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Tendonitis
Tendonitis (also spelled tendinitis) is a painful disorder of a tendon. Generally tendonitis is referred to by the body part involved, such as
Achilles tendonitis (affecting the Achilles tendon), or patellar tendonitis (jumper's knee, affecting the patellar tendon). It was believed that
tendonitis 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.
Current Research
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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.
Treatment
Due to their highly specialised ultrastructure, 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 tendonitis is not an inflammatory disorder, and that anti-inflammatory drugs
are not an effective treatment and that inflammation does not cause tendon dysfunction.
On-going Research
Both eccentric loading and extracorporeal shockwave therapy are currently being researched as possible treatments for tendonitis. 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. 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, though eccentric loading may be less effective among non-athletes.
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.
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.
Shock-Wave Therapy
Shock-wave therapy (SWT) may be effective in treating calcific tendinitis in both humans and rats. 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.
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.
Nitric Oxide
Nitric oxide (NO) also appears to play a role in tendon healing and inhibition of NO synthesis impairs tendon healing. Supplementing with arginine, the
amino acid that the body uses to form NO, may be useful in tendon healing. 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.
Stem Cells
The injection of stem cells may promote the healing of injuries to the tendon. Completely ruptured tendons may be sutured together with or without
grafted material.
Common Areas of Tendonitis
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 tendonitis will vary depending on the type, frequency and severity of exercise or use; for example, rock climbers
tend to develop tendonitis in their fingers, swimmers in their shoulders. Achilles tendonitis is a common injury, particularly in sports that involve
lunging and jumping while patellar tendonitis is a common among basketball and volleyball players due to the amount of jumping and landing.
A veterinary equivalent to Achilles tendonitis is bowed tendon, tendonitis of the superficial digital flexor tendon of the horse.
(adapted from Wikipedia, the free encyclopedia http://en.wikipedia.org/wiki/Tendonitis)
WITHDRAWN: Interventions for Shoulder Pain
Authors: Green S, Buchbinder R, Glazier R, Forbes A.
BACKGROUND: Shoulder pain is a common problem and although there are many accepted standard forms of conservative therapy for shoulder disorders including
non-steroidal anti-inflammatory drugs, glucocorticosteroid injections, oral glucocorticosteroid medication, manipulation under anaesthesia, physical
therapy, hydrodilatation (distension arthrography) and surgery, evidence of their efficacy is not well established. OBJECTIVES: To review the efficacy
of common interventions for shoulder
pain. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Group trials register, Cochrane Controlled Trials
Register, MEDLINE, EMBASE, CINAHL, and Science Citation Index) up to May 1998, and hand searched major textbooks, bibliographies of relevant literature,
the fugitive literature, and the subject indices of relevant journals including: American College of Rheumatology;British College of Rheumatologists;
the Biennial Conference of the Manipulative Physiotherapy Association of Australia;International Federation of Manual Therapists conference proceedings;
British Orthopaedic Association;and American Orthopaedic Association. SELECTION CRITERIA: Each identified study was assessed for possible inclusion by
two independent reviewers based on the blinded methods sections. The determinants for inclusion were that the trial include an intervention of interest
(non-steroidal anti-inflammatory drugs, intra-articular or subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy,
manipulation under anaesthesia, hydrodilatation, or surgery); that treatment allocation was randomized; and that the outcome assessment was blinded. DATA
COLLECTION AND ANALYSIS: Methodological quality was assessed by two independent, blinded reviewers. Data relating to selection criteria, outcome
measurement and treatment effect was extracted from the blinded trials. Range of motion scores were entered as degrees of restriction to movement, and
all
pain and overall effect scores were transformed to 100 point scales. For continuous outcome measures, where standard deviation was not reported it
was either calculated from the raw data or converted from standard error of the mean. If neither of these were reported, authors were contacted in an
effort to obtain the missing values. Effect sizes were calculated and combined in a pooled analysis if study population, endpoint and intervention were
comparable. MAIN RESULTS: Thirty one trials met inclusion criteria. Mean methodological quality score was 16.8 (9.5 - 22) out of possible score of 40.
Selection criteria varied widely even for the same diagnostic label. There was no uniformity in outcome measures used and their measurement properties
were rarely reported. Effect sizes for individual trials were small (-1.4 to 3.0). The results of only three studies investigating "rotator cuff
tendonitis" could be pooled. Benefit of subacromial steroid injection over placebo for improving range of abduction (weighted difference between means
(WMD) 35 degrees, 95% CI 14 to 55) was the only positive finding. AUTHORS' CONCLUSIONS: There is little evidence to support or refute the efficacy of
common interventions for shoulder
pain. As well as, the need for further well designed clinical trials, more research is needed to establish a uniform
method of defining shoulder disorders and developing outcome measures which are valid, reliable and responsive in these study populations.
Journal: Cochrane Database Syst Rev. 2007 Jul 18;(3):CD001156
Adapted from PubMed; click here to access full journal article.
Prediction of the Success of Nonoperative Treatment of Insertional Achilles Tendinosis Based on MRI
Authors: Nicholson CW, Berlet GC, Lee TH.
Orthopaedic Foot and Ankle Center, 6200 Cleveland Avenue, Suite 100, Columbus, OH 43231, USA. Nicholson.42@osu.edu
BACKGROUND: Insertional Achilles tendinosis is a common clinical diagnosis for posterior heel
pain. Nonoperative treatments often are unsuccessful. The
purpose of this paper was to review a series of patients with insertional tendinopathy to determine whether MRI stratification could predictably identify
patients in whom nonoperative treatment would fail. METHODS: Review of records identified 157 patients (176 tendons) who were treated for insertional
posterior heel pain. All patients who required surgery had MRI and their tendinosis was classified based on tendon size and degree of involvement
(type I, II, or III). Patients who required surgery had standard two-incision decompression and debridement. RESULTS: Of the 157 patients (176 tendons)
with insertional heel
pain, 83 (53%) responded to nonoperative treatment (96 tendons). Most of these patients who had MRI evaluation had type I
involvement. The remaining 74 patients (47%) required operative intervention after an average of 12 months of conservative treatment (80 tendons).
Most of these tendons were types II and III. Overall, two of the 16 type I tendons (12.5%) required surgery, 59 of the 65 type II tendons (90.8%) needed
surgery, and 19 (70.4%) of the 27 type III tendons required surgery. CONCLUSIONS: Patients with tenderness of the Achilles tendon insertion without
obvious signs of inflammation who demonstrate confluent areas of intrasubstance signal changes on MRI (types II and III) are not likely to respond to
nonoperative treatment. Early identification of these patients and operative intervention may lead to earlier return to function.
Journal: Foot Ankle Int. 2007 Apr;28(4):472-7.
Adapted from PubMed; click here to access full journal article.
Epidemiology and Aetiology of Marathon Running Injuries
Authors: Fredericson M, Misra AK.
Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University School of Medicine and Team Physician, Stanford
University Cross-Country and Track Teams, Stanford, California 94305-5336, USA. mfred2@stanford.edu
Over the last 10-15 years, there has been a dramatic increase in popularity of running marathons. Numerous articles have reported on injuries to runners
of all experience, with yearly incidence rates for injury reported to be as high as 90% in those training for marathons. To date, most of these studies
have been cohort studies and retrospective surveys with remarkably few prospective studies. However, from the studies available, it is clear that more
experienced runners are less prone to injury, with the number of years running being inversely related to incidence of injuries. For all runners, it is
important to be fully recovered from any and all injury or illness prior to running a marathon. For those with less experience, a graduated training
programme seems to clearly help prevent injuries with special attention to avoid any sudden increases in running load or intensity, with a particularly
high risk for injury once a threshold of 40 miles/week is crossed. In both sexes, the most common injury by far was to the knee, typically on the
anterior aspect (e.g. patellofemoral syndrome). Iliotibial band friction syndrome, tibial stress syndrome, plantar fasciitis, Achilles tendonitis and
meniscal injuries of the knee were also commonly cited.
Journal: Sports Med. 2007;37(4-5):437-9.
Adapted from PubMed; click here to access full journal article.
Stretching for Prevention of Achilles Tendon Injuries: A Review of the Literature
Authors: Park DY, Chou L.
Professional and recreational athletes commonly perform pre-exercise stretching to prevent musculoskeletal injuries. Little definitive evidence exists
that clearly demonstrates the efficacy of stretching in reducing injury. Achilles tendon injuries are among the most common injuries affecting active
individuals in the United States today. Clinicians commonly recommend stretching the Achilles tendon without concrete scientific evidence to support
such a claim. Few studies have addressed the effect of stretching in Achilles tendon injuries, and it is unclear if the conclusions made for
musculoskeletal injuries can be applied to the Achilles tendon. Biomechanical studies of the Achilles tendon and measurements of the tendon's reflex
activity have demonstrated possible mechanisms for the potential benefit of stretching, including load-induced hypertrophy and increased tendon tensile
strength. Recent prospective studies have contended that reductions in plantarflexor strength and increases in ankle dorsiflexion range of motion from
stretching the Achilles tendon may increase the risk of injury. Studies examining stretching in injury prevention, the biomechanical properties of
injuries to the Achilles tendon were compiled and reviewed. Although many theories have been published regarding the potential benefits and limitations
of stretching, few studies have been able to definitively demonstrate its utility in injury prevention.
Journal: Foot Ankle Int. 2006 Dec;27(12):1086-95.
Adapted from PubMed; click here to access full journal article.
Calcific Tendinitis: Natural History and Association with Endocrine Disorders
Authors: Harvie P, Pollard TC, Carr AJ.
Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Centre, University of Oxford, Oxford, England.
A retrospective, observational cohort study of 102 consecutive patients (125 shoulders) with calcific tendinitis is presented. Of the patients, 73
(71.6%) were women and 29 (28.4%) were men. Compared with population prevalences, significant levels of endocrine disorders were found. We compared 66
patients (62 women [93.9%] and 4 men [6.1%]; mean age, 50.3 years) (81 shoulders) with associated endocrine disease with 36 patients (11 women [30.6%]
and 25 men [69.4%]); mean age, 52.4 years) (44 shoulders) without endocrine disease. The endocrine cohort was significantly younger than the
non-endocrine cohort when symptoms started (mean, 40.9 years and 46.9 years, respectively), had significantly longer natural histories (mean, 79.7
months compared with 47.1 months), and had a significantly higher proportion who underwent operative treatment (46.9% compared with 22.7%). Disorders
of thyroid and estrogen metabolism may contribute to calcific tendinitis etiology. Classifying calcific tendinitis into type I (idiopathic) and type II
(secondary or endocrine-related) aids prognosis and management.
Journal: J Shoulder Elbow Surg. 2007 Mar-Apr;16(2):169-73. Epub 2006 Dec 22.
Adapted from PubMed; click here to access full journal article.
Surgical Treatment of Chronic Patellar Tendinosis: A Systematic Review
Authors: Kaeding CC, Pedroza AD, Powers BC.
Department of Orthopaedics, Ohio State University, Columbus, OH, USA.
There is no consensus in the literature on the best surgical procedure for patellar tendinosis when nonoperative treatment fails. With a systematic
review, we asked whether surgical treatment of the inferior pole of the patella, closing of the paratenon, or immobilization affected the percentage
of patients reporting good to excellent results (percent success). We completed a systematic review of surgical treatment for patellar tendinosis. A
literature search of Medline, CINAHL, and Sport Discus revealed 30 articles on treatment of patellar tendinosis. Ten met our initial inclusion criteria.
Most studies were retrospective and used varying techniques. Outcome measures were individual to the specific article, making it difficult to compare
the results of the studies. Studies that described surgical treatment of the inferior pole of the patella had 70.9% success compared to 91.7% for those
that performed no patella bony work. Closure of the paratenon was reported in seven studies with 84.8% success compared to 91.5% for the other studies.
Immobilization was used in four studies with 82.4% success compared to 94.9% success for four studies that did not immobilize postoperatively. Care must
be taken when comparing these weighted averages since only two of the nine studies described exactly the same technique. Ideally, prospective controlled
studies with validated assessment tools and activity scores are required to determine the best treatment for our patients.
Journal: Clin Orthop Relat Res. 2007 Feb;455:102-6.
Adapted from PubMed; click here to access full journal article.
The "Bench-Presser's Shoulder": An Overuse Insertional Tendinopathy of the Pectoralis Minor Muscle
Authors: Bhatia DN, de Beer JF, Vanrooyen KS, Lam F, Dutoit DF.
Cape Shoulder Institute, Cape Town, South Africa.
Tendinopathies of the rotator cuff muscles, biceps tendon and pectoralis major muscle are common causes of shoulder
pain in athletes. We describe the
clinical features and diagnostic tests of an overuse insertional tendinopathy of the pectoralis minor muscle. A new technique of ultrasonographic
evaluation and injection of the pectoralis minor muscle/tendon is presented; the technique is based on utilization of standard anatomic landmarks
(subscapularis, coracoid process, axillary artery) as stepwise reference points for ultrasonographic orientation. Between 2005 and 2006, we diagnosed
and treated seven sportsmen presenting with this condition. In five patients, the initiating and aggravating factor was performance of the bench-press
exercise (hence the term "bench-presser's shoulder"). Medial juxta-coracoid tenderness, a painful active- contraction test and bench-press maneuver,
and decrease in
pain after ultrasound-guided injection of a local anesthetic agent into the enthesis, in absence of any other clinically/radiologically
apparent pathology, were diagnostic of pectoralis minor insertional tendinopathy. All seven patients were successfully treated with a single
ultrasound-guided injection of a corticosteroid into the enthesis of pectoralis minor followed by a period of rest and stretching exercises.
Journal: Br J Sports Med. 2006 Nov 30
Adapted from PubMed; click here to access full journal article.
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