It is Tendinopathy, not Tendinitis

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Tendinopathy can be common in athletes. (iStockphoto.com)

Tendinitis is a term that has been used in sports medicine for many years to describe injuries to the tendon. The patella tendon is at risk for injury in sports like soccer, volleyball and basketball. The Achilles tendon is often injured in sports like running, gymnastics and dancing. Loading the tendon causes small injuries during these activities. The body usually heals the tendon and makes it stronger, but sometimes it does not heal well. This abnormal healing pattern causes further damage to the tendon, weakens it, and makes it susceptible to even more damage down the road.

We used to refer to these types of injuries as tendinitis. But as we learn more and more about tendons, we have learned that injured tendons are not inflamed and are not truly tendinitis. Instead, the tendons become degenerative with damage from abnormal healing, which is actually tendinopathy.

The normal tendon healing process involves three different phases. The initial inflammatory phase is only 48 hours in length. This quickly fades and is replaced by the proliferative phase. During this phase, the body produces a form of collagen called type III (which is not the normal tendon collagen), to protect the tendon and develop a scar patch. New blood vessels (neo-vessels) and nerve endings are brought in to help supply the repair. The type III collagen and the new blood vessels and nerves are removed in the next phase (remodeling) and normal type I collagen helps form normal tendon. This usually takes place at about 6 weeks to 3 months. When this normal process occurs, the tendon gets strong; but when it goes awry, abnormal tendon develops, leading to painful, thickened tendon.

In the past, we treated tendon injuries as an inflammatory process with non-steroidal anti-inflammatories like naproxen or ibuprofenor with injections of corticosteroid (“cortisone”). But we now know that these medications do not help the healing process. They may be used to reduce the discomfort that an athlete has,but they will not allow the tendon to heal properly. 

We now treat tendon injuries by trying to disrupt and alter the abnormal healing pattern. That allows the body to use its natural healing process to start healing again. Treating tendinopathy should start with special exercises that target the cause for the tendinopathy and disrupt the abnormal healing. Studies have shown that two methods of loading the tendon can be very effective to restart the proper healing process, and work better than standard traditional physical therapy.

  • Heavy slow resistance exercises are done 3 times a week with multiple sets each session and increasing weights over time. The heavy weight and slow repetitions load the tendon, signaling it to make new tendon. These exercises are different than the rapid loading, ballistic activities that caused the problem to develop.
  • Eccentric exercises are done multiple times a day and shorter duration of time than heavy slow. These exercises breakup the abnormal healing, pinching the neo-vessels and stimulating the tendons cells to make new tendon.  These exercises work in over 80% of patients and they have been shown to be as good as or better than injections.

If the athlete is not improving with either heavy slow resistance or eccentric exercise programs after six weeks, a procedural intervention is often recommended. These procedures are aimed at breaking up the abnormal healing. These can include injections of platelet rich plasma, high-volume saline, and mechanical destruction of abnormal neo-vessels called scraping procedures. Depending on the tendon, different interventions have shown to be successful.

There are many other procedures like percutaneous tenotomy, dry needling, stem cell therapy and surgery that have varying degrees of success and risk. Some of these procedures are not covered by insurance due to their newness, so they have high out-of-pocket costs and are not for everyone. Famous athletes get them done because they are rich and willing to try anything, no matter the danger. Whatever the procedure, we recommend ultrasound guidance with every tendon procedure so there is direct visualization of the tissue.

Bottom line - it is tendinopathy, not tendinitis. Start with mechanotherapy to restart the healing, but if after 6 weeks there is no improvement, then consider an intervention. BUT, ask a lot of questions about any studies that have shown that the intervention works and what side effects have been found. There are a lot of new treatments out there. Some may be dangerous; others will be the future of medicine.


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