Diagnosed with tendonitis?

Significant progress has been made over the last ten years in understanding tendon injuries. Undoubtedly, they are a popular research topic because they are common (30-50% of sporting injuries, are slow to heal, notoriously resistant to treatment and accompanied by significant morbidity (pain and loss of function).1

Perhaps the most significant recent finding is that the tendonitis diagnosis is most often incorrect. “...itis” conditions are inflammatory and are typically treated with anti-inflammatory medications, ice, electrical modalities, ultrasound, and corticosteroid injections.

Recent histological (cellular) studies reveal a lack of inflammatory cells in tendon injuries lasting longer than a week. Instead, degenerative changes occur in the tendon including the softening and disorganization of tendon tissue. In addition, there is found an increase in random blood vessels, pain signaling chemicals and nerve fibers transmitting pain signals. It has been hypothesized, but yet to be proven, that the changes found in the degenerative tendon are the result of a failed healing response. In this model, the tendon is overloaded but fails to heal properly due to a lack of sufficient blood supply. 1,2,3

The proper diagnosis for a degenerative tendon condition is tendinosis. A correct diagnosis has implications for appropriate treatment as anti-inflammatory strategies are inappropriate. Research fails to support electrical modalities, ultrasound, and extracorporeal shock wave therapy (ESWT) in the treatment of tendinopathies. Corticosteroids have been shown to alleviate short-term pain but to deliver worse long-term outcomes (there is some support for ESWT and corticosteroids in certain shoulder conditions, however).1,4,5

What then is an appropriate treatment regimen for tendinosis?

The first goal of treatment is to unload the tendon by reducing or eliminating offensive activity, correcting biomechanical faults and training errors, and/or using braces and supports to unload the tendon.1,2,3,5 There is theoretical and clinical support for ice, which may function by limiting the in-growth of blood vessels.5 Soft tissue techniques help to unload restricted muscle-tendon complexes and facilitate tendon healing.5

There is a growing body of evidence supporting eccentric exercise (EE) as a treatment of choice. EE is defined as muscle activation while the muscle lengthens i.e. the lowering phase of a biceps curl involves a loaded lengthening biceps. During eccentric loading, muscles generate maximal force. EE results in collagen production and improved collagen alignment resulting in increased tendon strength. Perhaps EE kick starts the healing response stuck in a cycle of tendinosis?6,7

For those failing conservative management, promising new medical techniques are being developed that may eventually become common practice (nitric oxide patches, sclerosing injections of polidocanol).8,9 Additionally, surgical removal of damaged tissue may be chosen for difficult cases, but this involves prolonged recovery time and risks associated with surgery.8

Recovery Times for Tendinopathy5
Short-term symptoms 6 - 10 weeks*
Long-term symptoms 3 - 6 months

(*In the early stage patients may be able to “warm-up” and continue to perform their activity. These patients are at increased risk of worsening their condition).5

References

1 Scott A. Ashe MC. Common tendinopathies in the upper and lower extremities. Current Sports Medicine Reports. 5(5):233-41, 2006 Sep.

2 Fedorczyk JM. Tennis elbow: blending basic science with clinical practice. Journal of Hand Therapy. 19(2):146-53, 2006 Apr-Jun.

3 Alfredson H. The chronic painful Achilles and patellar tendon: research on basic biology and treatment. Scandinavian Journal of Medicine & Science in Sports. 15(4):252-9, 2005 Aug.

4 Khan KM, Cook JL, Taunton JE, Bonar F. Overuse tendinosis, not tendonitis. The Physician & Sports Medicine 2000;28(5):38-48.

5 Brukner P, Khan K. Clinical Sports Medicine, 3rd ed. North Ryde: McGraw-Hill; 2002.

6 Langberg H. Ellingsgaard H. Madsen T. Jansson J. Magnusson SP. Aagaard P. Kjaer M. Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Scandinavian Journal of Medicine & Science in Sports. 17(1):61-6, 2007 Feb.

7 Ohberg L. Alfredson H. Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis? Knee Surgery, Sports Traumatology, Arthroscopy. 12(5):465-70, 2004 Sep.

8 Alfredson H. Lorentzon R. Sclerosing polidocanol injections of small vessels to treat the chronic painful tendon. Cardiovascular & Hematological Agents in Medicinal Chemistry. 5(2):97-100, 2007 Apr.

9 Murrell GA. Using nitric oxide to treat tendinopathy. British Journal of Sports Medicine. 41(4):227-31, 2007 Apr.
Khan K, Jill L, Cook PT. (2000) Overuse tendon injuries: where does the pain come from. Sports Med Arthroscopy Rev. 8:17-31.

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