Tendinitis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Synonyms and keywords: Tendinosis; tendonitis

Overview

Tendinitis (also with the nonmedical spelling tendonitis) is a painful disorder of a tendon. Generally tendinitis is referred to by the body part involved, such as Achilles tendinitis (affecting the Achilles tendon), or patellar tendinitis (jumper's knee, affecting the patellar tendon). It was believed that tendinitis was due to inflammation of a tendon, although this is coming into doubt. Chronic overuse of tendons leads to microscopic tears within the collagen matrix, which gradually weakens the tissue.

Common areas of tendinitis

Tendinous injuries are common in the upper and lower limbs (including the rotator cuff attachments), and are less common in the hips and torso. Individual variation in frequency and severity of tendinitis will vary depending on the type, frequency and severity of exercise or use; for example, rock climbers tend to develop tendinitis in their fingers, swimmers in their shoulders. Achilles tendinitis is a common injury, particularly in sports that involve lunging and jumping while patellar tendinitis is a common among basketball and volleyball players owing to the amount of jumping and landing.[1]

Causes

  • Drug side effect

Diagnosis

Swelling in a region of micro damage or partial tear can be detected visually or by touch. Increased water content and disorganized collagen matrix in tendon lesions may be detected by ultrasonography or magnetic resonance imaging.

Symptoms can vary from an ache or pain and stiffness to the local area of the tendon, or a burning that surrounds the whole joint around the inflamed tendon. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiffer the following day as swelling impinges on the movement of the tendon. Many patients report stressful situations in their life in correlation with the beginnings of pain which may contribute to the symptoms.

Treatment

Due to their highly specialized ultra-structure, low level of vascularization and slow collagen turnover, tendons and ligaments are very slow to heal if injured, and rarely regain their original strength. Partial tears heal by the rapid production of disorganized type-III collagen, which is weaker than normal tendon. Recurrence of injury in the damaged region of tendon is common.

Standard treatment of tendon injuries is largely palliative. Use of non-steroidal anti-inflammatory drugs combined with rest and gradual return to exercise is a common therapy, although there is evidence to suggest that tendinitis is not an inflammatory disorder, and that anti-inflammatory drugs are not an effective treatment[2] and that inflammation does not cause tendon dysfunction.[3]

On-going research

Both eccentric loading and extracorporeal shockwave therapy are currently being researched as possible treatments for tendinitis. One study found both modalities to be equally effective in treating tendinosis of the Achilles tendon and more effective than a 'wait and see' approach.[4] Other treatments for which research is on-going includes vitamin E, nitric oxide and stem cell injections.

Eccentric loading

Perhaps the most promising avenue of therapy is indicated in a line of research finding dramatic rates of recovery including complete remodeling of chronically damaged tendon tissue with eccentric loading,[5][6][7][8][9][10][11][12] though eccentric loading may be less effective among non-athletes.[13] However, a 2007 meta-analysis suggested that there is insufficient research to support the use of eccentric loading for the treatment of damage to tendons.[14]

Inflatable brace

The use of an inflatable brace (AirHeel) was shown to be as effective as eccentric loading in the treatment of chronic Achilles tendinopathy. Both modalities produced significant reduction in pain scores, but their combination was no more effective than either treatment alone.[15]

Shock-wave therapy

Shock-wave therapy (SWT) may be effective in treating calcific tendinitis in both humans[16] and rats.[17] In rat subjects, SWT increased levels of healing hormones and proteins leading to increased cell proliferation and tissue regeneration in tendons. Another study found no evidence that SWT was useful in treating chronic pain in the Achilles tendon.[18]

Vitamin E

Vitamin E has been found to increase the activity of fibroblasts, leading to increased collagen fibrils and synthesis, which seems to speed up the regeneration and increase the regenerative capacity of tendons.[19][20]

Nitric oxide

Nitric oxide (NO) also appears to play a role in tendon healing[21] and inhibition of NO synthesis impairs tendon healing.[22] Supplementing with arginine, the amino acid that the body uses to form NO, may be useful in tendon healing.[23] The use of a NO delivery system (glyceryl trinitrate patches) applied over the area of maximal tenderness was tested in three clinical trials for the treatment of tendinopathies and was found to significantly reduce pain and increase range of motion and strength.[24]

Related Chapters

References

  1. ↑ Mayo Clinic (2007). "Patellar tendinitis". Retrieved 2007-06-04.
  2. ↑ Khan, K.M. (2002-03-16). "Time to abandon the "tendinitis" myth: Painful, overuse tendon conditions have a non-inflammatory pathology". British Medical Journal. 324: 626–627. doi:10.1136 Check |doi= value (help). Retrieved 2007-04-02. Unknown parameter |coauthors= ignored (help)
  3. ↑ Marsolais D, Duchesne E, Côté CH, Frenette J. (2007). "Inflammatory cells do not decrease the ultimate tensile strength of intact tendons in vivo and in vitro: protective role of mechanical loading". J Appl Physiol. 102 (1): 3–4. PMID 16916923.
  4. ↑ Rompe JD, Nafe B, Furia JP, Maffulli N (2007). "Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial". Am J Sports Med. 3 (35): 374–83. PMID 17244902. Retrieved 2007-06-06.
  5. ↑ Alfredson Tom , MD, Håkan (1998). "Heavy-Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis". The American Journal of Sports Medicine. American Orthopaedic Society for Sports Medicine. 26: 360–366. Retrieved 2007-04-02. Unknown parameter |coauthors= ignored (help)
  6. ↑ Mafi, N. (2001). "Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis". Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. Springer International. 9 (1): 42–47. 11269583. Retrieved 2007-04-02. Unknown parameter |coauthors= ignored (help)
  7. ↑ Fahlstrom ., M. (2003). "Chronic Achilles tendon pain treated with eccentric calf-muscle training". Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. Springer International. 11 (5): 327–333. 12942235. Retrieved 2007-04-02. Unknown parameter |coauthors= ignored (help)
  8. ↑ Roos, E.M. (2004). "Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy -- a randomized trial with 1-year follow-up". Scandinavian Journal of Medicine & Science in Sports. Munksgaard International Publishers. 14 (5): 286–295. 15387802. Retrieved 2007-04-02. Unknown parameter |coauthors= ignored (help)
  9. ↑ Öhberg, L. (2004). "Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up". British Journal of Sports Medicine. BMJ Publishing Group Ltd. 38: 8–11. Retrieved 2007-04-02. Unknown parameter |coauthors= ignored (help)
  10. ↑ >Jonsson, P. (2005). "Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study". British journal of sports medicine. BMJ Publishing Group. 39 (11): 847–850. 16244196. Retrieved 2007-04-02. Unknown parameter |coauthors= ignored (help)
  11. ↑ Wilson, J.J. (2005). "Common overuse tendon problems: A review and recommendations for treatment" (PDF). American Family Physician. American Academy of Family Physicians. 72 (5): 811–818. Retrieved 2007-04-02. Unknown parameter |coauthors= ignored (help)
  12. ↑ Rees, J.D. (2006). "Current concepts in the management of tendon disorders". Rheumatology. Oxford University Press. 45 (5): 508–521. 16490749. Retrieved 2007-04-02. Unknown parameter |coauthors= ignored (help)
  13. ↑ Sayana MK, Maffulli N. (2007). "Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy". J Sci Med Sport. 1 (10): 52–8. PMID 16828343. Retrieved 2007-06-06.
  14. ↑ Woodley BL, Newsham-West RJ, Baxter GD (2007). "Chronic tendinopathy: effectiveness of eccentric exercise". Br J Sports Med. 4 (41): 188–98. PMID 17062655. Retrieved 2007-06-06.
  15. ↑ Petersen W, Welp R, Rosenbaum D (June 14, 2007). "Chronic Achilles Tendinopathy: A Prospective Randomized Study Comparing the Therapeutic Effect of Eccentric Training, the AirHeel Brace, and a Combination of Both". Am J Sports Med. PMID 17569792.
  16. ↑ Cacchio A, Paoloni M, Barile A, Don R, de Paulis F, Calvisi V, Ranavolo A, Frascarelli M, Santilli V, Spacca G (2006). "Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study". Phys Ther. 5 (86): 672–82. PMID 16649891. Retrieved 2007-06-06.
  17. ↑ Chen YJ, Wang CJ, Yang KD, Kuo YR, Huang HC, Huang YT, Sun YC, Wang FS (2004). "Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinitis and increase TGF-beta1 and IGF-I expression". J Orthop Res. 22 (4): 854–61. PMID 15183445. Retrieved 2007-06-06.
  18. ↑ Costa ML, Shepstone L, Donell ST, Thomas TL (2005). "Shock wave therapy for chronic Achilles tendon pain: a randomized placebo-controlled trial". Clin Orthop Relat Res (440): 199–204. PMID 16239807. Retrieved 2007-06-06.
  19. ↑ Gonzalez, Santander R (1996). "Effects of "in situ" vitamin E on fibroblast differentiation and on collagen fibril development in the regenerating tendon". The International Journal of Developmental Biology. University Of The Basque Country Press. 1 (Supplemental): 181–182. PMID 9087752. Unknown parameter |coauthors= ignored (help); |access-date= requires |url= (help)
  20. ↑ Plasencia., M.A. (1999). "Resorbable polyacrylic hydrogels derived from vitamin E and their application in the healing of tendons". Journal of Materials Science. Materials in Medicine. Kluwer Academic Publishers. 10 (10/11): 641–648. PMID 15347979. Unknown parameter |coauthors= ignored (help); |access-date= requires |url= (help)
  21. ↑ Xia, W. (2006). "Nitric oxide enhances collagen synthesis in cultured human tendon cells". Journal of Orthopaedic Research : Official Publication of the Orthopaedic Research Society. Wiley. 24 (2): 159–172. 16435353. Retrieved 2007-04-02. Unknown parameter |coauthors= ignored (help)
  22. ↑ Darmani, H. (2004). "Single dose of inducible nitric oxide synthase inhibitor induces prolonged inflammatory cell accumulation and fibrosis around injured tendon and synovium". Mediators of Inflammation. Hindawi Pub. Corp. 13 (3): 157–164. 15223606. Unknown parameter |coauthors= ignored (help)
  23. ↑ Erickson, Laurie (2002-07-01). "Future Treatments". Retrieved 2007-04-02.
  24. ↑ Murrell GA. (2007). "Using nitric oxide to treat tendinopathy". Br J Sports Med. 41 (4): 227–31. PMID 17289859.

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