para>The term tendinopathy has replaced the term tendinitis as a generic descriptor of clinical conditions associated with pain, swelling, and impaired performance in and around tendons, arising from overuse. Tendinitis and tendinosis are histologic diagnoses (1). Enthesopathy is a change in the normal tissue architecture at the tendon " “bone interface.
Tendinopathies can be pathologically classified as:
Tendinitis: acute inflammation of the tendon
Tendinosis: chronic degeneration of the tendon; also can be related to partial tendon rupture
Tenosynovitis: inflammation of the tendon sheath
Common sites of overuse tendon injuries include:
Knee: patella/jumper 's knee, medial plica, and pes anserine
Shoulder: rotator cuff
Ankle: Achilles and posterior tibialis
Hip: hamstrings and iliotibial tract
Elbow: lateral epicondylitis/tennis elbow, medial epicondylitis/golfer 's elbow, and triceps (2)
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EPIDEMIOLOGY
Incidence
- Predominant age: adolescence and middle age: rotator cuff, Achilles tendon, and patellar injuries
- Predominant sex: male = female
- Overuse injuries are more common in athletes.
- Blood type O is more frequently associated with chronic tendon injuries.
Pediatric Considerations
Tendon is more stable than the epiphyseal plate in children. Consider growth plate avulsion fractures following trauma in children (2). Tendinopathy is uncommon in children with open growth plates.
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Prevalence
Common outpatient musculoskeletal complaint ‚
ETIOLOGY AND PATHOPHYSIOLOGY
- Increased repetitive stress on the tendon increases risk of injury.
- Exact causes are theoretical (3).
- Overuse injuries involve incomplete and disorganized tendon and soft tissue repair mechanisms. This results in a susceptible tendon lacking strength and extracellular tissue organization (1).
- Acute tendon injury has triphasic healing response of inflammation, proliferation, and maturation.
RISK FACTORS
- Extrinsic factors
- Training errors (most common)
- Improper footwear/equipment (next most common)
- Hard or irregular training surfaces
- Environmental conditions
- Intrinsic factors
- Malalignment
- Limb length discrepancy
- Muscular imbalance
- Muscular insufficiency
GENERAL PREVENTION
Preparticipation screening to identify patients at risk for injury, warmup sessions, core and supporting muscle strengthening, safe activity environment, protective equipment using appropriate braces/taping, and health education have all been shown to prevent injury. ‚
COMMONLY ASSOCIATED CONDITIONS
- Bursitis (common)
- Arthritis
- Apophysitis
DIAGNOSIS
HISTORY
- History of repetitive use with onset of pain around muscle origin/insertion
- History of overuse/overtraining
- Pain at the specific point of the affected tendon
- Reproducible pain on muscle group activity
- Decreased active range of motion (ROM) of the muscle group involved
ALERT
Fluoroquinolones increase risk for developing tendinopathy (4).
With excessive posttraumatic tension/pain in a lower extremity, consider acute compartment syndrome.
With excessive swelling in traumatic injury, consider muscular tendon rupture.
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PHYSICAL EXAM
- Palpable pain over muscle tendon unit
- Warmth and redness
- Asymmetry and tendon thickness in chronic tendinopathies
- Assess ROM.
- Full musculoskeletal exam " ”always examine a joint above and a joint below the affected area.
- Neurologic exam as indicated
- Tendon crepitus or thickening
DIFFERENTIAL DIAGNOSIS
- Knee
- Patellofemoral pain syndrome: lateral tracking of patella, causing irritation and abrasion of the cartilage of the patella and pain
- Exertional compartment syndrome: reversible ischemia secondary to a noncompliant osseofascial compartment (1); most common in the lower extremities
- Stress fractures: Partial/complete bone fracture from repeated force; most common areas are the tibia, metatarsals, and fibula (1)[A].
- Shoulder
- Bursitis: often has coexisting tendinopathy
- Adhesive capsulitis
- Arthritis (joint space) is different from tendinopathy (isolated to origin/insertion) (5).
- Cervical radiculopathy
- Ankle
- Rupture: Achilles rupture is uncommon and is not a cause of tendinitis.
- Sprains: In acute sprains, tendinitis can develop if excess stress is placed on uninjured musculature.
- Hip: Stress fracture " ”if there is excessive pain during internal rotation of hip, place the patient on crutches until femoral fracture is ruled out.
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
If inflammatory arthritis is suspected: Erythrocyte sedimentation rate (ESR) (or C-reactive protein; both are not necessary); if elevated, check antinuclear antibodies, rheumatoid factor. ‚
- Imaging if diagnosis is uncertain or concerned for fracture
- US
- Can measure tendon width, water content within the tendon and peritendon, and collagen integrity
- Abnormal tendons have increased diameter, focal hypoechoic areas, localized swelling and thickening, collagen discontinuity, and sheath swelling or calcifications when viewed with US (5).
Follow-Up Tests & Special Considerations
MRI ‚
- Best imaging modality for musculoskeletal/soft tissue; not routinely needed for most tendinopathies
- Reveals tendon thickening
- Areas of mucoid degeneration seen as high intensity on T1- and T2-weighted images.
ALERT
Areas of increased signal on MRI must be correlated with clinical pathology because these could represent asymptomatic areas of degeneration.
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Pediatric Considerations
Osgood-Schlatter tibial apophysitis (common)
Sever disease: calcaneal apophysitis
Pelvic apophysitis
Little League elbow/Little League shoulder
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TREATMENT
GENERAL MEASURES
- Avoid overtraining. Ensure proper athletic technique, and use of proper footwear and equipment.
- During acute phase, rest the involved tendon.
- Treat as outpatient; treatment plans vary based on site of injury.
- Most plans include rest, medications, cryotherapy, and physical therapy
MEDICATION
First Line
NSAIDs provide good analgesic effects. ‚
- Naproxen: 250 to 500 mg BID with food
- Ibuprofen: OTC up to 800 mg TID with food (6)[B]
- Meloxicam: 7.5 to 15 mg/day
Second Line
- Corticosteroids (7)[C]
- Oral corticosteroids (prednisone, others); PO
- Injectable
- Methylprednisolone (Depo-Medrol): 40 mg used with 1% or 2% lidocaine (Xylocaine) 4 to 6 mL
- Contraindication: Tendons should not be injected with local anesthetic and/or cortisone to allow participation in an athletic event.
ALERT
Some of the COX-2 inhibitors are no longer available. Ongoing literature supports the use of celecoxib for tendinopathy in individuals who are at low cardiovascular risk.
Contraindication: Do not use NSAIDs in patients with recent history of GI bleed/ulcer.
Use caution with renal disease.
There is an increased risk of tendon injury, including tendon rupture and tendinitis, with fluoroquinolone use; concomitant steroid use increases risk (8)[C].
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ISSUES FOR REFERRAL
Orthopedics/sports medicine referral for elite athletes, continued pain >4 weeks, radiologic finding of avulsion/stress fractures, or diagnostic uncertainty ‚
ADDITIONAL THERAPIES
- Icing is beneficial (1)[C].
- Topical nitroglycerin has been used with success for lateral epicondylitis, rotator cuff tendinopathy, Achilles tendinopathy, and other chronic conditions. The main side effect of treatment is headache. Dosing is 0.2-mg topical patch; change daily.
- Gradual increase in patch strength and duration can limit side effects. Begin with 1/2 of a 0.1-mg patch applied to affected area 12 hr/day (9,10)[A].
- Physical therapy helps to recover normal strength and functional biomechanics.
- Scales (e.g., Victorian Institute of Sports Assessment) may help quantify patient progress (5).
ALERT
Muscle strengthening and correct biomechanics augment the healing process.
Eccentric loading strengthens the musculotendinous unit and protects it from increased stress to prevent reinjury (1)[C].
Pain should guide patient progress. If pain continues, decrease activity (2)[C].
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SURGERY/OTHER PROCEDURES
- Soft tissue techniques, extracorporeal shockwave (ECSW) therapy, platelet-rich plasma injections, and prolotherapy are available (11).
- Autologous platelet-rich plasma injections may improve patellar tendinopathy symptoms in comparison to ECSW therapy in athletes " ”platelet-rich plasma injections improved symptoms, function, load-induced pain, and level of sport activity at 6 and 12 months in athletes (12).
- For chronic tendinopathy (e.g., chronic patellar tendinitis), consider surgery if conservative treatment fails after 4 to 6 months (3)[C].
- Long-standing tendinopathies are associated with poor surgical outcomes.
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Orthotics: OTC/prescription, as needed
- Acupuncture has been used to treat pain associated with tendinopathies.
- Current research shows no benefit to laser therapy/other radiotherapies (3)[C].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Patient is susceptible to reinjury up to 3 weeks after resolution of symptoms with increased activity.
- .Follow-up at the discretion of the provider and patient after symptoms have resolved.
Patient Monitoring
As needed ‚
PATIENT EDUCATION
- Increase activity in stepwise fashion as long as the patient remains pain-free.
- Strengthening and stretching of muscle groups are involved.
PROGNOSIS
Symptoms usually subside with rest and proper therapy. Most tendinopathies improve without any major complications. ‚
COMPLICATIONS
Exacerbation of pain in affected area; secondary injury ‚
REFERENCES
11 Wilder ‚ RP, Sethi ‚ S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 2004;23(1):55 " “81.22 Maffulli ‚ N, Longo ‚ UG, Denaro ‚ V, et al. Novel approaches for the management of tendinopathy. J Bone Joint Surg Am. 2010;92(15):2604 " “2613.33 Sharma ‚ P, Maffulli ‚ N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am. 2005;87(1):187 " “202.44 Lewis ‚ T, Cook ‚ J. Fluoroquinolones and tendinopathy: a guide for athletes and sports clinicians and a systemic review of the literature. J Athl Train. 2014;49(3):422 " “427.55 New Zealand Guidelines Group. Diagnosis and Management of Soft Tissue Shoulder Injuries and Related Disorders. Wellington, New Zealand: New Zealand Guidelines Group; 2004.66 Cook ‚ JL, Purdam ‚ CR. Rehabilitation of lower limb tendinopathies. Clin Sports Med. 2003;22(4):777 " “789.77 Warden ‚ SJ, Brukner ‚ P. Patellar tendinopathy. Clin Sports Med. 2003;22(4):743 " “759.88 Pantalone ‚ A, Abate ‚ M, D 'Ovidio ‚ C, et al. Diagnostic failure of ciprofloxacin-induced spontaneous bilateral Achilles tendon rupture: case-report and medical-legal considerations. Int J Immunopathol Pharmacol. 2011;24(2):519 " “522.99 Gambito ‚ ED, Gonzalez-Suarez ‚ CB, Oqui ƒ ±ena ‚ TI, et al. Evidence on the effectiveness of topical nitroglycerin in the treatment of tendinopathies: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2010;91(8):1291 " “1305.1010 Cumpston ‚ M, Johnston ‚ RV, Wengier ‚ L, et al. Topical glyceryl trinitrate for rotator cuff disease. Cochrane Database Syst Rev. 2009;(3):CD006355.1111 Crowson ‚ CS, Rahman ‚ MU, Matteson ‚ EL. Which measure of inflammation to use? A comparison of erythrocyte sedimentation rate and C-reactive protein measurements from randomized clinical trials of golimumab in rheumatoid arthritis. J Rheumatol. 2009;36(8):1606 " “1610.1212 Jeong ‚ DU, Lee ‚ CR, Lee ‚ JH, et al. Clinical applications of platelet-rich plasma in patellar tendinopathy. Biomed Res Int. 2014;2014:249498.
ADDITIONAL READING
- Jiang ‚ D, Wang ‚ JH. Tendinopathy and its treatment with platelet-rich plasma (PRP). Histol Histopathol. 2013;28(12):1537 " “1546.
- Skjong ‚ CC, Meininger ‚ AK, Ho ‚ SS. Tendinopathy treatment: where is the evidence? Clin Sports Med. 2012;31(2):329 " “350.
- Tumilty ‚ S, McDonough ‚ S, Hurley ‚ DA, et al. Clinical effectiveness of low-level laser therapy as an adjunct to eccentric exercise for the treatment of Achilles ' tendinopathy: a randomized controlled trial. Arch Phys Med Rehabil. 2012;93(5):733 " “739.
CODES
ICD10
- M77.9 Enthesopathy, unspecified
- M65.9 Synovitis and tenosynovitis, unspecified
- M76.50 Patellar tendinitis, unspecified knee
- M76.60 Achilles tendinitis, unspecified leg
- M77.00 Medial epicondylitis, unspecified elbow
- M77.10 Lateral epicondylitis, unspecified elbow
ICD9
- 726.90 Enthesopathy of unspecified site
- 727.00 Synovitis and tenosynovitis, unspecified
- 726.64 Patellar tendinitis
- 726.71 Achilles bursitis or tendinitis
- 727.09 Other synovitis and tenosynovitis
- 726.32 Lateral epicondylitis
- 726.31 Medial epicondylitis
SNOMED
- Tendinitis (disorder)
- Tenosynovitis (disorder)
- Patellar tendonitis (disorder)
- Achilles tendinitis (disorder)
- shoulder tendinitis (disorder)
- Tendinitis of hip
- Lateral epicondylitis (disorder)
- Medial epicondylitis
CLINICAL PEARLS
- Tendinopathy is commonly associated with overuse.
- Signs and symptoms include pain, swelling, and site tenderness.
- Treatment includes rest of affected muscle " “tendon unit, ice, and NSAIDs for acute tendonitis.
- Ice, stretching, and eccentric exercises are recommended for treatment of chronic tendinopathies.
- Consider growth plate avulsion fractures following trauma in children.