Tendonosis: a new understanding

Tendonitis is a common diagnosis for anyone who has suffered a repetitive use injury. Basically, tendonitis refers to a tendon being inflamed. For any type of tissue the suffix ‘itis’ means inflammation.

Tendons are the collagen extensions of muscles which then attach the muscle to bone. A person can get tendonitis in the tendons associated with any joint in the body. Some common areas for tendonitis are the elbows (tennis elbow), the shoulder (rotator cuff) and the ankle (Achilles).

In most cases of tendonitis it will usually heal in four to six weeks, depending on severity. However, if the tendon is repeatedly stressed before it has a chance to heal, an overuse injury will develop. Ongoing tendonitis has generally been referred to as chronic tendonitis. Chronic tendonitis is considered one of the most common of all sport and workplace injuries.

However, in recent years the diagnosis of chronic tendonitis has come under question. Studies are showing that in ‘chronic tendonitis’ there is not an inflammatory process occurring. If there is no inflammation, then there can not be tendonitis.

In recent years, the word ‘tendonosis’ (‘osis’ meaning diseased or abnormal condition) is being used to describe what had been considered chronic tendonitis. It is believed to be a more accurate description of the process affecting the tendon.

Collagen fibers are what make up the ‘rope’ of the tendon structure. The problem in tendonosis is the ongoing breakdown of the tendon through disruption of collagen.

Inflammation is the first stage in healing, and is a very necessary step. When a tissue is damaged, the cellular disruption releases chemicals that make the nearby blood vessels leaky. This allows the healing elements in the blood to escape from the blood vessels and get into the tissues where it is needed. This process of tissues being flooded with blood is called inflammation.

Tendons are notorious poor healers because they have a poor blood supply. To heal the tendon blood has to get in to rebuild the injured tissue. This healing process can take several weeks. However, after a period of time (the exact length varies), even if the body has not healed the stimulation to heal is drastically diminished or gone.

The result is tendonosis. Healing is no longer occurring. What is occurring is the ongoing breakdown and poor repair of the collagen fibers of the tendon. Instead of the damaged collagen fibers being repaired with collagen, they are repaired with scar tissue.

The result of repairing the tendon with scar tissue is that it loses strength. The tendon becomes fragile and can be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue. The damaged area of the tendon repaired by scar tissue is left weakened and painful.

Tendonosis treatments focus on promoting better healing of collagen and breaking the cycle of failed healing. Treatment targets those actions that stimulate the production of collagen, rather than the production of scar tissue. Treatment is now unlike the treatment of tendonitis where the goal is to control the inflammation.

Treatment of tendonosis takes time and effort on the part of the patient and the health care provider.

Treatment

Treatment should include a combination of the following:

Rest

By the time you feel pain from tendonosis, your injury has been gradually building for many weeks. You will probably need to wait several months before a reasonable amount of repair has occurred, so have patience with this slow healing process.

Exercise

Gentle stretching and strengthening exercises can help heal tendonosis, as long as you are careful to progress gradually. Some studies have shown that eccentric exercise is especially helpful for tendonosis. Eccentric exercise is when a muscle is forced to lengthen while it contracts because it is being used as a brake or to absorb energy while doing ‘negative work.’

Therapy

There are various therapies that can be applied to injury sites to help with healing tendonosis including; chiropractic joint adjustments, heat, ultrasound, electrical muscle stimulation, acupuncture, massage, shockwave therapy, and cold laser treatment. Different people will respond to each modality to varying degrees.

Braces, supports and orthotics

Braces are often used for the wrist, elbow, knee, and ankle. Some people find that braces can add stability and support during activity. Orthotics in your shoes can be helpful if there is a structural imbalance affecting the ankles, knees, hips or low back.

Technique and ergonomic correction

The correct technique when playing sports can be very helpful in improving tendonosis Poor biomechanics can definitely make your injury worse.

Since tendonosis is an injury of chronic degeneration, and not inflammation, traditional anti-inflammatory treatments will not be effective in treatment. This can be a very difficult concept for those used to dealing with chronic tendon injury as an inflammatory process.

NSAID’s (Non Steroidal Anti Inflammatory Drugs) such as aspirin or ibuprofen would not be expected to help tendonosis. By the same token, cortisone would be ineffective as a treatment of tendonosis. Like NSAIDs, cortisone’s main beneficial effect is to reduce inflammation, and tendonosis is not an inflammatory condition.

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