Tendinitis

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Rethinking Treatment Options

Tendinitis has long been thought to be an overuse injury that requires a lengthy healing process. Use of non-steroidal or steroidal anti-inflammatory medications and rehabilitation were the only treatment options available. Surgery has been used to repair this problem as well. Our thinking now must change with regard to tendon pain. Tendinitis is now viewed as a relatively rare condition.

Current research is now showing that most long-term tendinopathy is actually tendinosis. Tendinosis is a condition demonstrating collagen degeneration. That is, the tendon’s cell structure is beginning to abnormally change.

When examined under a light microscope, abnormal tendon (B) from patients with chronic tendinopathies differs from normal tendon in several key ways. Histological analysis of Achilles, medial elbow, and rotator cuff tendons all show a marked loss of collagen fibers, loss of continuity of the collagen fibers, and frank defects in the collagen bundles (arrows in slide B).

The condition of tendinitis is an inflammatory disorder, as the suffix “–itis” implies. Time for recovery from tendinitis is relatively short, approximately 2 weeks. It is generally an overuse condition resulting from biomechanical overloading. Training errors are a common cause, but in some instances a more subtle mechanism may exist. Due to this shoes, racquets, training regimes, movement biomechanics, and muscle imbalances must be accessed to determine the cause of the injury. Tendinitis can be treated effectively with NSAID medications, anti-inflammatory modalities, active rest, and removal of the causative agent. If the condition lasts for more than two weeks when treated properly, another form of tendinopathy needs to be considered.

Quite possibly, tendinosis is the result of improperly treated tendinitis. That is, when the symptoms began there was indeed swelling of the tendon or its synovial sheath then, as the condition progressed, collagen degeneration began to take place. The same mechanisms for causing tendinitis are the same culprits in causing tendinosis. Biomechanical overloads leading to the tissue damage need to be determined and corrected.

Proper differential diagnosis (detailed patient history, appropriate clinical exam, and examination of sports implements) of the affected individual will lead to implementation of appropriate treatment regimens. Some physicians may utilize MRI or diagnostic ultrasound to demonstrate tendon collagen breakdown as part of their differential diagnosis. A highly provocative test for patellar tendinosis is the one leg decline squat (pictured on the previous page).

Treatment begins with proper evaluation of the injury and its causative factors. The rehabilitation plan should be based on the injury and the patient’s desire to return to competition. Patient education is very important. Time should be taken to explain the injury, its causes, and the treatment protocol used. Without proper education in the problem, athletes are more likely to continue to “push through the pain” and worsen the condition. Those patients who are still able to “warm up” the injury and engage in sports are the ones who need the most education. They are likely to try to continue to play with out undergoing appropriate treatment, and thus worsen the tendinosis.

Early stages of the rehabilitation should focus on decreasing the biomechanical loads. This can be accomplished by limiting jumping (patellar and Achilles tendon), limiting back hand strokes (tennis elbow), or decreasing throwing (rotator cuff tendons). Also, the foot ware should be assessed in cases of lower extremity tendinosis. Also, cryotherapy should be used. Ice has a vasoconstrictive property that may prevent neovascularizaton (an abnormal property of tendinosis).

Load decreasing devices such as tennis elbow straps or patellar tendon straps serve a very good purpose. The brace “bow-strings” the tendon changing the biomechanical loads that it receives. Utilizing heel lifts in Achilles tendinosis also appears to be beneficial.

Appropriate strengthening should focus on eccentric strength (muscular activity during a lengthening contraction or deceleration). Eccentric strength training seems to stimulate mechanoreceptors in the tendons to produce collagen. Animal studies have shown that loading the tendon improves collagen alignment and stimulates collagen cross-linkage formation, increasing the strength of the tendon.

Eccentric strength training, when used too aggressively, can cause the symptoms to worsen. It is very important that the athlete and the Athletic Trainer communicate effectively to avoid this complication.

Examples of knee strengthening exercises are:

• Slow descent (5 seconds or longer) squats,

• Progressing to 1-leg slow descent squats,

• Progressing to 1-leg decline squats (very advanced),

• Wall squats (slow descent) with Swiss-Ball® (hold at bottom position),

• Slow descent leg press,

• Stork stands with the knee flexed to 20º, and

• Slide board in basketball defense position.

• Theraband® calf pumps with slow return to dorsiflexion,

• Slow descent calf raises, and

• Progressing to slow descent 1 leg calf raises.

• Theraband® wrist flexion and extension curls with slow return ,

• Wrist pronation and supination utilizing a broom stick or small hammer for resistance, and

• PNF manual resistance with increased eccentric load.

Also, it should be noted that the tendon will become less flexible during this injury, therefore appropriate flexibility training should be utilized.

©2000 - 2009 David Edell

Information on this site is not a substitute for physician directed care.

Please consult your personal physician for more detailed information

concerning specific injuries or illnesses.

Last Update for AthleticAdvisor.com: 10/24/2009 12:09:35 AM