load despite mild pain (acceptable up to ~3-5/10). For patellar tendinopathy, single-leg decline-board eccentric squats are effective. Load progression, not rest, drives collagen remodeling.

Injection Therapies

Corticosteroid : useful short-term (a few weeks) for lateral epicondylitis and rotator cuff; risks include tendon weakening, skin atrophy, and depigmentation. Avoid repeated injections (>3).

Dry needling : disrupts degenerative tissue and may stimulate healing; often combined with PRP or autologous blood.

Autologous blood / prolotherapy : limited evidence; may stimulate inflammatory healing.

Regenerative Biologics

Platelet-rich plasma (PRP) concentrates platelet growth factors (PDGF, TGF-beta, VEGF) to stimulate tendon healing. Evidence is most supportive for lateral epicondylitis and patellar tendinopathy ; results for Achilles and rotator cuff are mixed. Leukocyte-rich vs leukocyte-poor preparations differ by tissue. Autologous tenocyte and mesenchymal stem cell preparations remain investigational for most indications. Candidates should know the moderate, condition-specific evidence and the absence of long-term superiority over exercise for many tendons—not uncritical adoption.

Rehab Principles Summary

Relative rest and activity modification (avoid provocative load; not absolute rest).

Progressive eccentric loading—the rehabilitative cornerstone.

Address contributing biomechanics (e.g., scapular dyskinesis, foot overpronation).

Reserve injections for refractory cases or to facilitate loading; combine with rehab, never substitute.

Surgery only after failed comprehensive conservative program (typically 6-12 months).

Tendon Anatomy & Healing

Tendons transmit muscle force to bone and are relatively avascular, especially at "watershed zones" (e.g., supraspinatus mid-substance, Achilles 2-6 cm above insertion) where degeneration and rupture cluster. Healing proceeds through inflammatory, proliferative, and remodeling phases, but tendons heal slowly with disorganized collagen and modest strength. This biology underlies the weeks-to-months loading requirement and the recurrence risk when load is progressed too quickly.

Common Tendon Ruptures

Tendon Mechanism Functional Loss
Achilles Sudden eccentric load (jumping) Loss of active plantarflexion, positive Thompson test
Quadriceps Sudden eccentric load; older adults Extensor lag; palpable defect
Patellar Direct blow / eccentric Inability to extend knee
Biceps (distal) Eccentric elbow flexion Weak flexion/supination, hook test
Supraspinatus Chronic degeneration ± trauma Painful arc, weakness, positive empty can
Extensor mechanism Jumping/landing Loss of active knee extension

Acute ruptures require surgical consideration for active patients and younger individuals; chronic degenerative tears are usually managed conservatively first. The Thompson test (calf squeeze with no plantarflexion) diagnoses Achilles rupture; the hook test diagnoses distal biceps rupture.

Load Management & Biomechanics

Addressing contributing biomechanics prevents recurrence: scapular dyskinesis for rotator cuff, gluteus medius weakness for iliotibial band and patellar issues, foot overpronation for Achilles/tibialis posterior, and grip/racquet technique for epicondylitis. Taping and orthoses may offload symptomatic tendons during loading. Load progression follows the "acute:chronic workload" principle—increasing total load modestly each week to avoid spikes that provoke symptoms.

When to Refer for Surgery

Surgical referral is reasonable when (1) comprehensive conservative management (eccentric loading ± injection) fails over 6-12 months, (2) a large acute tear in a young/active patient, or (3) functional demands are not met. Tendon transfer or debridement options exist; the physiatrist coordinates prehab (maximize strength and ROM before surgery) and post-surgical rehabilitation. The goal is to exhaust the evidence-based conservative pathway before surgical intervention, since results of surgery for degenerative tendons are often comparable to continued exercise.