good overview of the whole deak
By: David Adelberg MD
Everyone has heard of them, almost everyone has had one of them, no one likes them, so what are they?
Here are the terms: Tendons are the rope-like connective structures that connect muscle to bone.
More below.
The suffix -itis means inflammation (more below). Acute means new and chronic means the condition has persisted for more than, say, a few months.
The best demonstration of the overall organization of a muscle tendon bone unit is your own leg, Achilles and heel. With a little inspection and careful checking with your fingers, you can easily discern that the fleshy calf muscles (gastrocnemius and soleus) slowly taper and condense into the stout cord-like Achilles tendon that travels for several inches until it blends into the top and back wall of the heel bone (calcaneus).
The injury.
To get tendonitis, acute or chronic, you need a tendon injury. In daily life, limb and joint motion is a result of muscle contraction and simultaneous tendon traction on its target bone. Hence, the tendon is loaded (stressed). Either concentrically or eccentrically as the joint is flexed or extended. If the increase in demand is gradual, muscles and tendons will usually adapt without injury. But like any loaded structure, tendons will fail if overloaded. This can be like a dramatic explosive disruption of a complete Achilles tear on a basketball court or multiple small microscopic tears acquired over time from repetitive stress or local friction. Almost any activity in excess qualifies; such as weightlifting, throwing, tightening bolts etc. At last check, lifting a can of beer is still safe.
We are, of course, concerned here with the injury of microscopic tears. Being living structures, tendons do have limited repair capacity, but part of the initial response to injury is the inflammatory response. In this phase, the body recruits special cells attended by a sequence of chemical events that result in local tendon inflammation. The hallmarks of inflammation, you could probably list from experience, but are here, defined as swelling, pain, tenderness, increased warmth, and loss of function. With healing of the microscopic tears, the acute inflammation does subside.
Chronic tendonitis on the other hand is the accumulation over time of small scale injuries that do not heal. As such, one can say that chronic tendonitis is a chronic injury of failed healing resulting in areas of tendon degeneration.
When viewed by microscope, areas of chronic tendon degeneration may actually show an absence of inflammatory cells and as such, some authors feel that the term chromic tendonitis is inaccurate and prefer the term chronic tendinosis. The suffix -osis implies chronic degeneration without inflammation. Whichever term you prefer, this painful condition limits function and predisposes to tendon rupture.
Who gets tendonitis? Absolutely everyone, although individual genetic differences. lead to different genetic tendon compositions, leaving some individuals more vulnerable to tendon injury than others. Genetics will likely prove to be key in sorting out the tendonitis puzzle. Except in severe connective tissue disorders, there is no way yet of genetically identifying a person at risk. That said, women may be slightly more susceptible than men and increasing age certainly increases the risk for tendonitis.
Although it may he easy to understand how severe, repetitive tendon loading or friction can cause microscopic tendon tearing, it appears that in a few cases, even low level repetitive tendon stress (keyboard use) can cause the accumulation of micro tears that become symptomatic. This brings up two points. It is likely that many micro tears develop and heal without being noticed and second, by the time you experience pain of tendon inflammation, the tendon injury has likely been present for some days. Symptoms seem to present when the balance of ongoing injury and inflammation versus the healing process is tipped and the injury accumulates faster than the healing.
Structurally, tendons are largely woven of protein (collagen) fibers, like a rope. When these fibers are torn, the new collagen production needed for repair can take months. Hence, the long lime needed for tendon healing. Clearly, if there is new stress and injury during the slow healing phase, the balance will tip unfavorably. For discussion of tendon structure and composition and metabolism, see
www.emedicine.com.
Prevention.
Common sense remains number one. Stretching and staying below a level of activity that produces inflammation are the keys. In sports or weight training, this may be as easy as working with a coach and gradually increasing load in a training program. Avoiding activity leading to tendon injury on the job is often easier said than done. But proper work station ergonomics can help. See Treatment, below.
Current treatment.
The goal in acute tendonitis is decreased inflammation and in both acute and chronic tendonitis, the goal is to promote better Tendon healing and break the cycle of failed healing. At present, nothing appears to speed up healing and treatment is largely aimed at preventing the inadvertent slowing of healing, while allowing some function and muscle rehabilitation. The muscle of the injured muscle tendon unit often being measurably weakened after injury.
Rest as it likely takes months for a tendon to heal, resting it is key and generally means avoiding activities which cause pain. Activity restrictions should lesson with time and tendon healing, and does not mean activity restriction to the extent of muscle atrophy or joint stiffness.
Physical therapy. Progressive stretching and local muscle strengthening works when done gradually.
Presently, many practitioners find that eccentric exercise is particularly helpful. Eccentric means a muscle is forced to lengthen during contraction, for example, the quadriceps that lengthen while contracting as one performs the down part of a wall squat. Most physical therapists will devise a program that starts with evaluation and progresses from palliative modalities like heat, ultrasound, ice, and electrical stimulation, and move on to stretching and resistance exercises and finally, full activity. The time in supervised treatment usually depends on need; for example the rate of progress, the availability of equipment at home or gym and insurance coverage. You can guess which way the trend is going. One can count on the component of home exercises of treatment to he key in almost all situations. For some specifics on home exercise programs, you may wish to check
www.merk.com. A note on physical therapy modalities. These are palliative ,that is designed to reduce symptoms. They do not heal tendons or demonstrably speed tendon healing.
Shockwave therapy, the delivery of energy to tissues by blasting the area with sound shockwaves. This therapy is used in tennis elbow. (Lateral elbow extensor tendonitis and other areas). It appears that about one half of the patients receiving this treatment, typically once a week for about 3 weeks will experience some decrease in pain. It is usually tried when lesser physical therapy measures have failed.
Non-steroidal anti-inflammatory agents (NSAIDS), for those who can take them, remain a cornerstone of therapy in offering at least some pain relief. Ironically, non-steroidal anti-inflammatory agents seem to offer this benefit even in chronic tendinosis where inflammation per se figures less heavily. Many practitioners find that these medications work best when used preemptively, for example, before a traditionally painful activity, such as a physical therapy session.
Ice.
Especially at the end of a physical therapy session or a painful activity, ice offers many people good short-term pain relief. Ice, or cryotherapy, does not appear to affect the natural history of this disease either way-
Steroid injections (or help support your local orthopedist). Although such injections need to be properly given in regards to technique and number, these shots can dramatically decrease symptoms, usually taking about 4 or 5 days to do so. The most dramatic response can be seen in shoulder tendonitis and tennis elbow. This is fortunate, as these two are two of the most common, acute and chronic tendonitis conditions. In one form of shoulder or rotator cuff tendonitis, calcium deposits form in or near the rotator cuff tendons and can cause pain severe enough to prompt emergency room visits. A steroid shot into the space just outside the rotator cuff (the bursa) can reduce pain like an off switch. Such injections for non-calcific acute and chronic rotator cuff tendonitis can often be extremely helpful. Steroid injections do not cause tendons to heal and if steroid is injected into the tendon structure. it can cause injury predisposing tendon rupture. Hence, it is the usual practice to avoid injection into the tendon itself. However, the injection for tennis elbow is intentionally placed into the footprint of tendon origin at the lateral epicondyle. This is likely why most practitioners will limit the number of injections per year and in total into this structure.
Braces, orthotics, and splints. tese items help enforce rest. This is usually by limiting tendon excursion and hence, use. This will, then, necessarily interfere with normal local joint and tendon function, but that is the exact intention. Areas where this is particularly effective include a wrist splint for wrist tendonitis and knee splinting for tendonitis about the knee, quadriceps, patella and hamstrings. Orthotics can help with Achilles tendonitis by raising the heel and lower tendon peak loads and also help with posterior tibialis tendonitis by reducing midfoot collapse during the stance phase of walking. Perhaps, counter-intuitively, a wrist splint can be key for elbow tendonitis, either on the extensor side or flexor side. The stress on the tendons of origin at these elbow muscle groups is greatly diminished when one restricts motion of the attached muscles which are the wrist flexors and extensors. So by blocking wrist motion, one rests the forearm muscles and reduces tendon stress at the elbow anchoring site.
Around the knee, braces can be adjusted to allow various amounts of range of motion. In many cases, this can prevent the need for complete joint immobility in a brace, while allowing motion in a painless range. This range is usually best sorted out with a trainer or therapist.
As some function is required for virtually all hand use, splinting for thumb tendonitis is very limiting and hence, often unpopular and impractical. Nonetheless, for enforcing local tendon rest, it can be very effective.
In more advanced cases of chronic Achilles tendonitis, near complete rest that avoids crutches and allows walking can he achieved with a ski boot type orthosis that raises the heel internally, but allows flat foot contact on the floor. These devices typically have internal wedges under the heel that raise the heel to the point where local muscle contraction and hence tendon load are substantially reduced while weightbearing.
Conversely, while in bed or at rest, an Achilles stretching orthosis has been devised that pushes up on the forefoot, causing ankle dorsiflexion to the point where the Achilles and leg muscles are passively stretched. This device usually is called a resting night splint. Passive joint stretching devices have been constructed for virtually any stiff joint, but in those cases, the treatment is joint stiffness not tendonitis per se.
Owing to the large array of choices, if you are considering in-shoe orthotics for tendonitis, you should discuss the various types and construction with a qualified orthopedist or trainer or therapist. For example, will the $12 off-the-shelf model suffice or are you going to be sentenced to the $300 custom variety
Correcting technique. In weight training and throwing, tendon injury from errors in technique are not only common, but frequently amenable to changes in technique. These changes in technique are usually part of the program that includes the other interventions listed in this section. A throwing coach and lifting trainer are key. Weightlifting issues will be the subject of the next article in this series.
Workplace ergonomics. Although better for prevention than cure, there are several somewhat helpful changes that may decrease or prevent recurrence of symptoms.
Nutritional supplements. Sorry folks, but save your money. Now a multi-million dollar industry and as popular as tax refunds, there appears to be no convincing evidence that nutritional supplements help tendon healing or prevent tendon injury. Basic good nutrition may be as vital as oxygen to overall good health, but adding quantities of such items as Vitamin C, amino acids, glucosamine, and herbal extracts have not been shown to reduce injury or speed healing. The role of some supplements in reducing inflammation is hard to measure, and no standard effective recommendations seem to be available at present.
Body work and manipulation. If you like it, try it. Don't hold your breath waiting for these activities to speed tendon healing. Techniques in body work or manipulation that cause pain during or after a session should be viewed with the same caution that overwork and over-training and overuse, currently are.
Surgery.
Although another excellent way to support your local orthopedist, this remains the court of last resort. Whereas surgery may be the only treatment for complete tendon rupture, to my knowledge, it has no indication in acute tendonitis. When the problem is mechanical, like tendon injury from local friction, surgery can be curative, but surgery has risks that vary with the procedure and hence, surgery is not advised until less risky interventions fail. The less risky interventions include everything listed above in this treatment section.
Standard surgical risks common to virtually all tendon surgeries include failure, infection, stiffness, nerve injury, and blood vessel damage, anesthetic complications, both minor and major.
Nonetheless, when performed properly and followed by appropriate rehabilitation, the surgical success rates for chronic tendonitis range aboveve 90%. Some examples of surgery to correct chronic tendonitis are the following out-patient procedures. Decompression for rotator cuff tendonitis, tenodesis for biceps tendonitis, microdebridement for tennis elbow and little League elbow, tenalysis for thumb tendonitis, debridement for patella and quadriceps tendonitis, debridement and reconstruction for Achilles tendonitis, debridement and stabilization for peroneal tendonitis, and rarely, debridement for posterior tibialis tendonitis. Your orthopedic surgeon will usually take the time to discuss the role of surgery, its risks, benefits, outcomes, and alternatives of treatment, and give you procedural details, including down time, rehabilitation requirements, and thehe expectation for return of activity. If your orthopedist won't explain all of these, you probably have the wrong doc.
Future treatments, this remains the subject of research and speculation. The star here is gene therapy. If a genetics of predisposition is established, a treatment of gene therapy may be conceivable for prevention and healing. The closest but yet very distant treatment is stem cell work, for example, the local injection of stem cells into injury sites. There may be some early promising leads here.
As
some compounds can he shown to favorably change tendon metabolism in a test tube, experiments to see if there may be safe effective treatments include the use of:
Insulin-like growth factor - IGF-l
Growth and differentiation factor GDF-5
Platelet-derived growth factor - PDF
Cartilage-derived morphogenetic protein - CD.IP-22
Bone morphogenetic protein 12 - BAIP-12
Transforming growth factor Beta I - fGF Beta I. I would suggest memorizing this list to make you popular at your next party.
1n this review, we have defined acute and chronic tendonitis, glimpsed the structural injury and associated inflammation and risk factors. We have touched on prevention and treatment in its various forms. Any phrase or term in this review can be used in a Google search for further details.
David A. Adelberg MD ©2006
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I had cycles before so it was not a big deal--just better gear now--no lables written in crayon anymore.
