Tendinitis (Tendinopathy): A dreaded word. A persistent aching nuisance that seems to interrupt everything. It affects shoulders, knees, hips, elbows, and wrists – no joint seems safe.
Most have heard of (or experienced it), but what is tendinitis?
To get a better idea of this disorder, we have to know the anatomy of a tendon. These fibrous tissues connect muscle to bone & move the body by transmitting force1. They also protect muscles from over-contracting and damaging themselves. Tendons are watery (60-70%) with the dry part being primarily collagen; a structural component of connective tissues.1 They are surrounded in a protective sheath to reduce friction so they can glide smoothly.2 When muscle contracts, it pulls on tendon. Controversy still exists at the molecular level as to what occurs when force is transmitted, but we know they adapt and respond to load.2
What goes wrong? Tendinitis, or the more modern & inclusive term “tendinopathy” is a degenerative tissue condition.1 There may be one or more contributing causes to this degeneration. These include overuse, compressive forces (such as from ligament or bone), strained muscle, or friction forces on the tendon.2 In our athletic population, it is often a result of too much, too soon, too fast, or too new. This repetitive overload causes micro-trauma with failure to repair.2 These excess stresses result in disorganization of the collagen with an increase in many inflammatory markers. The tendon thickens but becomes weaker.2 Additionally, patients with tendinopathy often have spasms or “trigger points” in the muscle close to the tendon. These can cause constant tension on the tendon and aggravate the area.6
Unsure if you’ve experienced tendinopathy before? They present with some classic signs and symptoms. Pain is often worse in the morning, or at night.3 They often don’t hurt all that much while exercising, but after cooling down (or a few hours later) they’ll flare up.6 You may develop some crunching/crackling sounds around the area and notice some visible thickening of the tendon if comparing it to the other side.2
Well, that was a lot of information. How do you make it better? Tendons respond to one thing: strain (how much it is deformed). To adapt, and to heal… tendons need exercise! Small forces are not enough to induce changes to the structural nature of the collagen, tendons respond to heavy, sustained, tension.2,11 This means slow, large load, low repetition exercise. In turn, there may be discomfort/pain during exercise— and this is okay! — Pain below a 4/10 on a pain scale is acceptable with tendon rehab.2 Just like any other tissue, the healing happens when we rest! Based on tissue healing timelines, a rule of thumb for exercising tendons is 36 hours between training sessions. If we train a tendon too frequently, we might just exacerbate the problem. Over time, the tissue will adapt to the stimulus, resulting in a stronger, more robust tendon.
You’ve probably heard of all kinds of treatment for tendinopathy. According to the research, what actually works?
1. Treatments supported by evidence:
a. Exercise: HEAVY, slow exercise.1-11
b. Exercise again: it’s just that important.
c. Shockwave therapy: improves pain/function.1
2. Treatments with conflicting evidence:
a. Surgery: did not perform better than fake surgery.2
b. Low level laser: performs similarly if the machine is turned off (placebo).2
c. Platelet-rich-plasma-therapy: evidence conflicting.7
d. Prolotherapy: lacking evidence for efficacy.7
e. Bracing: ineffective but not harmful.2
f. Deep transverse frictions: not effective.5
3. Treatments actively advised against:
a. Corticosteroids: short-term benefit, damaging long term2
b. Therapeutic ultrasound: no effect2
c. Hot packs/ice: no effect2
d. K-tape: no effect9
What is the general prognosis with tendinopathy?Like many areas of physiotherapy, it depends. Speaking broadly, however, initial recovery with a diligent exercise-based rehab can be expected by 2-3 months. Full recovery can often be expected within 3-6 months. Approximately 80% of individuals will recover within 12 months. Persistent tendinopathy problems will require a much more multi-modal, multidisciplinary approach.1,2
1. Ammendolia, Antonio & Marotta, Nicola & Demeco, Andrea & Marinaro, Cinzia & Moggio, Lucrezia & Barletta, M. & Costantino, Cosimo. (2020). Effectiveness of Radial Shockwave Therapy in Calcific and Non-Calcific Tendinopathy of the Shoulder: a Systematic Review and Meta-Analysis. Muscles. 10. 40. 10.32098/mltj.01.2020.05.
2. Irby et al., (2020). Clinical management of tendinopathy: A systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments. Scandinavian Journal of Medicine & Science in Sports [0905-7188]
3. Leong, Hio Teng et al., (2019). Risk Factors for Rotator Cuff Tendinopathy: A Systematic Review and Meta-analysis. Journal of Rehabilitation Medicine, Volume 51, Number 9, October 2019, pp. 627-637(11)
4. Lin, M.-T.; Wei, K.-C.; Wu, C.-H. Effectiveness of Platelet-Rich Plasma Injection in Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Diagnostics 2020, 10, 189.
5. Loew et al., “Deep transverse friction massage for treating lateral elbow or lateral knee tendinitis”. Cochrane Database of Systematic Re
6. Lowe, Whitney. 2019. “Current Views on Lateral Epicondylitis.” Massage & Bodywork 34 (5): 94–97.
7. Musnick , Musnick. (2018). Tendinopathy– Addressing the chronic pain and pathophysiology. Metabolic Therapies in Orthopedics, Second Edition [1-138-03921-7; 1-351-70865-1] views (11):CD003528. doi:10.1002/14651858.cd003528.pub2. ISSN 14651858. PMC 7154576. PMID 25380079.
8. Ortega-Castillo, M., Martin-Soto, L., & Medina-Porqueres, I. (2020). Benefits of Kinesiology Tape on Tendinopathies: A Systematic Review. Montenegrin Journal of Sports Science and Medicine, 9(2), 73-86. doi: 10.26773/mjssm.200910
9. Sprague AL, Smith AH, Knox P, et al (2018). Modifiable risk factors for patellar tendinopathy in athletes: a systematic review and meta-analysis. British Journal of Sports Medicine; 52:1575-1585.
10. Van der Vlist AC, Breda SJ, Oei EHG, et al. (2019). Clinical risk factors for Achilles tendinopathy: a systematic review. British Journal of Sports Medicine 2019;53:1352-1361.
11. Wilson, JJ; Best TM (Sep 2005). “Common overuse tendon problems: A review and recommendations for treatment”. American Family Physician. 72 (5): 811–8. PMID 16156339.