Meet the Tendinopathies, a Very Dysfunctional Family

May 17, 2012

“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.