Tendinopathy is the term we used to describe a tendon that exhibits signs of structural disorganisation on imaging studies such as ultrasound. The term tendinopathy was coined as a replacement for the more commonly known term tendinitis. Essentially, the term tendinits dropped out of favour once it was discovered that clinical presentations of pain in or near a tendon, do not reveal the presence of inflammatory markers within tendon tissue. In other words tendon injuries are not inflammatory conditions- so the use of the term tendinitis, which infers the presence of inflammation has been considered inappropriate. Confounding the issue is the fact that while a tendon may itself not be inflamed, the lining on the tendon, known as the tenosynovium, can become inflamed.
So we can have a tendon which shows sign of disorganisation under ultrasound, which would justify the use of the term tendinopathy. And we can have an inflamed lining of the tendon, which we would label as a tenosynovitis. Sounds confusing? Yep- It doesn’t need to be, but unfortunately as science drives knowledge forward, it often leaves a trail of outdated and redundant terms in its wake. This is unfortunate and confusing for patients but probably unavoidable.
My hope in writing this piece is that if you have a tendon injury, or if you have pain in or near a tendon, you can better understand the different diagnostic terms that you’re likely to hear if/when you seek out information or treatment. I hope that we can cut through some of the confusion and provide a framework for understanding how to recover from tendon injury, tendon surgery or tendon pain.
Should we call it a tendinopathy or tendinitis?
Technically, it is more correct to use the term tendinopathy for the reasons provided above. But the term tendinitis has been used so widely and for so long that it isn’t likely that it will stop being used. The bottom line is that from your perspective as a patient, it is really only a matter of semantics. I say this because the treatment we carry out for tendon problems is the same, regardless of whether we call it a tendinitis or a tendinopathy. I suggest that we leave the nomenclature to the researchers and focus on those aspects of symptoms that we can affect in the treatment setting.
Ok, then how do we treat tendon problems?
There are basically three phases of treatment to follow. The first is a “desensitizing phase” where the focus is on activity modification. Essentially, if you’ve got a symptomatic achilles tendon, or tennis elbow, or golfer’s elbow, rotator cuff tendon problems, the main reason there is pain, is that the nerve endings that are plugged into the tendon have become highly sensitized. This means that loading the tendon is more painful than it would normally be.
In order to normalize the sensitivity of the nerve endings within and around the tendon tissue, we need to stop subjecting it to loads that will continue to keep the system sensitized and irritated. Identifying the activities that we need you to back off from can be tricky, and may require a bit of trial and error. We don’t always need to cut activities out altogether, it may be sufficient to simply modify how you perform an activity. Or it may be a matter of modifying how long or how often you carry out the aggravating activity. Manual therapy to the soft tissues and joints near the symptomatic tendon can also help to reduce the sensitivity to loading. So the initial desensitizing phase usually comprises a bout of manual therapy over a couple of weeks in parallel with some modifications to those daily activities that we suspect are maintaining an unnecessarily high state of sensitivity.
What happens after the sensitivity has been normalized?
Usually your symptoms overall will be much less severe. At this stage we begin to expose the tendon to load again with exercise. The idea is to reintroduce load to the tendon gradually, so as not to trigger another increase in sensitivity. The most sensible way to do this is to start with low loads and build up gradually. It’s also important to load your tendon tissues in such a way that they are more likely to respond favourably. Tendons generally respond well to tensile load (like someone pulling on a rope), as opposed to transverse load (like someone stepping on garden hose). Determining which exercises are appropriate for your condition can be tricky. We need to consider the biomechanics of nearby joints and how this plays into the load profile that is placed on a tendon during a given exercise. For some conditions, such as achilles tendon problems, we have some reasonable protocols to follows. For other body regions, getting this part right can take a little experimenting and progress may be slower.
What’s the third phase?
The third phase of tendon rehabilitation is a guided return to pre-injury activities. Essentially, it is the transition from rehab exercises to those occupational or sporting activities that you’ve been avoiding during phases one and two. For some people, returning to these activities is not a problem. For others, there can be flare up of symptoms. If this is the case, we need to respond quickly and discuss longer term options. Is the activity necessary for your sport or occupation? Can we modify how you perform it in the long term? Can we manage how often or for how long you perform it in the long term?
If you’ve been diagnosed with tendinitis, tenosynovitis, tendinopathy, golfer’s elbow, tennis elbow, rotator cuff impingement, runner’s knee or plantar fascitis, your symptoms should respond well to the management approach outlined above. While some of these conditions can require surgical or medical intervention, the need is quite rare. All of these diagnoses are driven, at least in part by sensitized nerve endings in and around the affected tendon tissue. If it doesn’t bring about a resolution of symptoms, tidying up such sensitivity will at least provide a clearer clinical picture to guide a progression to medical or surgical management. For more information give us a call 9665 9667.