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Tendinopathies (Main)

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Other Names

  • Tendinitis
  • Tendinosis
  • Tendinopathy

Background

  • Pain in or around tendons that is activity related is traditionally called tendonitis
  • Tendinitis refers to acute injuries, while tendinopathy or tendinosis refers to chronic degenerative changes of the tendon
  • Tendinopathy is a broad term encompassing painful, degenerative conditions occurring in and around tendons in response to overuse [1]
  • Most cases of tendinopathy are due to overuse, repetitive injuries, although acute trauma can cause the same symptoms
  • Failure rate of management is as high as 25%[2]

Pathophysiology

Chronic Tendinopathy

  • The prolonged repetitive stress puts mechanical stress on the tendon leading to "microtears" or "microruptures"
  • Subsequently, the healing process is altered
  • Histologic changes seen in chronic tendinopathies includes:[3]
    • Collagen degradation
    • Vascular ingrowth
    • Fibrocartilage metaplasia
    • Also noted is the absence of inflammatory cells

Tendon Biomechanics

Models of Tendinopathy

  • Inflammation
    • Research suggests there is little to no inflammation present when a tendinitis becomes a tendinopathy
    • This is being called into question. Dean et al has shown that inflammatory response is a key component of chronic tendinopathy[4]
    • For example, an increase number of cytokines, inflammatory prostaglandins, and metalloproteinases (MMPs) and tendon cell apoptosis seem to be provoked by continuing mechanical stimuli[5]

Risk Factors

Extrinsic

  • Training errors
  • Hill work
  • Technique
  • Fatigue
  • Playing surface
  • Footwear
  • Increasing training volume or intensity too quickly
  • Excessive use of static stretching

Intrinsic

  • Genetics
    • COL5A1
    • MMP3
    • Tenascin-C
  • Age
    • <18: Myotendinous junction
    • 18-55: Increasing incidence achilles, patellar
    • >55: Rotator cuff
  • Gender
    • Achilles (Male = Female)
    • Patellar (Male > Female)
    • Men: 60% of running related tendinopathy
  • Systemic Disease
  • Hormonal changes
    • Perimenopauysal women due to loss of estrogen
  • Medications

Tendinopathies by Region

Upper Extremity

Lower Extremity

Other

Clinical Features

  • General: Relevant Clinical Exam Tests
  • Physical exam will require evaluation of the affected joints(s)
  • In the case of tendinopathies, patients will have pain with activation of affected muscles and tendons
  • They will typically be pain at the insertion point of the tendon

Evaluation

  • Primarily a clinical diagnosis
  • Radiographs
    • 3 view initial imaging modality of choice
    • May show enthesiophytes in chronic cases
  • MRI
    • To exclude other diagnosis
  • CT
    • Not necessary

Management

Medications

NSAIDS

  • General
    • Risks of long term use include gastrointestinal, cardiovascular and renal complications
    • Overall, the evidence suggests both oral and local NSAIDS are effective in relieving the pain associated with tendinopathy in the short term (7–14 days)[1]
  • Shoulder bursitis/ tendinitis
    • Naproxen more effective than placebo, less effective than corticosteroid injection of shoulder bursitis tendinitis at 4 weeks[6]
    • Boudreault et al: systematic review demonstrated low-to-moderate evidence they provide short term pain relief, no change in function[7]
      • Category 1A evidence, Similar efficacy to corticosteroid injections
  • Lateral epicondylitis
    • Systematic review showed some support for NSAID use up to 2 weeks[8]
    • No difference between placebo and naproxen at 1 year follow up[9]

Topical NSAIDS

  • Needs to be updated

Topical Nitroglycerin

  • General
    • Limited research[10]
    • Challoumas et al were able to review 10 randomized clinical trials investigating nitroglycerin and tendinopathies: 4 for the rotator cuff, 3 for wrist extensors, 2 for achilles and 1 for patellar tendon.[11]
    • Although the evidence in the individual studies were not great, all of them reported improved pain with topical GTN compared to placebo.


Physical Therapy

Eccentric Strengthening

  • General
    • Multiple studies have shown improvement in tendinopathies using eccentric exercises[12]
  • Achilles Tendinopathy
    • 82% of patients randomized to the eccentric strengthening protocol described improvement in pain levels compared with 36% in the concentric training group[13]
  • Lateral Epicondylitis
    • Eccentric strengthening protocols have also been successful in the treatment of lateral epicondylitis[14]
  • Rotator Cuff tendonitis
    • In one study, 125 patients were randomized to arthroscopic acromioplasty, a formal supervised rotator cuff strengthening program, or a placebo laser treatment.[15]
    • Both the acromioplasty group and the physical therapy group had improved pain scores at 6 months compared with the placebo group
    • There was no difference in pain scores between the two treatment groups.

Extracorporeal Shock Wave Therapy

  • General
    • Optional treatment modality used by some physical therapists
  • Rotator Cuff Tendinitis
    • In patients with calcific tendonitis of the rotator cuff, SWT was beneficial for function, pain and size of calcifications compared to placebo[16]
  • Lateral Epicondylitis
    • 2007 systematic review attempt to summarize the research on SWT for lateral epicondylitis but was limited by significant heterogeneity among included studies.[17]
    • Nonetheless, they concluded there was evidence for effectiveness of shock wave treatment for tennis elbow
    • One randomized, multicenter trial found no difference[18]
  • Patellar Tendinopathy
    • SWT was superior to controls up to 3 years following initiation of therapy[19]
  • Achilles Tendinopathy
    • SWT produced similar improvements in pain and function when compared to eccentric loading[20]

Low Level Laser Treatment (LLLT)

  • General
    • Four systematic reviews have addressed LLLT and all agreed the best current level of evidence does not support its use in the treatment of tendinopathy[21][22][23][24]

Iontophoresis and Phonophoresis

  • General
    • Iontophoresis and phonophoresis involve using ionizing current or ultrasound to deliver medications locally.
    • Typically corticosteroids or NSAIDS
  • Two adequately powered studies showed no benefit[25][26]
  • Lateral Epicondylitis
    • Two adequately powered studies showed no benefit[27][28]

Transverse Friction Massage

  • General
    • Three studies, including a cochrane review and none showed benefit over other physical therapy modalities[29][30][31]

Therapeutic Ultrasound

  • General
    • US results in decreased pain and increased pressure tolerance in patients with epicondylitis, tendinitis, and tenosynovitis[32]
    • Systematic review found no benefit in most disease entities except lateral epicondylitis[33]
  • Lateral Epicondylitis
    • Greater improvements in pain score, weight lifting, grip strength compared to placebo[34]
  • Calcific Tendinitis Shoulder
    • In patients with symptomatic calcific tendinitis of the shoulder, ultrasound treatment helps resolve calcifications and is associated with short-term clinical improvement[35][36]

Therapeutic Hyperthermia

  • Supraspinatous Tendinopathy
    • Patients who received hyperthermia experienced significantly better pain relief compared to ultrasound or exercise[37]
  • Patellar and Achilles Tendinopathy
    • Better improvement in pain compared to ultrasound at 434 MHz[38]


Procedures

Corticosteroid Injection

  • General
    • Mainstay treatment for many tendinopathies
  • Lateral Epicondylitis
    • Studies show benefit early in treatment, but the long term efficacy has not been demonstrated[39]
    • At six weeks, treatment with corticosteroid injections was more effective than physiotherapy[40]
    • In this study, at 6 weeks, corticosteroid injections were superior, however long-term differences favored physical therapy[41]
    • Early local corticosteroid injection is effective for lateral epicondylitis.[42]
  • Subacromial Bursitis/ Rotator Cuff tendinopathy
    • Some studies have found benefit, others have not
    • Systematic review little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease[43]
    • Triamcinolone was superior to naproxen in the relief of pain (P = 0.04) and the clinical index (P = 0.04) [6]
    • Another study concluded subacromial injection of corticosteroids is an effective short-term therapy for the treatment of symptomatic subacromial impingement syndrome[44]
    • Akgun et al found improvement at acute (1 month) and subacute (3 months) especially when combined with NSAIDS[45]
    • Several studies have found no benfit[46][47]
  • Achilles Tendonitis
    • Risks involved
    • Case reports of achilles tendon rupture after corticosteroid injections[48][49][50]
    • Gill et al performed 83 consecutive inejctions without complication using fluroscopy[51]

Dextrose Prolotherapy

  • General
    • Limited research[52]
  • Rotator cuff tendinopathy
    • Dextrose prolotherapy was superior to placebo for long term pain improvement and patient satisfaction[53]
  • Lateral Epicondylitis
    • A double blind, randomized controlled trial demonstrated that dextrose prolotherapy was well tolerated and effective at reducing pain and improving strength testing in patients with lateral epicondylosis[54]
  • Adductor tendonitis
    • For soccer and rugby players with chronic groin pain from osteitis pubis and/or adductor tendinopathy, dextrose prolotherapy demonstrated a significant reduction in chronic pain[55]
  • Patellar tendonitis
    • In athletes with patellar tendinopathy, there was a reduction in pain and improvement in ultrasound hypoechogenicity following ultrasound guided dextrose prolotherapy[56]
  • Achilles Tendonitis
    • In patients with Achilles tendinopathies, dextrose prolotherapy demonstrated a significant reduction in pain at rest and during tendon loading activities. [57]
    • When combined with eccentric exercises, gave more rapid improvement in symptoms than eccentric exercises alone, however long term VISA-A scores were similar.[58]

Needle Tenotomy

  • General
    • Limited literature
  • Lateral Epicondylitis
    • Nearly 2/3 of patients reported improvement in pain up to 28 months [59]
  • Patellar Tendinitis
    • Improvement in post-procedure pain score and sonographic findings[60]
  • There are favorable case reports for Achilles (4), proximal gluteus medius (1), proximal iliotibial tract (1), proximal hamstring (1), common extensor elbow (1), and proximal rectus femoris (1)[61]

Sclerotherapy

  • General
    • Involves injecting a chemical into a blood vessel and subsequent angiosclerosis
  • Lateral Epicondylitis
    • Sclerotherapy has a potential to reduce the tendon pain and increase grip strength, in patients with chronic painful tennis elbow.[62]
  • Patellar Tendinopathy
    • Sclerosing injections with polidocanol resulted in a significant improvement in knee function and reduced pain in patients with patellar tendinopathy[63]
  • Achilles Tendinopathy
    • Sclerosing neovessels appears to be an effective treatment for painful chronic Achilles tendinosis[64]
    • Treatment with sclerosing polidocanol injections in patients with chronic painful mid-portion Achilles tendinosis showed remaining good clinical results at a 2-year follow-up[65]
    • Injections with the sclerosing substance Polidocanol have the potential to reduce tendon pain during activity in patients with chronic painful mid-portion Achilles tendinopathy[66]

UltraSound Guided Galvanic Electrolysis (USGET)

  • General
    • Ultrasound guided procedure consisting of application of a non-thermal galvanic current through tendons
    • Relatively new technique still requiring investigation
  • Achilles Tendonitis
    • Abat et al found combining USGET with physical therapy was superior to physical therapy plus standard electrophysical therapy[67]

Regenerative Medicine

Stem Cell Therapy

  • General
    • Suffer from lack of standardization in properation or methods of application (i.e. how much and how often)
    • Also which source of stem cells is superior?
  • Lateral Epicondylitis
    • From baseline through 52 weeks of periodic follow-up, VAS scores progressively decreased and tendon defects significantly increased.[68]
  • Patellar Tendonitis
    • Pascual-Garrido et al found inoculation with bone marrow stem cells improved pain in 7 of 8 patients at 5 years follow up[69]

Platelet Rich Plasma

  • General
    • Growing, widespread use in acute and chronic tendon injuries despite overall conflicting evidence and lack of consensus
    • There is no standardization of PRP preperation or application.
    • Examples of lack of consensus include Leukocyte rich or leukoocyte poor? How frequently to inject?
    • Systematic review by Filardo et al: Helped with patellar tendonitis and lateral epicondylitis but not with rotator cuff or achilles tendon[70]
    • Systematic review by Fitzpatrick et al: shown good clinical evidence that favors the use leukocyte-rich PRP (LR-PRP) under ultrasound guidance for the treatment of patellar tendinopathy, lateral epicondylitis, Achilles tendonitis and rotator cuff tendinopathy[71]


Complementary and Alternative Medicine

Acupuncture

  • General
    • Very, very limited research
  • Rotator Cuff tendinitis
    • In one study of athletes with rotator cuff tendinitis, a single-blinded study of acupuncture treatment for 4 weeks was superior to placebo for pain relief[72]
    • When using a placebo TENS compared to acupuncture, there was no difference in the treatment of rotator cuff tendinitis[73]
  • Lateral Epicondylitis
    • In patients with lateral epicondylitis, a cochrane review of two small studies demonstrated short term pain benefit of less than 24 hours[74]
  • Achilles Tendinopathy
    • A non-blinded study found acupuncture improved pain and function compared to eccentric exercises[75]


Surgery

  • General
    • Considered last option when non-surgical plan fails to provide adequate relief of pain and return of function
  • Rotator Cuff Tendinopathy
    • ?Unclear surgical guidelines
  • Lateral Epicondylitis
    • Patients tend to have a low rate of complications[76]
  • Achilles Tendinopathy
    • Overall, poor quality data[77]

Complications

  • Chronic Pain
  • Loss of function
  • Inability to return to work

See Also

References

  1. ↑ 1.0 1.1 Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008 Jul;466(7):1539-54. doi: 10.1007/s11999-008-0260-1. Epub 2008 Apr 30. Review. PubMed PMID: 18446422; PubMed Central PMCID: PMC2505250.
  2. ↑ ohrer H, David S, Nauck T. Surgical treatment for achilles tendinopathy - a systematic review. BMC Musculoskelet Disord. 2016 May 10;17:207. doi: 10.1186/s12891-016-1061-4. Review. PubMed PMID: 27165287; PubMed Central PMCID: PMC4862213.
  3. ↑ Adams, Julie E., and Rohan Habbu. "Tendinopathies of the hand and wrist." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 23.12 (2015): 741-750.
  4. ↑ Rees JD, Stride M, Scott A. Tendons--time to revisit inflammation. Br J Sports Med. 2014 Nov;48(21):1553-7. doi: 10.1136/bjsports-2012-091957. Epub 2013 Mar 9. Review. PubMed PMID: 23476034; PubMed Central PMCID: PMC4215290.
  5. ↑ Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008 Jul;466(7):1539-54. doi: 10.1007/s11999-008-0260-1. Epub 2008 Apr 30. Review. PubMed PMID: 18446422; PubMed Central PMCID: PMC2505250.
  6. ↑ 6.0 6.1 Petri M, Dobrow R, Neiman R, Whiting-O’Keefe Q, Seaman WE. Randomized, double-blind, placebo-controlled study of the treatment of the painful shoulder. Arthritis Rheum. 1987;30:1040–1045.
  7. ↑ Boudreault, Jennifer, et al. "The efficacy of oral non-steroidal anti-inflammatory drugs for rotator cuff tendinopathy: a systematic review and meta-analysis." Journal of rehabilitation medicine 46.4 (2014): 294-306.
  8. ↑ Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft W. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Cochrane Database Syst Rev. 2002:CD003686.
  9. ↑ Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. Bmj. 1999;319:964–968
  10. ↑ https://www.sportsmedreview.com/blog/2019/managing-refractor-tendinopathy-topical-glyceryl-trinitrate
  11. ↑ Challoumas D, Kirwan PD, Borysov D, et al. Topical glyceryl trinitrate for the treatment of tendinopathies: a systematic review. British Journal of Sports Medicine 2019;53:251-262
  12. ↑ O'Neill S, Watson PJ, Barry S. WHY ARE ECCENTRIC EXERCISES EFFECTIVE FOR ACHILLES TENDINOPATHY? Int J Sports Phys Ther. 2015 Aug;10(4):552-62. PubMed PMID: 26347394; PubMed Central PMCID: PMC4527202.
  13. ↑ Mafi N, Lorentzon R, Alfredson H. 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 Surg Sports Traumatol Arthrosc. 2001;9(1):42-7. PubMed PMID: 11269583.
  14. ↑ Croisier JL, Foidart-Dessalle M, Tinant F, Crielaard JM, Forthomme B. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br J Sports Med. 2007;41:269–275.
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  42. ↑ Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. Bmj. 1999;319:964–968.
  43. ↑ Koester MC, Dunn WR, Kuhn JE, Spindler KP. The efficacy of subacromial corticosteroid injection in the treatment of rotator cuff disease: A systematic review. J Am Acad Orthop Surg. 2007;15:3–11.
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  51. ↑ Gill SS, Gelbke MK, Mattson SL, Anderson MW, Hurwitz SR. Fluoroscopically guided low-volume peritendinous corticosteroid injection for Achilles tendinopathy. A safety study. J Bone Joint Surg Am. 2004;86-A:802–806.
  52. ↑ https://www.sportsmedreview.com/blog/managing-refractory-tendinopathy-part-3-dextrose-prolotherapy
  53. ↑ Bertrand, Helene, et al. "Dextrose prolotherapy versus control injections in painful rotator cuff tendinopathy." Archives of physical medicine and rehabilitation 97.1 (2016): 17-25.
  54. ↑ Scarpone, Michael, et al. "The efficacy of prolotherapy for lateral epicondylosis: a pilot study." Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine 18.3 (2008): 248.
  55. ↑ Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil. 2005 Apr;86(4):697-702.
  56. ↑ Ryan, Michael, et al. "Ultrasound-guided injections of hyperosmolar dextrose for overuse patellar tendinopathy: a pilot study." British journal of sports medicine 45.12 (2011): 972-977
  57. ↑ Maxwell, Norman J., et al. "Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study." American Journal of Roentgenology 189.4 (2007): W215-W220.
  58. ↑ Yelland, Michael J., et al. "Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial." British journal of sports medicine 45.5 (2011): 421-428
  59. ↑ McShane, John M., Levon N. Nazarian, and Marc I. Harwood. "Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow." Journal of ultrasound in medicine 25.10 (2006): 1281-1289.
  60. ↑ Kanaan Y, Jacobson JA, Jamadar D, Housner J, Caoili EM. Sonographically guided patellar tendon fenestration: prognostic value of preprocedure sonographic findings. J Ultrasound Med 2013; 32 (5) 771-777
  61. ↑ Chaudhry, F. A. "Effectiveness of dry needling and high-volume image-guided injection in the management of chronic mid-portion Achilles tendinopathy in adult population: a literature review." European Journal of Orthopaedic Surgery & Traumatology 27.4 (2017): 441-448.
  62. ↑ Zeisig E, Ohberg L, Alfredson H. Sclerosing polidocanol injections in chronic painful tennis elbow-promising results in a pilot study. Knee Surg Sports Traumatol Arthrosc. 2006;14:1218–1224
  63. ↑ Hoksrud A, Ohberg L, Alfredson H, Bahr R. Ultrasound-guided sclerosis of neovessels in painful chronic patellar tendinopathy: a randomized controlled trial. Am J Sports Med. 2006;34:1738–1746.
  64. ↑ Ohberg L, Alfredson H. Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment. Br J Sports Med. 2002;36:173–175; discussion 176-177.
  65. ↑ Lind B, Ohberg L, Alfredson H. Sclerosing polidocanol injections in mid-portion Achilles tendinosis: remaining good clinical results and decreased tendon thickness at 2-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2006;14:1327–1332.
  66. ↑ Alfredson H, Ohberg L. Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial. Knee Surg Sports Traumatol Arthrosc. 2005;13:338–344.
  67. ↑ Abat F, Sánchez-Sánchez JL, Martín-Nogueras AM, Calvo-Arenillas JI, Yajeya J, Méndez-Sánchez R, Monllau JC, Gelber PE. Randomized controlled trial comparing the effectiveness of the ultrasound-guided galvanic electrolysis technique (USGET) versus conventional electro-physiotherapeutic treatment on patellar tendinopathy. J Exp Orthop. 2016;3(1):34. doi: 10.1186/s40634-016-0070-4.
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  73. ↑ Razavi, Mahnaz, and Gunilla Brodda Jansen. "Effects of acupuncture and placebo TENS in addition to exercise in treatment of rotator cuff tendinitis." Clinical rehabilitation 18.8 (2004): 872-878.
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John Kiel on 14 June 2019 10:09:02
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7 October 2020 11:24:45
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