A decade ago important research
involving a very common injury was published and, to this day, problems persist
with respect to misdiagnosis and treatment regardless of the groundbreaking
importance of the article.
The journal, The Physician and
Sports Medicine, May 2000, published an article titled “Overuse tendonosis, not
tendinitis,” that gave great insight as to the treatment of tendinopathies, a
term that refers to injuries of the tendons.
Tendons are found where muscles
attach to bones, are composed mostly of collagen and lack the contractile
tissue seen in muscle. They, therefore, act like springs or elastics that store
and release energy.
Tendinitis is an inflammation of
the tendon; whereas, tendinosis is an intratendinous degeneration, commonly due
to aging, micro/macrotrauma, or vascular compromise.
A tendon with tendinosis shows a
loss of collagen and minimal or an absence of inflammatory cells. Therefore,
treatment of tendinosis needs to combat collagen breakdown rather than
The typical treatment should
require a period of rest and modalities that optimise collagen production and
maturation such a Low Level Laser. Once this is done, attention to
strengthening with the aim of breaking the tendinosis cycle can then be implemented.
There are at least eight areas that
need to be considered with this diagnosis:
Imaging: Tendinopathies are well
visualized with both MRI and modern diagnostic ultrasound showing lost continuity
of tendon collagen (i.e., tendinosis).
Patient education: Patients who
have a short duration of symptoms but are still able to “warm up” the injury
and engage in sports are the ones who need the most education. They are likely to continue in sports without
undergoing appropriate treatment, and thus worsen the tendinosis.
Biomechanical deloading: Training
errors are a common cause. Assess any equipment being used, examine movement
biomechanics, and diagnose and treat any muscle imbalances.
Because the pathology of tendinopathies show abnormal neovascularisation, patients
will benefit from cryotherapy due to ice having a vasoconstrictive role.
Electrotherapy, such as HVGS or laser,
can also stimulate collagen synthesis. Non-steroid anti-inflammatory drugs and
corticosteroids show little evidence of being helpful. Since tendinopathies are
not an inflammation and corticosteroids injections inhibit collagen repair
around the tendon, this treatment has lost favour.
Load-decreasing devices: Because
tendinosis results from excessive load on collagen, braces and supports that
decrease load through the tendon may benefit the patient.
Interaction with the chiropractor:
It is important that chiropractors and physicians have a parallel approach to
management. Short-duration tendon symptoms take an average of two to three
months of treatment; chronic symptoms may require four to six months to achieve
a similar outcome.
Recent advancements with
combination therapies involving neuro-muscular re-education and Low Level Laser
have decreased the healing times for some individuals to days or weeks rather
Appropriate strengthening: Clinical
effectiveness has been shown with eccentric strengthening programs.
Strengthening stimulates mechanoreceptors in tenocytes to produce collagen and
help reverse the tendinosis cycle.
Surgery as a last resort: Surgery
can be used to excise tissue affected by tendinosis, but will not stimulate
collagen synthesis or maturation and an increased risk of scar tissue may also
be a side effect. However, when conservative
approaches have failed, surgery has shown to be successful.
Tendinopathies have proved
frustrating to both the patient and to the healthcare providers. This may be
due to attributing the pathology to tendinitis rather than tendinosis.
Healthcare providers must
acknowledge that the cause is most often due to tendinosis not tendinitis and
treat the problem using a different paradigm. Advice and suggestions for
patients along these lines of clinical thought can help them recover more
quickly and avoid unnecessary or ineffective treatment.
Bouliane is a chiropractor based in Grand Cayman.