Doctor's Blog

“Doc, I have a tendinitis that keeps coming back.”  This is a common complaint heard in the orthopedic office, but the term “tendinitis” is misused in this context.  Tendinitis is an acute condition that typically resolves with proper treatment and does not recur. What this patient has is a tendinopathy. The patient`s use of this misnomer can be excused because this is a confusing area. The distinction is important, however, for though the pain can be similar, the cause, structural abnormality, and treatment are different.

Tendinopathy, also called tendinosis, refers to chronic, longstanding tendon pain that often occurs without an injury. Tendinitis is an acute painful condition that usually follows an injury.   Both tend to occur at or near where tendon attaches to bone. Tendinitis, as its suffix “itis” implies, exhibits the typical signs of inflammation: warmth, redness, and swelling. This inflammation leads to and is an important part of normal healing. With tendinopathy, for unknown reasons, there is little or no inflammation and healing is unsuccessful.   It is this chronic non-healing state that gives rise to the pain of tendinopathy.

It is not entirely clear why the body fails to heal the tendon breakdown of tendinopathy, but there are a number of conditions that are linked with its occurrence.   They include low level repetitive injury (“overuse”), poor conditioning (“underuse”), faulty mechanics, ageing, family history (genetics), and medical conditions such as diabetes, smoking, and peripheral vascular disease.

There are favorite areas in the body that this “family “of tendinopathies tends to target:  rotator cuff, both sides of the elbow, kneecap tendon, lateral hip, the heel and lower leg. You may know them by their more common names: shoulder bursitis, tennis and golfer`s elbow, runner`s knee, trochanteric bursitis, Achilles tendinitis, plantar fasciitis and shin splints.   Of course, tendinitis can strike any of these areas but more often it is a  tendinopathy  despite the misleading  “itis” that many of the common names contain.

The obvious question of whether tendinitis can lead to tendinopathy has not been fully answered.  There is some evidence that they are two different entities and not connected.

The treatment of tendinitis is fairly straightforward and includes ice, rest, and anti-inflammatory medications with an expected return to full activities in 2-6 weeks. The treatment for tendinopathies is more complex and involves a careful balancing of protection and stretching of the injured tendon, as well as strengthening of the muscles around it.  Our goal is to start up the healing process, guide it as it gains momentum and follow it until it is robust.  As healing begins to gain some traction, the pain diminishes.    This is NOT the time, however, to become complacent and return to full activities (see March`s column, “The Vicious Cycle”). Instead, one embarks on   a gradual but progressive strengthening program for the injured muscle-tendon unit.  Rehabilitation continues until the strength is well in excess of baseline.    The principle to remember is that the stronger a muscle is the less chance the tendinopathy will recur.

In future columns we will discuss specific tendinopathies, their individualized treatments, promising areas of research and the role, if any, of surgery.

Muscle and ligament strains are common orthopedic complaints.  The pain from these injuries can be disabling, and proper rehabilitation is essential to ensure a full recovery.

Resting a sprain is natural and appropriate, but it comes at a cost.   When muscles are not used they become weak and lose bulk (atrophy) in response to their diminished role.   With this loss in strength the injured muscles, as well as the joints and ligaments they support, are now more vulnerable to another injury.

As the pain from our original injury subsides, we assume we have returned to “normal” and, typically, resume our regular activities.   The injured limb or spine, however, now deconditioned or “out of shape”, is not normal, and re-injury occurs.   This is followed again by pain, protection, atrophy and an even lower threshold for re-injury.  This is the Vicious Cycle.

How do we balance our need for rest and protection with our need to minimize risk of re-injury?   This is accomplished by rehabilitation of the whole limb or spine before returning to full activities.   Therapy begins soon after injury and focuses on strengthening the surrounding uninjured muscles while protecting the injured one(s).   Included in this therapy are the muscle groups distant from the injury but also affected by lack of use.

As the pain subsides, the strained muscles are slowly introduced to a controlled set of progressive, non-impact, strengthening exercises.  The limb or spine must be fully reconditioned to at least its pre-injury status before regular activity levels can be resumed.

Rehabilitation from an injury is complex, and we must walk a fine line between doing too much and doing too little.  A certified physical therapist or trainer can be invaluable in this process.   It is very discouraging to fall into the vicious cycle, and extrication can be long and difficult.   Full fitness and conditioning after injury is our “ounce of prevention” against this debilitating condition.

“Scratch an orthopedist and you`ll find a carpenter”.  There is truth in this old saying, as both occupations use mechanical principles in their daily work.

Pain, stiffness, weakness, and instability are common symptoms that prompt people to seek orthopedic advice.  We search for the diagnosis, medical or surgical, but our focus is on an orthopedic explanation.   In other words, we look for a mechanical abnormality that involves muscle, tendon, ligament or bone.

Mechanical abnormalities include cartilage wear, torn ligaments, strained muscles or tendons, joint instability, pinched nerves, fractures and so on.   Rubbing, wearing, tearing, straining, stretching, slipping, breaking, pressing, pinching, sticking, locking, snapping and catching  are the terms in which we think in searching for a diagnosis.

Our approach  is a mechanical one.

For example, when a person presents with shoulder pain, we look for common mechanical causes such as arthritis (wearing down of cartilage), frozen shoulder (stiffening of the shoulder capsule), pinched nerve or rotator cuff tear. If “knee buckling” is the complaint, the orthopedist suspects knee or hip arthritis, a torn knee cartilage, or knee cap instability.

Sometimes a condition which presents as orthopedic can be due to other causes. In our examples for instance, shoulder pain can be caused by a heart or lung problem and knee buckling by diabetes, Multiple Sclerosis, or old polio.

That is why you may sometimes hear us say, “I don’t know what is causing your symptoms, but it’s not orthopedic.”  In other words, we can’t find a mechanical cause that involves the musculoskeletal system.  At this point we might recommend a referral back to your primary physician or to a specialist in another field, such as a neurologist.

There are many causes of the common complaints of pain, stiffness, weakness, and instability.   Most, but not all, have an orthopedic basis. We do our best to find the correct diagnosis but we`re best at finding an orthopedic one.

Why it is Common for Female Athletes to Tear their Knee Ligaments,or “Move your Feet, Not your Hands”

Female athletes tear their anterior cruciate ligaments as much as eight times more than male athletes.

This is due in part to anatomic and physiologic factors, but much is due to what we call “neuromuscular deficits or imbalances”. This can be defined as the inability of the athlete to move around the court or field with her trunk or core well-balanced over her legs. Preventive exercise programs addressing these weaknesses can significantly reduce the risk of these devastating injuries.

The anterior cruciate ligament is a key stabilizing structure of the knee. In women athletes, a rupture of this ligament occurs most often during rapid deceleration activities and, unlike in male athletes, predominantlyin non-contact situations. This injury occurs in 1 in 5 women who participate in sports at the college level.

In women athletes there is a strong predictive association between neuromuscular imbalances and torn anterior cruciate ligaments. A female athlete with these imbalances tends to play her sport in an off- balance position, a position that poorly absorbs the energy of deceleration.

For example, when an athlete rebounds she ideally lands with the trunk well positioned over the pelvis, which in turn is centered over the knees; the knees, ankles, and feetare all slightly flexed. By landing perfectly balanced on the balls of the feet, the energy of impact (many times body weight) is absorbed and “softened” by the muscles of the calf, thigh, pelvis and spine. This energy absorption protects the vulnerable knee ligaments from being injured.

Contrast this with the woman who lands “off balance”, with her arms reaching for the ball, waist bent, knees straight, and foot flat on the floor. In this position the energy of landing is transferred directly, unmodified, to the knee. When this force exceeds the breaking point of the anterior cruciate, the anterior cruciate tears and renders the knee unstable.

It is important to identify these “at risk” female athletes. This can be done by direct observation on the field or with a few simple testsadministered by a physical therapist or a qualified athletic trainer.Once recognized, these athletes are instructed in neuromuscular training programs which emphasize balance, core strengthening, proper body positioning, and sport specific exercises. These programs, administered by physical therapists and athletic trainers,are highly successful, reducingthe incidence of knee ligament injuries in female athletes by 50%.

So, in practice, when you are going for the ball and your coach yells, “Move your feet, not your hands!”,do it. It`s good

A bursa is a thin sack positioned between two anatomic structures that rub together. Bursae are filled with a slippery fluid which facilitates motion by reducing friction. Typically, bursae are located between a prominent boney eminence (often with a tendon attached to it) and skin, bone or another tendon.

When bursae become inflamed or irritated, they swell and can become painful. This condition is called “bursitis”. Common sites for bursitis include the tip of the elbow (olecranon), the kneecap (pre-patella), the outside hip bone (trochanteric) and the shoulder (rotator cuff).

Treatment should be specifically tailored to discovering what is actually causing the bursa to be inflamed. It could be an infection, gout, rheumatoid arthritis, injury, or a bony prominence that`s rubbing excessively on the bursa. Sometimes the bursa can be an “innocent bystander” becoming inflamed only because of a problem in the underlying tendon it`s trying to protect. This problem is usually a chronic fraying or tearing of that tendon`s attachment to bone and, in the course of the body`s repeated attempts at repair, the overlying bursa becomes secondarily inflamed.

Occasionally, the body, perhaps frustrated in its repair attempts, deposits calcium into the area of tendon degeneration. If that calcium leaks into the overlying bursa, an intense inflammatory response is mounted against the “intruder”. Calcific bursitis results and it can be very painful.

Discovering the exact diagnosis comes from taking a good history and doing a thorough physical exam. X-ray, MRI, and bursal fluid examination are used, when indicated, to assist in making the diagnosis.

In most cases the treatment is conservative, employing rest, medication, physical therapy, and possibly a steroid injection. A small number of cases do come to surgery. This may involve removing the bursa, smoothing out a bone protuberance, or repairing a torn tendon.

In cases in which the problem is a frayed or torn tendon, poor fitness plays a large role in causation. Not only is a weak muscle unable to do its job fully in stabilizing a joint, but its tendon`s attachment to bone is less than perfect. Consequently, treatment is incomplete without a conditioning program. Strengthening the muscle increases its tendon`s grip on bone. With improved holding power, the tendon is less likely to fray under future stresses.

Bursitis is common and its effects range from annoying to downright disabling. As a diagnosis, however, the term bursitis is not complete, for it tells us little about the actual underlying problem. Discovering the underlying condition is critical, for it gives us our best chance at a lasting cure. This search can be a challenge, for, in many instances, bursitis is “more than meets the eye”.