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Tendons Tend to Cause Problems

October 1, 2014

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tennis-elbow.175809Everyone has heard of “tennis elbow” but the chances are that unless you’ve dealt with it yourself, you may not know what this condition really is. Tennis, of course, is only one of many activities that can give rise to the difficulty, and your elbow is only one of many potential sites where the pathology causing this can occur. The underlying problems are known as tendinitis and tendinopathy.

Tendons are those strong fibers in your body that connect muscle to bone, enabling you to move when your muscles contract. Tendinitis arises when injury or overuse inflames a tendon. It can occur when you have overused that tendon doing something like an unfamiliar exercise or doing it at a higher level than you normally would. For instance, going to a step class and working out very hard for the first time in weeks could likely result in Achilles tendinitis.

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Physical therapists rarely get the chance to actually treat tendonitis, however, because in the time before you see a therapist it’s often either gone away or evolved into something else. And that something else — known as tendinopathy — requires treatment in order to improve and to prevent possible rupture.

Early in the course of the problem, rest and abstinence from performing the activity that caused the tendinitis may resolve it. But the issue may reoccur if you don’t change the way you perform the activity that triggered it in the first place. And even though the initial inflammation may subside, if this problem continues to bother you for an extended period of weeks there will be actual cellular changes in the tendon that will need to be addressed by your doctor or physical therapist, to help you resolve the problem.

There are various terms that describe problems of a tendon.

  • Tendinitis
  • Tendinopathy
  • Tendinosis

They are often used interchangeably but they really aren’t the same thing.

Tendinitis is an inflammation of the tendon without major cellular changes in the tendon.

Tendinosis describes microtears in the tissue in and around the tendon, and cellular changes of the tendon tissue. These tears are most likely to occur near where the tendon attaches to the bone.
Tendinopathy is a combination of tendinosis and tendonitis.

Check out this video for a more indepth look at the differences between Tendinitis vs Tendinosis

tendon.174721Changes associated with tendinopathy include degeneration and disorganization of the collagen fibers that form part of the tendon, plus increased tendon cells, blood vessels and nerves, which don’t belong there. In fact, having more nerves in the area may be why you’re feeling more pain when you have tendinopathy.

Tendinopathy appears to result from an imbalance between the protective/regenerative changes and the pathologic responses that result from tendon overuse. The net result is tendon degeneration, weakness, tearing, and pain.

What are the symptoms of tendinitis or tendinopathy?

  • There may be pain, stiffness, and weakness of the muscles in the affected area.
  • Use of the muscles attached to the affected tendon may increase your pain.
  • You are likely to have more pain and stiffness during the night or when you get up in the morning.
  • The tendon may be tender to touch, warm, reddened, or swollen.
  • Using the tendon in activity may produce a crackling sound or sensation.

Who is likely to get tendinitis or tendinopathy?

Everyone–but people who perform the same motions over and over again when doing their jobs, recreational activities or daily tasks are more likely to damage a tendon. Tendon injuries can also be the result of gradual wear and tear to the tendon from aging.
The causes of tendinopathy are multi-factorial and include both intrinsic and extrinsic factors.

Intrinsic factors can include changes in blood supply, differences in cellular make-up of the tendon, increased vascularization, increased neural tissue in the tendon with increased neurochemicals in the tissue of tendon. These tendon changes occur more frequently as we age. Other intrinsic factors include chronic disease like diabetes mellitus, obesity and hypertension.

A normal tendon is a poorly vascularized type of tissue. This means it naturally has a poor blood supply. When tendinopathy occurs there is an increased growth of blood vessels into the tendon, which apparently is not associated with the attempted repair of the tissue damage. This increased vascularity may be a contributing factor to pain and chronicity of tendon lesions.

When the body attempts to repair the tendon, the type of collagen produced has less tensile strength than the original collagen. The type of cells in the tendon change as we age. We have fewer immature cells called tenocytes. Tenocytes are fibroblast-like differentiated cells that form the mature tendon. There may be excessive tenocyte apoptosis, the physiological process often referred to as “programmed cell death.”

In tendinosis, various types of degeneration may be seen in tendons: mucoid degeneration (mucous deposits), lipoid degeneration (fatty deposits) and fibrocartilaginous metaplasia (excessive amounts of fibrocartilage), which is often accompanied by calcium deposition.

In symptomatic chronic tendinopathy there is an ingrowth of sensory and sympathetic nerves from the paratendon (the connective tissue sleeve that surrounds the tendon) with release of nociceptive (pain causing) substances. This allows more pain messages to be sent to the brain. New blood vessel growth has been found to correlate with the location of pain in patients with symptomatic tendinopathy.

Extrinsic factors include overuse, poor biomechanics, and weakness in supporting musculature. There may be increased compression of tendons and shearing forces on tendons due to poor biomechanics that can lead to damage.

9860588_xl.173406How is tendinopathy treated?

The latest research indicates there is little or no inflammation present in persistent tendinopathy, unlike in initial tendinitis. Therefore, treatment aimed at controlling inflammation such as using corticosteroid injections, nonsteroidal anti-inflammatory medications (NSAIDS), and icing the affected region is likely not the best option.

Recent studies show that physical therapy, however, has been shown to be effective in the treatment of tendinopathy. This therapy may include exercises consisting of stretching and strengthening, as well as manual treatment provided by your therapist that incorporates massage and manual stretching. Experimental research has demonstrated the beneficial effects of motion and mechanical loading on tenocyte function. Repetitive motion increases DNA content and protein synthesis in human tenocytes. So you may be asked to perform exercises that are a little painful to help your tendon recover.

Trigger point dry needling, (also called intramuscular needling), is used by some therapists to decrease spasm of the muscles connected directly to the injured tendon. Treatment of muscles that work to support the affected tendon may be treated as well. The affected tendon may be needled to provoke a healing response in the tendon. Your therapist may also address the loss of range of motion and strength.

If you think you have tendinopathy

If you feel the symptoms described above are consistent with a problem you are suffering from, you should consult a physical therapist. And you shouldn’t hesitate if tendinopathy goes untreated it’s likely to worsen and possibly even rupture. In many states, including Virginia, you may see a physical therapist without seeing a doctor. Most insurance plans, with the exception of Medicare, will cover your treatment without a prescription from a doctor.

Bibliography

Steven A Fenwick,1 Brian L Hazleman,2 and Graham P Riley2 “The vasculature and its role in the damaged and healing tendon” Arthritis Res. 2002; 4(4): 252–260.

Harrison, R; Jones, M; Grobbelar, AO; McGrouther, DA; Brown, RA; Mudera, V; (2003) Tendon Healing Intrinsic or Extrinsic? Direct Evidence for Dual Mechanisms in Early Stages of Tendon Injury. In: Tissue Engineering. (pp. 852 – 852).

Housner, Jeffrey A MD*†; Jacobson, Jon A MD‡; Morag, Yoav MD‡; Pujalte, George Guntar A MD†; Northway, Rebecca M MD§; Boon, Tracy A AAS, RDMS, RVT‡ “Should Ultrasound-Guided Needle Fenestration Be Considered as a Treatment Option for Recalcitrant Patellar Tendinopathy? A Retrospective Study of 47 Cases” Clinical Journal of Sport Medicine: November 2010 – Volume 20 – Issue 6 – pp 488-490

N Maffulli1, H D Moller2, C H Evans3 “Tendon healing: can it be optimized?” Br J Sports Med 2002;36:315-316 doi:10.1136/bjsm.36.5.315

Pankaj Sharma, MRCS; Nicola Maffulli, MD, MS, PhD, FRCS(Orth) “Tendon Injury and Tendinopathy: Healing and Repair” J Bone Joint Surg Am, 2005 Jan;87(1):187-202.