Tendinopathy

Last updated

Tendinopathy
Other namestendinosus [1]
Achilles-tendon.jpg
Achilles tendon (a commonly affected tendon)
Specialty Primary care
Symptoms Pain, swelling [2]
CausesInjury from repetitive activities, overuse [2]
Diagnostic method Based on symptoms, examination, medical imaging [3]
TreatmentRest, NSAIDs, splinting, physiotherapy [2]
Prognosis 80% better within 6 months for overuse tendinopathy [1]
FrequencyCommon [1] [2]

Tendinopathy is a type of tendon disorder that results in pain, swelling, and impaired function. [2] The pain is typically worse with movement. [2] It most commonly occurs around the shoulder (rotator cuff tendinitis, biceps tendinitis), elbow (tennis elbow, golfer's elbow), wrist, hip, knee (jumper's knee, popliteus tendinopathy), or ankle (Achilles tendinitis). [1] [2]

Contents

Causes may include an injury or repetitive activities. [2] Less common causes include infection, arthritis, gout, thyroid disease, diabetes and the use of quinolone antibiotic medicines. [4] [5] Groups at risk include people who do manual labor, musicians, and athletes. [2] Diagnosis is typically based on symptoms, examination, and occasionally medical imaging. [3] A few weeks following an injury little inflammation remains, with the underlying problem related to weak or disrupted tendon fibrils. [6]

Treatment may include rest, NSAIDs, splinting, and physiotherapy. [2] Less commonly steroid injections or surgery may be done. [2] About 80% of overuse tendinopathy patients recover completely within six months. [1] Tendinopathy is relatively common. [2] Older people are more commonly affected. [2] It results in a large amount of missed work. [1]

Signs and symptoms

Symptoms include tenderness on palpation, swelling, and pain, often when exercising or with a specific movement. [7]

Cause

Causes may include an injury or repetitive activities. [2] Groups at risk include people who do manual labor, musicians, and athletes. [2] Less common causes include infection, arthritis, gout, thyroid disease, and diabetes. [5] Successful treatments include rehabilitation therapy and/or surgery. [8] Obesity, or more specifically, adiposity or fatness, has also been linked to an increasing incidence of tendinopathy. [9]

Quinolone antibiotics are associated with increased risk of tendinitis and tendon rupture. [10] A 2013 review found the incidence of tendon injury among those taking fluoroquinolones to be between 0.08 and 0.2%. [11] Fluoroquinolones most frequently affect large load-bearing tendons in the lower limb, especially the Achilles tendon which ruptures in approximately 30 to 40% of cases. [12]

Types

Pathophysiology

As of 2016, the pathophysiology of tendinopathy is poorly understood. While inflammation appears to play a role, the relationships among changes to the structure of tissue, the function of tendons, and pain are not understood and there are several competing models, none of which have been fully validated or falsified. [13] [14] Molecular mechanisms involved in inflammation includes release of inflammatory cytokines like IL-1β which reduces the expression of type I collagen mRNA in human tenocytes and causes extracellular matrix degradation in the tendon. [13] In a 2020 systematic review, it was noted that while various inflammatory markers were present in two thirds of the reviewed articles, the heterogenicity of data and lack of comparable studies meant no conclusion about a common pathophysiology from this systematic review. [15]

There are multifactorial theories that could include: tensile overload, tenocyte related collagen synthesis disruption, load-induced ischemia, neural sprouting, thermal damage, and adaptive compressive responses. The intratendinous sliding motion of fascicles and shear force at interfaces of fascicles could be an important mechanical factor for the development of tendinopathy and predispose tendons to rupture. [16]

The most commonly accepted cause for this condition is seen to be an overuse syndrome in combination with intrinsic and extrinsic factors leading to what may be seen as a progressive interference or the failing of the innate healing response. Tendinopathy involves cellular apoptosis, matrix disorganization and neovascularization. [17]

Classic characteristics of "tendinosis" include degenerative changes in the collagenous matrix, hypercellularity, hypervascularity, and a lack of inflammatory cells which has challenged the original misnomer "tendinitis". [18] [19]

For chronic tennis elbow, histological findings include granulation tissue, microrupture, degenerative changes, and there is no traditional inflammation. As a consequence, "lateral elbow tendinopathy or tendinosis" is used instead of "lateral epicondylitis". [20] Examination of pathologic tennis elbow tissue reveals noninflammatory tissue, so the term "angiofibroblastic tendinosis" is also used. [21]

Cultures from tendinopathic tendons contain an increased production of type III collagen. [22] [23]

Longitudinal sonogram of the lateral elbow displays thickening and heterogeneity of the common extensor tendon that is consistent with tendinosis, as the ultrasound reveals calcifications, intrasubstance tears, and marked irregularity of the lateral epicondyle. Although the term "epicondylitis" is frequently used to describe this disorder, most histopathologic findings of studies have displayed no evidence of an acute, or a chronic inflammatory process. Histologic studies have demonstrated that this condition is the result of tendon degeneration, which causes normal tissue to be replaced by a disorganized arrangement of collagen. Therefore, the disorder is more appropriately referred to as "tendinosis" or "tendinopathy" rather than "tendinitis". [24]

Colour Doppler ultrasound reveals structural tendon changes, with vascularity and hypo-echoic areas that correspond to the areas of pain in the extensor origin. [25]

Load-induced non-rupture tendinopathy in humans is associated with an increase in the ratio of collagen III:I proteins, a shift from large to small diameter collagen fibrils, buckling of the collagen fascicles in the tendon extracellular matrix, and buckling of the tenocyte cells and their nuclei. [26]

Diagnosis

Diagram illustrating tendonitis and tendon rupture Tendonitis Tendon rupture -- Smart-Servier (cropped).jpg
Diagram illustrating tendonitis and tendon rupture

Symptoms can vary from aches or pains and local joint stiffness, to a burning that surrounds the whole joint around the inflamed tendon. In some cases, swelling occurs along with heat and redness, and there may be visible knots surrounding the joint. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiff the following day as muscles tighten from the movement of the tendon. Many patients report stressful situations in their life in correlation with the beginnings of pain which may contribute to the symptoms.[ citation needed ]

Medical imaging

Ultrasound imaging can be used to evaluate tissue strain, as well as other mechanical properties. [27] Ultrasound-based techniques are becoming more popular because of its affordability, safety, and speed. Ultrasound can be used for imaging tissues, and the sound waves can also provide information about the mechanical state of the tissue. [28]

Treatment

Treatment of tendon injuries is largely conservative. Use of non-steroidal anti-inflammatory drugs (NSAIDs), rest, and gradual return to exercise is a common therapy. A meta-analysis revealed that exercise using weights or a resistance band is more effective than using bodyweight alone. In addition, having rest days is more effective than exercising every day. [29] [30] Resting assists in the prevention of further damage to the tendon. Ice, compression and elevation are also frequently recommended. Physical therapy, occupational therapy, orthotics or braces may also be useful. Initial recovery is typically within two to three days and full recovery is within three to six months. [1] Tendinosis occurs as the acute phase of healing has ended (six to eight weeks) but has left the area insufficiently healed. Treatment of tendinitis helps reduce some of the risks of developing tendinosis, which takes longer to heal.[ citation needed ]

There is tentative evidence that low-level laser therapy may also be beneficial in treating tendinopathy. [31] The effects of deep transverse friction massage for treating tennis elbow and lateral knee tendinitis is unclear. [32]

NSAIDs

NSAIDs may be used to help with pain. [1] They however do not alter long term outcomes. [1] Other types of pain medication, like paracetamol (acetaminophen), may be just as useful. [1]

Steroids

Steroid injections have not been shown to have long term benefits for tendonitis, but appear to improve pain and function in the short term more effectively than other treatments except NSAIDs. [33] They appear to have little benefit in tendinitis of the rotator cuff. [34] There are some concerns that they may have negative effects. [35]

Other injections

There is insufficient evidence on the routine use of injection therapies (autologous blood, platelet-rich plasma, deproteinised haemodialysate, aprotinin, polysulphated glycosaminoglycan, skin derived fibroblasts etc.) for treating Achilles tendinopathy. [36] As of 2014 there was insufficient evidence to support the use of platelet-rich therapies for treating musculoskeletal soft tissue injuries such as ligament, muscle and tendon tears and tendinopathies. [37]

Prognosis

Initial recovery from overuse tendinosus is usually within two to three months, and 80% will recover fully within three to six months. [1]

Epidemiology

Tendon injury and resulting tendinopathy are responsible for up to 30% of consultations to sports doctors and other musculoskeletal health providers. [38] Tendinopathy is most often seen in tendons of athletes either before or after an injury but is becoming more common in non-athletes and sedentary populations. For example, the majority of patients with Achilles tendinopathy in a general population-based study did not associate their condition with a sporting activity. [39] In another study the population incidence of Achilles tendinopathy increased sixfold from 1979–1986 to 1987–1994. [40] The incidence of rotator cuff tendinopathy ranges from 0.3% to 5.5% and annual prevalence from 0.5% to 7.4%. [41]

Terminology

Tendinitis is a very common, but misleading term. By definition, the suffix "-itis" means "inflammation of". Inflammation [42] is the body's local response to tissue damage which involves red blood cells, white blood cells, blood proteins with dilation of blood vessels around the site of injury. Tendons are relatively avascular. [43] Corticosteroids are drugs that reduce inflammation. Corticosteroids can be useful to relieve chronic tendinopathy pain, improve function, and reduce swelling in the short term. However, there is a greater risk of long-term recurrence. [44] They are typically injected along with a small amount of a numbing drug called lidocaine. Research shows that tendons are weaker following corticosteroid injections.

Tendinitis is still a very common diagnosis, though research increasingly documents that what is thought to be tendinitis is usually tendinosis. [45]

Anatomically close but separate conditions are:

Research

The use of a nitric oxide delivery system (glyceryl trinitrate patches) applied over the area of maximal tenderness was found to reduce pain and increase range of motion and strength. [53]

A promising therapy involves eccentric loading exercises involving lengthening muscular contractions. [54]

Other animals

Bowed tendon is a horseman's term for tendinitis (inflammation) and tendinosis (degeneration), most commonly seen in the superficial digital flexor tendon in the front leg of horses.

Mesenchymal stem cells, derived from a horse's bone marrow or fat, are currently being used for tendon repair in horses. [55]

Related Research Articles

<span class="mw-page-title-main">Tendon</span> Type of tissue that connects muscle to bone

A tendon or sinew is a tough band of dense fibrous connective tissue that connects muscle to bone. It sends the mechanical forces of muscle contraction to the skeletal system, while withstanding tension.

<span class="mw-page-title-main">De Quervain syndrome</span> Restricted movement of tendons controlling the thumb

De Quervain syndrome occurs when two tendons that control movement of the thumb become constricted by their tendon sheath in the wrist. This results in pain and tenderness on the thumb side of the wrist. Radial abduction of the thumb is painful. On some occasions, there is uneven movement or triggering of the thumb with radial abduction. Symptoms can come on gradually or be noted suddenly.

<span class="mw-page-title-main">Shoulder problem</span> Medical condition

Shoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed. This instability increases the likelihood of joint injury, often leading to a degenerative process in which tissues break down and no longer function well.

<span class="mw-page-title-main">Achilles tendon</span> Tendon at the back of the lower leg

The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon at the back of the lower leg, and is the thickest in the human body. It serves to attach the plantaris, gastrocnemius (calf) and soleus muscles to the calcaneus (heel) bone. These muscles, acting via the tendon, cause plantar flexion of the foot at the ankle joint, and flexion at the knee.

<span class="mw-page-title-main">Psoriatic arthritis</span> Long-term inflammatory arthritis

Psoriatic arthritis (PsA) is a long-term inflammatory arthritis that occurs in people affected by the autoimmune disease psoriasis. The classic feature of psoriatic arthritis is swelling of entire fingers and toes with a sausage-like appearance. This often happens in association with changes to the nails such as small depressions in the nail (pitting), thickening of the nails, and detachment of the nail from the nailbed. Skin changes consistent with psoriasis frequently occur before the onset of psoriatic arthritis but psoriatic arthritis can precede the rash in 15% of affected individuals. It is classified as a type of seronegative spondyloarthropathy.

<span class="mw-page-title-main">Plantar fasciitis</span> Connective tissue disorder of the heel

Plantar fasciitis or plantar heel pain is a disorder of the plantar fascia, which is the connective tissue that supports the arch of the foot. It results in pain in the heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest. Pain is also frequently brought on by bending the foot and toes up towards the shin. The pain typically comes on gradually, and it affects both feet in about one-third of cases.

<span class="mw-page-title-main">Tennis elbow</span> Condition in which the outer part of the elbow becomes sore and tender

Tennis elbow, also known as lateral epicondylitis or enthesopathy of the extensor carpi radialis origin, is an enthesopathy of the origin of the extensor carpi radialis brevis on the lateral epicondyle. Those with tennis elbow often report pain and tenderness over the bony prominence of the lateral epicondyle, which serves as the common origin of the forearm and hand’s long extensor tendons. Symptoms range from mild tenderness to severe, persistent pain. The pain may also extend into the back of the forearm. Onset of symptoms is generally gradual, although they can seem sudden and be misinterpreted as an injury.

<span class="mw-page-title-main">Achilles tendinitis</span> Medical condition of the ankle and heel

Achilles tendinitis, also known as Achilles tendinopathy, is soreness of the Achilles tendon. It is accompanied by alterations in the tendon's structure and mechanical properties. The most common symptoms are pain and swelling around the back of the ankle. The pain is typically worse at the start of exercise and decreases thereafter. Stiffness of the ankle may also be present. Onset is generally gradual.

<span class="mw-page-title-main">Rotator cuff tear</span> Shoulder injury

Rotator cuff tendinopathy is a process of senescence. The pathophysiology is mucoid degeneration. Most people develop rotator cuff tendinopathy within their lifetime.

Prolotherapy, also called proliferation therapy, is an injection-based treatment used in chronic musculoskeletal conditions. It has been characterised as an alternative medicine practice.

<span class="mw-page-title-main">Nintendo thumb</span> Injury caused by video games

Nintendo thumb, also known as gamer's thumb and similar names, is a form of repetitive strain injury (RSI) caused by excessive playing of video games with the traditional Nintendo controller. This injury mainly occurs due to repeated thumb movements while playing video games. The symptoms can include blistering, paraesthesia, as well as swelling of the thumbs, though any finger can be affected. This can lead to stress on tendons, nerves, and ligaments in the hands, and further onto lateral epicondylitis, tendinitis, bursitis, and carpal tunnel syndrome. Similar injuries can occur with other gaming systems, such as PlayStation thumb from playing Sony PlayStation. The general recommendation for the treatment is to rest and stop the repetitive motion of the affected finger. In more severe and painful cases, using NSAIDs is also recommended.

<span class="mw-page-title-main">Achilles tendon rupture</span> Medical condition where the tendon at the back of the ankle breaks

Achilles tendon rupture is when the Achilles tendon, at the back of the ankle, breaks. Symptoms include the sudden onset of sharp pain in the heel. A snapping sound may be heard as the tendon breaks and walking becomes difficult.

<span class="mw-page-title-main">Patellar tendinitis</span> Human disease

Patellar tendinitis, also known as jumper's knee, is an overuse injury of the tendon that straightens the knee. Symptoms include pain in the front of the knee. Typically the pain and tenderness is at the lower part of the kneecap, though the upper part may also be affected. Generally there is no pain when the person is at rest. Complications may include patellar tendon rupture.

<span class="mw-page-title-main">Golfer's elbow</span> Tendon inflammation disease of the elbow

Golfer's elbow, or medial epicondylitis, is tendinosis of the medial common flexor tendon on the inside of the elbow. It is similar to tennis elbow, which affects the outside of the elbow at the lateral epicondyle. The tendinopathy results from overload or repetitive use of the arm, causing an injury similar to ulnar collateral ligament injury of the elbow in "pitcher's elbow".

<span class="mw-page-title-main">Enthesitis</span> Inflammation where tendons and ligaments attach to bones

Enthesitis is inflammation of the entheses, the sites where tendons, ligaments and joint capsules attach to bones.

<span class="mw-page-title-main">Subacromial bursitis</span> Medical condition

Subacromial bursitis is a condition caused by inflammation of the bursa that separates the superior surface of the supraspinatus tendon from the overlying coraco-acromial ligament, acromion, and coracoid and from the deep surface of the deltoid muscle. The subacromial bursa helps the motion of the supraspinatus tendon of the rotator cuff in activities such as overhead work.

<span class="mw-page-title-main">Calcific tendinitis</span> Disorder characterized by calcium deposits in a tendon

Calcific tendinitis is a common condition where deposits of calcium phosphate form in a tendon, sometimes causing pain at the affected site. Deposits can occur in several places in the body, but are by far most common in the rotator cuff of the shoulder. Around 80% of those with deposits experience symptoms, typically chronic pain during certain shoulder movements, or sharp acute pain that worsens at night. Calcific tendinitis is typically diagnosed by physical exam and X-ray imaging. The disease often resolves completely on its own, but is typically treated with non-steroidal anti-inflammatory drugs to relieve pain, rest and physical therapy to promote healing, and in some cases various procedures to breakdown and/or remove the calcium deposits.

<span class="mw-page-title-main">Extracorporeal shockwave therapy</span> Ultrasonic, non-invasive, outpatient treatment

Extracorporeal shockwave therapy (ESWT) is a treatment using powerful acoustic pulses which is mostly used to treat kidney stones and in physical therapy and orthopedics.

Therapeutic ultrasound refers generally to any type of ultrasonic procedure that uses ultrasound for therapeutic benefit. Physiotherapeutic ultrasound was introduced into clinical practice in the 1950s, with lithotripsy introduced in the 1980s. Others are at various stages in transitioning from research to clinical use: HIFU, targeted ultrasound drug delivery, trans-dermal ultrasound drug delivery, ultrasound hemostasis, cancer therapy, and ultrasound assisted thrombolysis It may use focused ultrasound or unfocused ultrasound.

<span class="mw-page-title-main">Platelet-rich plasma</span> Blood product used in transfusion medicine

Platelet-rich plasma (PRP), also known as autologous conditioned plasma, is a concentrate of plasma protein derived from whole blood, centrifuged to remove red blood cells but retaining platelets. Though promoted for treating various medical conditions, evidence of its benefits was mixed as of 2020, showing effectiveness in certain conditions and ineffectiveness in others.

References

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