By: Dale J. Buchberger, PT, DC, CSCS, DACBSP
Tendonitis as a medical term is commonly overused. One reason for its overuse is that the term commonly implies an inflammatory state and this is something that is recognizable to the general public. When diagnostic terms are recognizable patients are less likely to ask questions. For instance, what if my 77-year-old mother walked into the doctors’ office with elbow pain? The conversation might go something like this; Well Mrs. Buchberger it looks like you have “Tennis elbow” or lateral epicondylitis. This is a form of tendonitis. Since my mother has heard the term tendonitis before she might respond with, “oh, ok. What can we do for that?” Notice she didn’t question the doctor because she was familiar with the term. She may be offered some of the following: nonsteroidal anti-inflammatory medications commonly referred to as NSAID’s (Advil, Aleve, Motrin, etc.), ice, heat, a variety of braces or supports, a physical therapy order, cortisone injection, etc. and the list goes on. My question to you is: What if it is not tendonitis? What if the doctor told my mother she had “tendinosis”? Would she have acted as passively? Or would she have questioned this strange term? Hopefully this article will improve efficiency for at least two-thirds of the healthcare equation (provider and patient). The other one-third is the insurance industry and that is not an article; that would be a dissertation.
The key for both provider and patient is in a clear understandable definition of the terms. Definitions that all parties can understand, make sense of and relate to. If we accomplish this, efficiency is sure to follow. The following are definitions for various types of tendon afflictions. The difference between each one is significant because the treatment approaches for each are different.
Tendonitis: Implies that an inflammatory process is present in or on the tendon. Recent studies have found that in cases of “tendonitis” inflammatory cells were not present in the affected tendon and in fact degenerative cells were present instead confirming inaccurate use of the term “tendonitis”.
Tenosynovitis: Implies an inflammatory process of a tendon that is structurally or anatomically surrounded by a synovial sheath. A “synovial sheath” is a lining of particular tendons that produces synovial fluid and has a greater chance of swelling when irritated. This would be appropriate in the long head of the biceps tendon in the front of the shoulder but not in the case of say the patellar tendon at the knee.
Tendinopathy: This is a term that merely implies a painful entity of a tendon. It does not specify the cause of the pain but only that the tendon is painful.
Tendinosis: Is a term that defines objective findings of degenerative cells within the substance of the tendon. The tendon may display intra-substance tearing secondary to the degenerative process. While the tendon may appear “swollen” it is not inflamed but actually “thickened” due to the accumulation of degenerative tissue. More times than not the majority of tendon disorders are actually tendinosis and not tendonitis.
Why is it important to understand these terms? As I had previously stated, the term defines the treatment approach that will be most effective. For instance, tendonitis since it implies inflammation may be treated with an “anti-inflammatory approach”. This may include some or all of the following; rest, ice, ultrasound, electrical stimulation, NSAIDS (prescription or over the counter), cortisone injections, compression wraps, stretching, etc.
If you have tendinosis the approach is much different. Patients with tendinosis actually need a more aggressive approach to their treatment. The more aggressive approach is directed at improving circulation and remodeling in the degenerated tendon. This requires an emphasis on manual therapy techniques and therapeutic exercises that use eccentric (e-sen-trick) muscle contractions. Eccentric muscle contractions occur when the muscle is contracting but lengthening at the same time. If the muscle were contracting and shortening (as in picking up an item with your hand causing your elbow to bend) this would be called a “concentric” contraction. Ultrasound is a commonly applied treatment modality used in physical therapy, chiropractic and athletic training settings and has been shown to improve tendon strength. It is a good adjunct to manual therapy and eccentric exercises applied to the injured tendon.
The treatment of tendon disorders has expanded and become more complex than “ice, stretch and take two of these”. There are also new injectable treatments that are becoming increasingly popular because of their use in professional sports but the research to support their use in the general public is in its infancy. Nutrition is another area of interest in musculoskeletal disease processes. In the near future we should have a large base of research and knowledge available for the efficient treatment of tendon disorders. This will reduce confusion for the general population.