Tendinopathy happens when your tendons start to break down and cause pain. It’s different from common inflammation. This article explains what causes tendinopathy, its symptoms, and the best ways to treat it.
Key Takeaways
- Tendinopathy is characterized by tendon degeneration without significant inflammation, distinct from tendonitis, requiring careful management and treatment.
- The Tendon Pathology Continuum Model outlines three overlapping stages of tendinopathy, aiding clinicians in understanding and tailoring treatment strategies.
- Effective management of tendinopathy involves a combination of eccentric strengthening exercises, physiotherapy, and emerging therapies, with early diagnosis being crucial to prevent complications.
Understanding Tendinopathy
Tendinopathy is a painful overuse or repetitive strain injury that typically affects active individuals. Unlike tendonitis, which implies inflammation, tendinopathy tendons are characterised by degeneration without significant inflammation. This distinction influences treatment and management approaches.
The condition arises from specific biological changes within the tendon. Tendons, which are made up of cells called tenocytes embedded in a mix of collagen, elastin, proteins, and water, respond to load and attempt to adapt to a given stimulus. However, when subjected to excessive or repetitive stress, known as tendon overuse, the protein production within the tendon matrix is altered, leading to tendon degeneration and a decrease in the tendon’s ability to handle loading.
Achilles tendinopathy is a specific type associated with the Achilles tendon, often seen in runners and athletes. However, tendinopathy can affect various tendons in the body, including the patellar tendon, rotator cuff tendinopathy, and those involved in lateral elbow tendinopathy (tennis elbow). The symptoms of tendinopathy can significantly impact athletic performance and daily activities, making it a challenging condition to manage.
Research indicates that little or no inflammation is present in tendinopathy, highlighting its complex pathophysiology. The continuum model of tendon pathology serves to integrate clinical and research findings, informing treatment decisions for different manifestations of tendinopathy. However, the relationship among tendon structure, pain levels, and functional outcomes remains unclear and extremely unique to each individual, adding another layer of complexity to understanding and treating this condition.
Tendon Pathology Continuum Model
Image courtest of BJSM: https://bjsm.bmj.com/content/43/6/409
The Tendon Pathology Continuum Model (Cook & Purdam, 2009) provides a framework for understanding the progression of tendinopathy. It describes three overlapping stages: Reactive tendon pathology, Tendon dysrepair, and Degenerative tendon pathology. These stages are not linear and can coexist within different areas of the same tendon.
Reactive tendon pathology is the first response of the tendon to increased acute loading. This stage is non-inflammatory and involves an increase in the proteoglycan content of the extracellular matrix, leading to tendon thickening. This thickening reduces the force per unit area of the tendon and is a reversible process if managed appropriately.
The Tendon dysrepair stage involves ongoing cell activation as the tendon attempts to balance the extracellular matrix, causing greater disruption and possible ingrowth of blood vessels and nerve endings.
In the Degenerative tendon pathology stage, the cellular makeup of the tendon maintains the changes from the previous stages, but the ability to reverse these changes decreases due to significant collagen disorganisation. Different parts of the same tendon can exist in different stages of the continuum simultaneously, which means that healthy areas can coexist next to degenerative portions.
This model helps clinicians understand the complexity of tendinopathy and tailor treatments accordingly (Ganderton et. al, 2015).
Symptoms of Tendinopathy
The symptoms of tendinopathy can vary widely among individuals, but pain is a common denominator. This pain can change over time and can be influenced by activity levels. Early on, tendons may only present as sore after activity, but as the condition progresses, pain can occur at the beginning of activity, potentially warming up and disappearing, only to return after exercise. In advanced stages, pain can persist throughout general day-to-day and worsen with activity, sometimes necessitating the cessation of certain activities and limiting general function.
Weakness in the affected limb is another common symptom, making it difficult to perform everyday tasks. This weakness is initially due to the brain’s control over muscle force production rather than true muscle weakness. However, prolonged pain and reduced activity can lead to muscle atrophy, further decreasing muscle strength. Thickening or a lump in the tendon can also be present and tender to touch.
These symptoms can significantly impact athletic performance and daily life, making early diagnosis and treatment crucial. Recognising the variability in symptoms is vital for effective management and recovery.
Causes and Risk Factors
Tendinopathy often arises from repetitive motions that stress the tendons over time, especially those involving elastic energy storage and release. Repetitive, improper or altered technique during physical activities can overload tendons, increasing the risk of tendinopathy. Certain occupations that involve repetitive tasks or awkward positions can also heighten the likelihood of developing this condition.
Lack of adequate recovery time after physical activity is another significant risk factor. Age-related changes make tendons less flexible and more susceptible to injuries. Medical conditions such as diabetes can elevate the risk of developing tendinopathy. Additionally, medications like fluoroquinolone antibiotics and corticosteroids may increase susceptibility to tendon injuries.
Being aware of these causes and risk factors is vital for preventing tendinopathy and managing existing conditions. Addressing these factors can help individuals reduce their risk of developing tendinopathy.
Diagnosing Tendinopathy
Diagnose tendinopathy involves differentiating it from other musculoskeletal disorders, which requires a thorough clinical evaluation and, at times, imaging. The diagnostic process begins with a detailed history and clinical examination to identify the characteristic symptoms of tendinopathy. Tendinopathy diagnosis can be aided by imaging techniques such as MRI and ultrasound to evaluate tendon abnormalities and reveal changes due to injury or disease.
Ultrasound imaging provides the advantage of dynamic visualisation, allowing assessment of tendons during movement. High-frequency transducers are used to achieve clear visualisation of the tendon’s internal structure. Tendons affected by tendinopathy typically show a loss of their normal fibrillar structure on ultrasound imaging, often described as hypoechoic or heterogeneous in scan reports. Increased vascularity within the tendon, detectable using Power Doppler ultrasound, indicates neovascularisation associated with tendinopathy.
On MRI, the first sign of tendon abnormality is usually an increase in signal intensity, indicating potential degeneration or injury. These imaging techniques, combined with clinical evaluation, provide a comprehensive approach to diagnosing tendinopathy.
Evidence-Based Treatments for Tendinopathy
Treating tendinopathy can be a long process, aiming to balance the processes within the tendon and promote an increase in the affected tendon’s ability to deal with activity and load. Traditional treatments include electrotherapy, eccentric strengthening exercises, and, in some cases, corticosteroid injections. Emerging treatments aim to address the limitations of these traditional interventions, which can yield suboptimal long-term outcomes.
It’s important to understand that injections or surgery are less common treatments for tendinopathy and are typically considered only when conservative treatments fail. Let’s explore some of the evidence-based treatments in detail.
Eccentric Strengthening
Eccentric strengthening exercises have shown significant benefits in treating tendinopathy. In patients with chronic Achilles tendinopathy, 82% experienced improvement in pain levels after undergoing eccentric strengthening. These exercises involve lengthening the muscle-tendon unit under load, promoting tendon healing and reducing pain.
A study on lateral epicondylalgia reported considerable improvement in pain, strength, and function from eccentric strengthening. Limited evidence supports that eccentric exercises may be more effective than concentric exercises and other treatment modalities.
Incorporating these exercises into a rehabilitation program can help manage and alleviate the symptoms of tendinopathy.
Treatment Modalities that aren’t that useful for tendinopathy
Therapists may use various modalities such as:
- ultrasound
- iontophoresis
- deep transverse friction massage
- low-level laser therapy
- hyperthermia
However, these have limited support for positive long-term change in the research.
Current data provides mixed evidence supporting the use of these modalities in treating tendinopathy. Modalities like therapeutic ultrasound and low-level laser therapy currently lack sufficient evidence to prove their effectiveness for tendinopathy treatment.
Despite this, evidence-based physiotherapists play a crucial role in managing tendinopathy through personalised treatment plans, load management, activity modification and exercise that promote positive change in the tendon.
Corticosteroid Injections
Corticosteroid injections are commonly used in the management of tendinopathy, providing more short-term pain relief than NSAIDs but lacking long-term benefits. These injections deliver medications locally to reduce pain and inflammation, but they should not be considered until a comprehensive, prolonged bout of conservative treatment has been attempted.
Despite offering short-term relief, there may be potential long-term drawbacks to corticosteroid injections, including the risk of tendon damage and long-term degradation of tendon quality, leading to increased complications for treatment later in life. It’s essential to weigh the benefits and risks before opting for corticosteroid injections in treating tendinopathy.
Emerging Therapies in Tendinopathy Treatment
Emerging therapies in tendinopathy treatment hold promise for improving patient outcomes and may change clinical practices in the management of these injuries. These new methods aim to address the limitations of traditional treatments and offer innovative approaches to tendon repair and healing.
Sclerotherapy, ultrasound-guided prolotherapy, and percutaneous ultrasonic tenotomy are among the new treatment methods being explored for chronic tendinopathy. Let’s delve into some of these emerging therapies in more detail.
Platelet-Rich Plasma (PRP)
Platelet-rich plasma (PRP) injections are a method of introducing growth factors to treat tendinopathy. The injection of platelet-rich plasma or autologous blood is a common practice to enhance tendon repair. Despite its popularity, there have been no controlled studies published on the effectiveness of PRP injections in the treatment of tendinopathy.
PRP injections aim to promote healing by increasing blood flow and delivering growth factors directly to the affected tendon. While the theoretical benefits are promising, more research is needed to establish their efficacy in tendinopathy treatment.
Stem Cell Therapy
Stem cell therapy is an emerging treatment being researched for tendon injuries. Stem cells can enhance tendon repair by improving collagen organisation and elasticity when derived from bone marrow. Adding bone marrow-derived stem cells to tendon repair results in increased modulus and improved collagen organisation.
Research is ongoing to determine the effective applications of stem cell therapy for tendon injuries. The potential of stem cells to promote tendon healing and regeneration offers hope for more effective treatments in the future.
However, more randomised clinical trials are needed to validate these findings and establish standardised protocols for stem cell therapy in tendinopathy.
Extracorporeal Shock Wave Therapy (ESWT)
Extracorporeal Shock Wave Therapy (ESWT) has been investigated for its effectiveness in treating tendinopathy. Conditions advocated for treatment with ESWT include:
- plantar fasciitis
- lateral epicondylalgia
- calcific and non-calcific tendonitis
- Achilles tendon tendinopathy
Surgical Options
Surgical intervention may be recommended for Achilles tendinopathy when conservative treatments fail to alleviate pain. Neglecting tendinopathy can lead to an increased risk of tendon tears and ruptures, potentially resulting in the need for surgical intervention. The most common surgical procedure for tendinopathy is open surgical débridement of the tendon or peritendinous tissue.
For non-insertional Achilles tendinopathy, the typical approach is to excise the damaged tendon segment. The success rate for Achilles tendinopathy surgeries is reported to be between 80% and 90%. However, recurring symptoms after surgery are more common among athletes due to their physical demands on the achilles tendon injuries, which can sometimes lead to an achilles tendon rupture.
Post-surgery recovery may involve several months of rehabilitation and the use of a protective boot.
Preventing Tendinopathy
Preventing tendinopathy involves a combination of strategies aimed at reducing excessive activity overload and allowing sufficient time for healing after intense physical activities. Here are some key strategies to consider:
- Proper technique during physical activities.
- Avoiding repetitive impact movements.
- Regular, heavy strengthening exercises.
These measures can significantly reduce the risk of tendon injuries and are crucial for maintaining tendon health.
Listening to your body’s signals and taking rest after large amoutns of stressful activity is crucial for managing tendinopathy.
However, it’s important to note that pain might not always be a reliable short-term indicator of rehabilitation progress.
Maintaining a nutritious diet rich in the following vitamins and minerals supports tendon strength and overall musculoskeletal health:
- Vitamin C
- Vitamin B6
- Vitamin E
Even repeated minor movements, like clicking a mouse, can lead to tendinopathy if not managed properly, emphasizing the need for ergonomic adjustments and regular breaks. By incorporating these preventive measures, individuals can reduce the likelihood of developing tendinopathy and manage existing conditions more effectively.
Complications and Long-Term Outlook
Ignoring tendinopathy can lead to a worsening condition, increased risk of further damage, and delayed recovery. Chronic untreated tendinopathy can progress to tendinosis, characterized by a breakdown of collagen and loss of tendon strength. This can result in muscle atrophy, tendon ruptures, and potentially long-term disability.
Failure to treat tendinopathy may lead to scar tissue development, which reduces flexibility and can cause persistent pain and inflammation. Chronic untreated tendinopathy can severely impact daily activities, limiting mobility and functionality.
The clinical effectiveness of treatments like PRP in managing tendinopathy remains contested, with some studies indicating no significant improvement over placebo. Addressing tendinopathy promptly and effectively is crucial for preventing these complications and ensuring a better long-term outlook.
Summary
Understanding tendinopathy, its causes, symptoms, and treatments can empower individuals to take proactive steps towards recovery and prevention. From the Tendon Pathology Continuum Model to emerging therapies like PRP and stem cell therapy, there are various approaches to managing this condition. Early diagnosis, appropriate treatment, and preventive measures are key to reducing pain and improving function.
By staying informed and working closely with healthcare professionals, individuals can navigate the complexities of tendinopathy and achieve better outcomes. Remember, managing tendinopathy is a journey that requires patience, persistence, and a holistic approach to health and well-being.
Frequently Asked Questions
What is the difference between tendinopathy and tendonitis?
The key difference between tendinopathy and tendonitis is that tendinopathy involves tendon degeneration without significant inflammation, while tendonitis specifically indicates inflammation of the tendon.
What are the common symptoms of tendinopathy?
Common symptoms of tendinopathy include pain, weakness in the affected limb, thickening, or a lump in the tendon. These symptoms may vary in intensity over time.
How is tendinopathy diagnosed?
Tendinopathy is diagnosed primarily through a comprehensive clinical evaluation, sometimes enhanced by imaging techniques such as MRI or ultrasound for confirmation. Accurate diagnosis is essential for effective treatment.
What are the emerging therapies for tendinopathy treatment?
Emerging therapies for tendinopathy treatment include Platelet-Rich Plasma (PRP) injections, stem cell therapy, and Extracorporeal Shock Wave Therapy (ESWT), which provide innovative methods for enhancing tendon repair and healing.
How can tendinopathy be prevented?
Tendinopathy can be effectively prevented by avoiding excessive activity overload, employing proper techniques in physical activities, ensuring regular strengthening exercises, maintaining a nutritious diet, and heeding your body’s signals for rest. Prioritizing these measures can significantly reduce the risk of developing tendinopathy.