Tendinopathy

Do you have shoulder, elbow, knee or ankle pain, but you don’t have arthritis?  Have you had an injury in one of those areas in the past that flares up with strenuous activity?  Maybe you’ve had steroid injections with benefits but they no longer help?  If so, you likely have tendinopathy. 

What?

Tendinopathy is a general term characterized by a combination of pain, swelling, and impaired performance. Tendons are rope-like structures that connect your muscle to bone. They are similar in structure to ligaments which connect bone to bone. When your muscles tighten and relax, your tendons and bones move.  One example of a tendon is your Patellar tendon, which attaches to your knee cap to your lower leg and causes knee movement.  If you have pain and/or swelling in that area, you might have Patellar tendinopathy, also known as “Jumper’s knee”.

The term Tendinopathy is often used to include both tendinitis (tendonitis) and tendinosis.  However, tendinitis means inflammation of your tendon.  It’s a painful injury that can either be short-term (acute) or progress to a long-term (chronic) condition.  You may develop tendonitis after a sudden injury like lifting a heavy weight or from repetitive activities that cause micro-tears in your tendons over time.  Tendinosis is the breakdown (degeneration) of the collagen fibers in your tendon.  It occurs when the acute phase of healing has ended (six to eight weeks) but has left the area insufficiently healed and is often the result of tendon overuse making it a long-term (chronic) condition.

Where?

Common sites for tendinopathy include the rotator cuff (supraspinatus tendon), wrist extensors (lateral epicondyle), wrist flexors (medial epicondyle), patellar and quadriceps tendons, and the Achilles tendon. In athletes, common locations include the Achilles and patellar tendons. In the general population, the Achilles and lateral epicondyle are the most commonly affected.

• Achilles tendinopathy - the strongest, largest tendon in your body
• Patellar tendinopathy - actually a ligament, connects the kneecap to the top of the tibia
• Rotator cuff tendinopathy - group of tendons that keep your shoulder joint stable
• DeQuervain’s tenosynovitis (tendinopathy) - affects your wrist and thumb
• Tennis elbow - also known as lateral epicondylitis
• Golfer’s elbow - also known as medial epicondylitis

Who's at risk?

Tendinopathy affects about 2% to 4% of the general population. While it affects people of all ages, some people are more likely than others to develop tendinopathy.  Higher risk groups include: 

• Athletes - swimmers, runners, golfers, tennis players
• Industrial athletes - gardner, roofer, landscaper, painter, etc 
• People over 40 years of age
• People who perform repetitive tasks/manual labor
• People who take certain medications - fluoroquinolone, glucocorticoids
• People with particular medical conditions - dyslipidemia, arthritis, gout, obesity, thyroid disease, type 2 diabetes
• People with poor muscle strength
• Women

Signs and Symptoms 

Symptoms can vary from dull aches or pains with local joint stiffness and swelling to burning that surrounds the inflamed tendon.  Swelling is often associated with heat, redness and pain on palpation.  The pain and swelling are typically aggravated by exercising or with a specific movement and results in impaired performance.  You may have tendinopathy if you're experiencing some or all of the following symptoms:

• Burning pain
• Joint stiffness.
• Joint swelling.
• Crackling or grating sensation when you move your joint.
• Muscle weakness and loss of strength.
• Redness or warmth in the painful area.

Diagnosis

Successful treatment requires an accurate diagnosis.  The first steps are obtaining a history and performing a thorough focused physical examination.  The history will focus on the pains location, duration, type, severity, aggravating and alleviating factors.  The physical examination will locate the site of redness, swelling and tenderness to palpation.  Range of motion and strength will be tested.  The examiner will also perform special tests that point to pathology in specific structures, such as the rotator cuff.

While diagnosis can be made from reported history and physical examination, additional information may be needed.  Imaging tests such as Ultrasound or MRI may be ordered. Ultrasound can be used to evaluate tissue strain, as well as other mechanical properties such as disorganized tendon fibers and tears. MRI provides a detailed image of soft tissue revealing the general health or injury in the tendon.

Treatment

The treatment for your tendinopathy depends on the type you have and which tendon is involved.  The treatment for both types may include activity modification, relative rest, ice, stretching and strengthening. 

Common treatment for tendinitis: 

• Relative rest - avoid aggravating activities
• Nonsteroidal anti-inflammatory drugs (NSAIDs) - may be helpful with pain, but don’t alter long term outcomes (Advil, Motrin, etc.)
• Corticosteroid injections - has not been shown to have long-term benefit.  May have negative effects due to apoptosis (a form of programmed cellular death)
• Orthotics, splints and braces - protect tendons and ligaments, lessening the load
• Physical Therapy - stretch and strengthen your muscles
• Massage - stimulating nerve endings and pressure points promotes healing, relaxation and can reduce pain
• Acupuncture - stimulates specific points in the body

Common treatment for tendinosis:

• Rest - if you perform repetitive tasks at work, try a short break every 15 minutes or try resting for 5 minutes every 30 minutes.
• Ice - apply an ice pack or cold compress for 15 minutes every couple of hours.  Don’t put the ice directly on the skin. 
• Eccentric strengthening exercises - tightening your muscles while holding something heavy. Helps with tendon strength and collagen production.
• Stretching - keeps  you flexible, increases circulation and reduces tendon tension (tightness).
• Massage - deep-friction massage can generate new collagen fibers, reduce  pain and increase strength.
• Hyperthermia - heating to increase temperature to increase blood flow which stimulates healing.
• Supplements - Vitamin C, manganese, zinc, vitamin B6 and vitamin E are all connected to tendon health.
• Extracorporeal shock wave treatment (ESWT) - high-energy sound waves stimulate blood flow to the area and encourage healing.
• Minimally invasive tendon debridement - removes damaged tissue promoting healing of the tendon.
• Platelet-rich plasma injections - promotes repair of damaged tendons.  Stimulates the healing process, decreases pain and enables a return to activities sooner.

The prognosis for people with tendinopathy is usually very good.  Most people recover without the need for invasive treatment or surgery. However, tendinopathy can return if you have another injury or continue to perform repetitive tasks.  In recurrent cases, steroid injections are often offered.  However, they have not been shown to have any long-term benefit.  The best option currently available for resolution is platelet rich plasma injection.  

Wondering if you’re a candidate for PRP injections?  To find out, schedule a free introductory call.