Tendinopathy

Overview

Tendinopathy is a term for any condition that affects a tendon. Tendons are cords that attach muscle to bone. Tendinopathy, which can cause pain and tenderness, is common. It is often caused by overuse or repeated movement and tends to affect certain tendons in the arm or leg.

Tendinopathy is an umbrella term for conditions affecting the tendon that include tendinitis, tendinosis and tenosynovitis:

• Tendinitis is new or sudden swelling and irritation, called inflammation, of a tendon. Often, people mistakenly call all tendon conditions by this term.
• Tendinosis is breakdown change in the tendon that occurs gradually over time.
• Tenosynovitis is inflammation of a thin layer of tissue that surrounds a tendon, called the sheath.

Tendon conditions can occur in any tendon, but they are common in the shoulders, elbows, wrists, hips, knees and heels. Most tendinopathy can be treated with rest, physical therapy and medicine to reduce pain.

Types

There are many types of tendinopathy. Common tendinopathies include:

• Achilles tendinitis. The Achilles tendon is the band of tissue that connects calf muscles at the back of the lower leg to your heel bone. Achilles tendinitis is caused by overuse or strain on the Achilles, such as when a runner increases the intensity of a running program.
• Biceps tendinopathy. Also known as bicipital tendinitis, this type of tendinopathy is irritation of the tendon that connects the biceps muscle to the shoulder joint. It's often caused by moving your arms over your head repeatedly. It also can occur at the elbow and is typically seen in people who lift heavy weights in their jobs or fitness programs.
• Calcific tendinopathy. This type of tendinopathy results from calcium deposits in a tendon. What causes calcium deposits isn't clear, but researchers believe there may be a genetic component. This condition can cause pain when moving the joint and is most common in the shoulder.
• De Quervain tenosynovitis. This painful condition, also known as Gamer's thumb, affects the tendons on the thumb side of the wrist. It is caused by long-term repeated motions of the hand or wrist. If you have de Quervain tenosynovitis, you may feel pain when you turn your wrist, grasp anything or make a fist.
• Gluteal tendinopathy. This condition is caused by inflammation of a tendon in the side of the hip. It can cause pain and tenderness in that area. It is much more common in women. You also may hear this condition referred to as greater trochanteric pain syndrome or trochanteric bursitis. The greater trochanter is part of the hip bone where muscles and tendons attach. Causes may include overuse, injury, being overweight and hormone changes.
• Golfer's elbow. Also known as medial epicondylitis, golfer's elbow causes pain where the tendons of the forearm muscles attach to the bony bump on the inside of the elbow. The pain might spread into the forearm and wrist. It's not limited to golfers, but it is often caused by repeated rotation of the forearm and wrist.
• Hamstring tendinopathy. This condition affects the tendon that connects the hamstring muscles to the "sit-bone" in the hip. It often causes pain with sitting and climbing stairs and is commonly seen in runners.
• Patellar tendinitis. This condition, also referred to as jumper's knee, is an injury to the tendon connecting the kneecap, called a patella, to the shinbone. Patellar tendinitis is most common in athletes whose sports involve frequent jumping, such as basketball and volleyball. But even people who don't take part in jumping sports can get patellar tendinitis.
• Rotator cuff injury. The rotator cuff is a group of muscles and tendons that surround the shoulder joint. Rotator cuff injuries are most often caused by wear and tear of the tendon tissue over time due to repeated overhead motions or heavy lifting. It's common in people with jobs such as carpentry or in people who play sports such as baseball or tennis. A rotator cuff injury can cause a dull ache in the shoulder that worsens at night or with reaching.
• Tennis elbow. Also known as lateral epicondylitis, tennis elbow pain can be caused by overuse of the muscles and tendons in the elbow. It's often linked to repeated motions of the wrist and arm, for example, the motions used in tennis and other similar sports.

Symptoms

Tendinopathy symptoms can vary based on the type. Symptoms tend to occur where the tendon attaches to the bone and often include:

• Pain, often described as a dull ache, especially when moving the hurt limb or joint.
• Stiffness or weakness in the affected area.
• Tenderness in the affected area.
• Mild swelling.

When to see a doctor

You can treat many cases of tendinopathy with self-care measures, such as rest, ice and pain relievers. See your healthcare professional if your symptoms don't lessen after a few days and if they get in the way of daily activities.

Causes

Tendinopathy can be caused by wear and tear on a tendon. This can happen due to overuse or naturally over time as people age and their tendons become less flexible. Most people develop tendinopathy because their jobs or hobbies involve motions they repeat over and over. Jobs such as carpentry or house painting or sports such as baseball, tennis and golf require the same motions to be repeated. Over time, this puts stress on the tendons. Some tendinopathies also can be caused by sudden injury such as a fall or accident.

How you move when doing your sport or activity can affect your risk of developing tendinopathy. Moving incorrectly can overload the tendon. Having proper form and technique is especially important when having to repeat movements for sports or a job.

Risk factors

Risk factors for developing tendinopathy include older age and having jobs or hobbies that involve doing the same motion over and over. Some medical conditions and certain medicines also may increase the risk.

Age

As people get older, their tendons become less flexible, making the tendons easier to injure.

Work

Tendinopathy is more common in certain workers, such as gardeners, carpenters and painters, whose jobs involve:

• Repeated motions, such as raking or swinging a hammer.
• Overhead motions, such as reaching up.

Activities

When you're doing physical activities, the following can increase your risk of developing a tendinopathy:

• Sudden increase in amount or difficulty of training.
• Too little recovery time after an injury or too little time to get used to the activity again after time off.
• Hard surfaces, such as concrete or gym floors.
• Poor equipment, such as old shoes or ones without good support.
• Poor posture or poor technique, such as incorrect form when playing tennis or throwing a ball.

Medical conditions and medicines

If you have certain medical conditions, such as diabetes, or take certain medicines, you can have an increased risk of tendinopathy. Medicines that may increase risk include:

• Antibiotics known as fluoroquinolones.
• Corticosteroids such as cortisone.
• Statins, used to lower cholesterol levels.
• Aromatase inhibitors, used to lower breast cancer risk.

Prevention

To lower your chance of developing a tendinopathy, follow these suggestions:

• Ease up. Avoid activities that place too much stress on the tendons, especially for long periods. If you have pain during an exercise, stop and rest.
• Mix it up. If one exercise or activity causes you pain, take a break from it and try something else. Cross-training can help you mix high-impact exercise, such as running, with low-impact exercise, such as biking or swimming.
• Improve the way you move. If you don't do an activity or exercise properly, you could be setting yourself up for problems with the tendons. Think about taking lessons or getting professional instructions when starting a new sport or using exercise equipment.
• Prepare your muscles. Strengthen muscles used in your activity or sport. For example, if you play baseball, use weights to strengthen the specific muscles you need to use. Strengthening muscles that you'll be using can help them bear the load better and lower the risk of injury.

Diagnosis

Often a medical history and a physical exam are enough to diagnose many types of tendinopathy. Your healthcare professional may press on the affected joint and move the joint into different positions.

Sometimes your healthcare professional may use imaging tests to help with diagnosis. Imaging tests may include:

• X-rays. This imaging test can show bone spurs or other potential causes for your pain, such as arthritis. Your healthcare professional might use X-rays to rule out other conditions that could be causing the symptoms.
• Ultrasound. This type of imaging test uses sound waves to make images of structures within your body, such as muscles and tendons.
• Magnetic resonance imaging (MRI). An MRI uses radio waves and a magnetic field to create detailed images of the affected area of the body.

Treatment

The goals of tendinopathy treatment are to relieve pain, reduce irritation and prevent future tendon conditions. Self-care, including rest, ice and pain relievers, might be all that's needed. Changing how you do certain activities and doing physical therapy exercises can help improve pain and prevent future injuries. Other treatment options include noninvasive and surgical procedures.

Treatment options for tendinopathy may include:

Medicines

Nonsteroidal anti-inflammatory medicines, such as aspirin, naproxen sodium (Aleve), ibuprofen (Advil, Motrin IB, others), or acetaminophen (Tylenol, others) may relieve pain. You also can apply pain-relieving creams or gels to the skin.

Physical therapy

Physical therapy exercises can help strengthen the muscle and tendon in the affected area. You can do resistance exercises to effectively treat many long-lasting, called chronic, tendon conditions.

Surgical and other procedures

• Steroid injections. The effectiveness of steroid shots for tendinopathy varies depending on the condition. A steroid shot around a tendon might help ease the pain for a short time. But repeated steroid shots can weaken a tendon and increase the risk of the tendon tearing over time.
• Dry needling. In this procedure, a healthcare professional makes small holes in the tendon with a fine needle, which. can reduce tendon pain.
• Shockwave therapy. This treatment involves sending shockwaves to injured tissue to relieve pain and help the tissue heal. A tool placed on the skin delivers the shockwaves.
• Ultrasound therapy. This treatment can be used to promote healing in a damaged tendon by increasing blood flow to the area.
• Barbotage. This minimally invasive procedure uses a needle and saline to break up and remove calcium deposits. Ultrasound is used to guide the needle to the correct location.
• Tenotomy. This procedure is usually guided with ultrasound and uses either a needle or a specialized device to make holes in the tendon, which can help trigger factors involved in tendon healing. Specialized needle-like devices also can remove unhealthy tendon tissue, called debridement, which may make the procedure even more effective.
• Platelet-rich plasma therapy. This treatment involves taking a sample of your own blood and spinning the blood to separate out the platelets and other healing factors. The solution is then injected into the area of long-term tendon irritation. Research is still exploring the best way to use platelet-rich plasma, but it has shown promise in the treatment of many chronic tendon conditions.
• Surgery. Depending on the seriousness of the injury, you may need to have surgery to repair the tendon, especially if the tendon has torn away from the bone. There are both minimally invasive and open procedures. Minimally invasive techniques usually have less pain and quicker recovery time than an open procedure. An open procedure requires a larger incision. Which procedure is best for you may depend on the type of injury to the tendon and its location.

Self-care

Many times, tendon pain and injury can be treated at home. Self-care steps include:

• Rest. Avoid doing things that increase the pain or swelling. Don't try to work or play through the pain. Healing requires rest, but not complete bed rest. You can do other activities and exercises that don't stress the injured tendon. Swimming and water exercise may be good options.
• Ice. To decrease pain, muscle spasm and swelling, apply ice to the injured area for up to 20 minutes several times a day. Ice packs, ice massage, or slush baths with ice and water all can help. For an ice massage, freeze a paper cup full of water so that you can hold the cup while applying the ice directly to the skin.
• Pain relievers. Over-the-counter pain relievers such as ibuprofen (Advil, Motrin IB, others) or acetaminophen (Tylenol, others) may help reduce the pain caused by swelling in the tendon.

Preparing for an appointment

You might start by talking to your family healthcare professional. Your healthcare professional may refer you to a specialist in physical medicine and rehabilitation, sports medicine, or orthopedic surgery for more-specialized care.

What you can do

You may want to write a list that includes:

• Details about your symptoms.
• Other medical conditions you've had.
• All the medicines, vitamins and supplements you take, including doses.
• Questions you want to ask the care team.

For tendinopathies, some basic questions to ask include:

• What is the most likely cause of my symptoms?
• Are there other possible causes?
• What tests do I need?
• What treatment do you recommend?
• Will I need to stop any of my medicines before or after the treatment?
• I have other medical conditions. How best can I manage them together?
• Will I need to limit my activities?
• What self-care can I do at home?

What to expect from your doctor

Your healthcare professional is likely to ask you questions, such as:

• Where do you feel pain?
• When did your pain begin?
• Did it begin all at once or come on bit by bit?
• What kind of work do you do?
• What are your hobbies?
• Have you been instructed in proper ways to do your activity?
• Does your pain occur or worsen during certain activities?
• Have you recently had a fall or other kind of injury?
• What treatments have you tried at home?
• What did those treatments do?
• What, if anything, makes your symptoms better?
• What, if anything, makes your symptoms worse?