Guide to Tendonitis

Chronic, or long-term, tendon problems are common. Tendon problems are especially common in people who play certain types of sports.  For instance, tendon problems account for almost 30 percent of all running injuries and 40 percent of all tennis injuries.

We commonly use the term tendonitis, which means inflammation of the tendon, to refer to these chronic tendon problems. Health professionals now know, however, that the tendon does not always show signs of inflammation when it is injured. Other changes aside from inflammation in the tendon and surrounding tissue can cause the discomfort associated with chronic tendon pain. The term tendonitis is still the most commonly used term to describe any problem with the tendon, but for accuracy it should be reserved to describe acute problems involving inflammation of the actual tendon tissue.  The term ‘tendonosis’ is a better and forthcoming term used for chronic tendon problems, and generally should replace the term tendonitis in chronic tendon cases.  The suffix “osis” simply means that the tendon is affected with an abnormal process.  With tendonosis the structural make-up of the tendon itself is exhibiting degenerative change rather than simply being inflamed. For the purpose of this article however, the term tendonitis will continue to be used as we discuss both acute and chronic tendon problems.

This guide will help you understand:

• how tendonitis develops
• how health care professionals diagnose the condition
• what can be done for tendonitis
• First Choice Physical Therapy’s approach to rehabilitation

Where does tendonitis develop?

Tendons connect muscle to bone. A tendon is made of material called collagen. Collagen is a key building block of the body and is considered a connective tissue which forms tough strands that are like the strands of a nylon rope. Like the strands in a rope, the strands of collagen line up. The more strands, and the better they line up, the stronger they are. The tendon is wrapped in a thin, slippery covering called the tendon sheath. The tendon sheath allows the tendon to slide easily against the tissues around it.

Many parts of the tendon can be injured. Tendon problems can involve the area where the tendon attaches to the bone, the tissue that surrounds the tendon (the tendon sheath), or the main tissues of the tendon. Doctors use different terms to specifically refer to injuries of different parts of the tendon, however, again it should be noted that the term tendonitis is often used in layman’s terms as a general catch-all term that describes any process affecting the tendon whether it be the tendon itself, the sheath, or its attachment to the bone.

Tendon injuries can show up anywhere in your body. However, health care professionals most commonly see tendonitis at certain sites.

Achilles Tendonitis

The tendon sheath, the tissues of the tendon, and the attachment to the bone can all become injured in the Achilles tendon, found in the lower leg. Damaged Achilles tendons carry a higher risk of rupturing because of the weight they bear while standing and walking.

Posterior Tibial Tendonitis

Tendonitis along the inside edge of the ankle and into the instep of the foot is called posterior tibial tendonitis. It is usually caused by age-related degeneration. If this tendon breaks, it can cause the arch of the foot to become flat and painful, and severely limit your ability to stand up onto your toes.

Patellar and Quadriceps Tendonitis

Problems in the tendons of the knee occur mostly in people whose exercise involves running or jumping. Patellar tendonitis is also called jumper’s knee. It occurs in the tendon directly below the knee cap. Quadriceps tendonitis affects the tendon directly above the knee cap.

De Quervain’s Disease and Trigger Finger

Tendon problems are common in the hand and wrist. De Quervain’s disease or tendonitis causes pain in the wrist just above the thumb. Folding your thumb into your hand and tilting your hand down causes excruciating pain with this injury. Trigger finger generally causes pain in the palm just below the knuckles when the inflammation first begins, but eventually the tell-tale sign of this injury is that it catches through movement. The finger snaps as you try to open or close your fist instead of smoothly bending.
Lateral Epicondylitis

Lateral epicondylitis, also called tennis elbow, affects the area where the tendons coming from the muscles of the forearm attach to bone on the outside of the elbow. It causes pain when using the wrist and hand and you do not need to be a tennis player to develop this! Any excessive use of your wrist or hand (especially gripping activities, wrist rotating or bending and straightening activities, as well as excessive vibration through the wrist and forearm) can lead to this injury.

Medial Epicondylitis

Medial epicondylitis, also called Golfer’s elbow, affects the area where the tendons coming from the muscles of the forearm attach to bone on the inside of the elbow. It also causes pain when using the wrist and hand.  Patients other than golfers can develop this condition with excessive wrist bending and straightening, side-to-side wrist motions, or excessive gripping activities

Rotator Cuff Tendonitis

Rotator cuff problems of the shoulder range from mild pain and damage to the tendons, right up to complete tears of the tendons. Rotator cuff problems can cause pain at rest, and even a mild tendonitis can limit shoulder activities especially those that are done at or above shoulder height.

Often, the muscles or other tissues of the shoulder joint become tight, misaligned, or weak around the area of shoulder tendon injury, which can lead to chronic problems and quickly adds to the wear and tear that occurs on the tendon. Some of the pain and swelling associated with a rotator cuff tendonitis may also be in the surrounding tissues of the shoulder.

Why do I have this problem?

Health care professionals don’t always know exactly what causes each tendon problem.  It is believed that repetitive and/or excessive stress on the tendon is the most common cause. The tendons can be injured by the repetitive pounding of running and jumping, or by the stress caused by lifting heavy loads over and over again but can also be injured by simple repetitive movements such typing, painting, or gripping. In general, the heavier the load or the more often the stress is repeated, the more likely you are to develop tendonitis.  Tendonitis usually builds up over weeks or months although it can occur as a result of a single trauma such as a fall or blow directly onto a tendon.  If the tendon is too damaged, or if it doesn’t get time to heal, the problem becomes chronic (long-lasting). In medical terms, it is generally accepted that the term chronic refers to injuries lasting longer than 3 months.

Aging seems to cause tendon damage in some cases. As we age, the tissues of the tendon can break down, or degenerate. Age-related tendon problems however, do not seem to cause inflammation which is seen in classic tendonitis. The tendon material itself is more affected in these conditions and, as described above, in such cases these changes are better termed tendonosis.

Some researchers think that a decreased blood supply to the tendons can cause the tendon damage in tendonosis. The decreased blood supply does not allow the tendon to get enough oxygen. This leads to a condition where the tendon degenerates. The collagen material that makes up the tendon actually becomes weaker and loses its nylon rope appearance. This type of degeneration has specifically been noted in the rotator cuff around the shoulder, in the Achilles tendon in the heel and in the tendons of the elbow.

What does tendonitis feel like?

Tendonitis causes pain. This is the primary symptom of tendonitis (and tendonosis.) The affected tendons are sometimes swollen, but often the swelling is difficult to see from the outside, or there isn’t any swelling at all. In some cases this swelling occurs from actual thickening of the tendon itself. In other cases the swelling comes from thickening or swelling of the tendon sheath or other tissues near the tendon. Tendon problems often cause pain after resting, such as when you first get up in the morning. This pain usually goes away within minutes, or even seconds of moving the affected part, but returns if you repetitively start using the tendon again such as during running, or lifting.

The pain or swelling in your tendon may make your joint hard to move. Some types of tendon problems cause crepitus, a crackling feeling when the joint moves. In rare instances the weakened tendon may actually rupture, or break with a sudden force and this may require surgery to repair.

How do health care professionals identify tendonitis?

Your health care professional will take a detailed medical history, including many questions about your activities, your job, and your symptoms. They will also physically examine the sore area. The probing and movement may cause pain, but it is important for them to know exactly where it hurts.

X-rays do not usually show tendon damage but you may still be asked to get an X-ray or another imaging test to rule out other problems. Sometimes tendon injuries and other joint or muscle problems occur together. In some cases a magnetic resonance imaging (MRI) scan may be recommended to look at the tendons. The MRI scan is a test that uses magnetic waves instead of X-rays. This test shows the tendons and other soft tissues of the body. Unlike an x-ray it can show the damage in the material that makes up the tendon. Ultrasound images are also often used to identify tendon problems, but are not as detailed as MRIs.

In some cases it is difficult to find the exact source of your pain. In these cases, you may be asked to go through more sophisticated imaging tests such as ones which require a dye to be injected prior to the imaging test.  This dye shows up on the imaging test and helps to identify the source of pain . To help with diagnosing the source of your pain your doctor may also try injecting a local anesthetic into the tendon suspected of causing the pain. If your pain goes away, it indicates that the correct tendon causing the pain has been located.

What can be done by your doctor for the problem?

Tendon problems can be difficult to treat effectively. They can last for many months to several years, even with treatment. You should expect your treatment to take from six to nine months. Even if treatment is effective, your pain may come back. The exact treatment recommended would depend on which tendon is affected and how the tendonitis is affecting your daily life.  Starting treatment early on, as soon as your symptoms occur, can be the key to a much quicker and a complete recovery.

In regards to medication your doctor may recommend nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, to help control the inflammation and pain. NSAIDs are usually only used for a short time with tendon problems because, as mentioned previously, eventually the inflammation goes away and is not the source of the problem; the resultant tendon degeneration becomes the issue.

Corticosteroid injections around the tendon are also sometimes used however doctors disagree on whether to use corticosteroid injections for tendon problems. In some cases injections into the tendons can cause more injury such as a tendon tear. It is generally recommended to give no more than three corticosteroid injections, at least three months apart as the corticosteroid, although often helpful for the pain, can weaken the tendon fibers and thus make the tendon more susceptible to a tear. Patients need to avoid heavy activity for a few weeks after the injection.

Physical Therapy at First Choice Physical Therapy will help immensely with any tendon problem you have, whether acute or chronic. Beginning treatment with us as early as you can once you develop the problem is the best way to guarantee that the problem resolves and that it does not become chronic.

On your first visit to First Choice Physical Therapy your Physical Therapist will ask you questions about where precisely the pain is, when the pain began, what you were doing when the pain started, and what movements aggravate or ease the pain.  If you are involved in sport, your training history including any increases in frequency or intensity of activity or change in equipment will also be important for us to inquire about.  If you have not seen your doctor, and your problem has not been identified, then the history alone will often lead your Physical Therapist to your tendon being the source of your pain.

Next your Physical Therapist will do a physical examination of the area around the tendon as well as your entire associated limb and other joints near the area. Your Physical Therapist will assess your postural alignment, flexibility and joint laxity with regards to the closest joint and may want to look at how you stand or sit. If the tendon is in your lower extremity, they will also observe your foot position and watch you walk, and possibly squat, run, or jump. If you are involved in sport, they may also ask you to bring in some of your equipment to the next appointment, such as your running shoes or tennis racket, so it can be examined for potential faults or factors that may be contributing to the development of your pain.

Next your Physical Therapist will check the strength and lengths of the muscles directly attaching to your painful tendon as well as any other related muscles. If any muscles are weak or tight, they can contribute to the stress on the related tendon.  Often joints that may seem unrelated to the problem to you will need to be assessed by your Physical Therapist as weaknesses or imbalances in and around other areas frequently contribute to the pain that arises in a tendon of the associated arm or leg. For instance, the grip strength of your hand may be tested even if it is your elbow that is causing your pain, or the strength around your hip may be assessed if your Achilles tendon is the issue.

Initially the treatment at First Choice Physical Therapy will focus on decreasing any inflammation and pain around your tendon. Your Physical Therapist may use electrical modalities to do this such as ultrasound or interferential current.  Heat and/or ice can also be very useful at any stage of tendon healing to decrease pain and also inflammation if there is any.  Your Physical Therapist can advise you on whether heat or ice or both is the best treatment in your particular case. Your Physical Therapist may also use massage for the muscles around the tendon or even directly over the tendon to ease your discomfort and again assist with decreasing any inflammation if it is present.

A crucial component to the healing of any tendon injury is relative rest.  As most tendon injuries result due to repetitive activities over time that cause too much stress on the tendon and then lead to pain, your Physical Therapist will strongly advise you to avoid any activities that cause you discomfort. This may mean, for instance, if it is a tendon in your elbow that is affected, that you have to use your other arm as often as possible to give the painful tendon a period of relative rest.  This may also mean resting for a short period from any sport you do, or at least decreasing the amount you play over a period of time. Your Physical Therapist will specifically guide you regarding the needed rest for your individual injury. This rest may seem quite difficult to achieve, however it is well known that generally without relative rest for an injured tendon, there is little chance for it to heal and the problem can easily become chronic, or can lead to a more severe injury, such as a tear in the tendon.  A period of rest where the tendon is not being aggravated also greatly improves the ability of any medication you may be taking along with the Physical Therapy treatment you are receiving to assist the healing of the injury.  This rest period allows a short time frame where the tendon is not being aggravated while at the same time, it is also receiving the necessary treatments to expedite healing of the tendon. After your period of rest your Physical Therapist will advise you when it is safe to slowly start back at your activity.

There are many braces on the market that are designed to assist with the rehabilitation of tendonitis injuries. There is basically a brace for all potential areas of tendonitis in the body including areas such as the Achilles, elbow and wrist. Your Physical Therapist can advise you regarding whether a brace would be useful in your case, and can also advise you on where to purchase them. Quite often your Physical Therapist will trial some strapping or taping prior to you investing in a brace for the affected area. Taping the area is obviously cheaper than a brace, and gives you and your Physical Therapist a good idea as to whether a brace would help with your pain. Tape, although often helpful, can not often be used for long periods or repetitive treatments because the skin gets irritated, and in addition it may be difficult for you to tape the area independently when you are not at First Choice Physical Therapy. For this reason, a brace is often recommended.

In certain tendon problems, such as Achilles tendonitis, other types of orthotics may be suggested.  The pain associated with Achilles tendonitis often responds well to a heel insert that lifts the heel of the affected side, and shortens the relative length of the tendon. This in essence decreases the stretch on the tendon and can often be enough to allow some relative rest for the injured area.

In the case of any lower extremity tendon issue, shoe orthotics may also be suggested by your Physical Therapist.  Poor alignment of the lower extremity will put undue stress on the tendons of the lower extremity. Correcting the position of your foot, if it is a contributing factor to this misalignment, will decrease this stress and will also assist the healing process of the tendon.

During the next part of treatment your Physical Therapist will prescribe stretching and strengthening exercises for your affected area. Your Physical Therapist may do some stretching for you in the clinic, but they will also teach you how to stretch the affected area as well as any related muscles as part of your home program. Strengthening the affected tendon and associated muscles will also be a part of your home program. Initially strengthening will be simple exercises and may or may not include using any weights. As soon as appropriate, however, your Physical Therapist will prescribe eccentric exercises which are crucial to making a full recovery from a tendon injury.

Eccentric contractions occur as the muscle lengthens and the tendon is put under stretch.  Landing from a jump is an example of an eccentric contraction for the knee or Achilles tendon. These types of contractions encourage the tendon to adapt to the more aggressive force that will eventually be needed to return to regular physical activity.

Adding weights to these exercises as well as doing the exercises in a speeded fashion will also encourage the tendon to adapt to the more aggressive forces that it will need to endure repetitive activities of daily living or sporting activities.  All exercises should be completed with minimal or no pain and advancing the exercises should be done at the discretion of your Physical Therapist as not to flare up the healing tendon.

Maintaining proper posture and alignment of your body during regular everyday activities can also greatly affect how quickly your tendon heals.  For upper extremity issues, good sitting posture is vital in order to decrease the stress on the arms, neck and back.

Shoulders should remain upright and out of the slouched position as this puts stress on the neck, upper back, and shoulders, and in turn affects how well you can use your arm. If you are frequently using a computer, the position of your hand on the keyboard or mouse over a prolonged period can also add stress to your tendons and accentuate the problem. Your Physical Therapist will advise you regarding your posturing as well as make suggestions for ergonomic tools that may help you decrease the stress on your tissues and encourage more rapid healing. If you are a manual worker the amount of lifting and gripping involved in your day will be assessed. Excessive gripping or lifting especially without having good grip (ie: using too large or poorly gripped gloves) will add to the strain on your injured body part, so changes to these activities in your everyday life will be suggested.

For lower extremity issues, the alignment of your hips over top of your feet can add to or decrease the stress that is put through your injured area. Your Physical Therapist will advise you on proper alignment of your hips, knees, ankles and feet, and will encourage you to maintain and use this posture throughout your day even during simple activities such as walking or climbing stairs. These simple changes can make a massive difference to the cumulative stress that is placed on your painful tendon.

As soon as it is appropriate your Physical Therapist will integrate you back into the activities that you were having difficulty doing, whether that be typing on the computer, or playing high-level sport. A period of controlled and supervised slow reintegration is crucial to avoid further pain or a flare up of the healing area.

Most people with acute or chronic tendon problems, with the help of Physical Therapy at First Choice Physical Therapy, are relieved of their pain and can eventually take part in their normal activities. In a few cases, however, a high level of pain lingers on even after the appropriate rest and a significant amount of therapy.  For these patients, a more aggressive form of treatment will need to be considered. In these cases, your Physical Therapist will refer you back to your doctor. A relatively new form of treatment may be available to you called platelet rich plasma injections (PRP.) Platelet-rich plasma refers to a sample of serum (blood) plasma that comes from the patient themselves, and is treated to extract as much as four times more than the normal amount of platelets. Platelets are the smallest cells in the blood and are essential for blood clotting and injury healing. This serum is then injected back into the problem area to encourage new tissue healing.  PRP treatment enhances the body’s natural ability to heal itself and can shorten recovery time from acute and chronic soft tissue injuries.

If no other conservative treatment is successful, surgery may be necessary to debride the degenerative tendon and encourage new healing. Surgery can be very successful in treating the problem of chronic tendon pain but ongoing rehabilitation after surgery will be necessary to ensure complete success.  If surgery is necessary for your tendon problem, your Physical Therapist at First Choice Physical Therapy can guide you through the appropriate post surgical rehabilitation necessary that is specific to your injury and your individual requirements in order to return you as quickly as possible back to your everyday and sporting activities.