Name = Tendinitis
Caption = |n bnc DiseasesDB = 31624
ICD10 = ICD10|M|77|9|m|70
ICD9 = ICD9|726.90
eMedicineSubj = emerg
eMedicineTopic = 570
MeshID = D052256
Tendinitis or tendonitis (from the Greek Τενοντίτις, 'itis' denoting inflammation or swelling) used to be thought of as a painful
inflammationof a tendon, however, there is rarely much inflammation associated with the condition, thus 'tendinitis' is an inaccurate term, tendinopathy being currently used. More recent research indicates that tendinopathy is an overuse injury resulting in microtears in the muscle fibres, leading to an increase in tendon repair cells, yet an absence of inflammatory cells. This may lead to reduced tensile strength, thus increasing the chance of tendon rupture. Generally tendinitis is referred to by the body part involved, such as Achilles tendinitis(affecting the Achilles tendon), or patellar tendinitis ( jumper's knee, affecting the patellar tendon). Chronic overuse of tendons leads to microscopic tears within the collagenmatrix, which gradually weakens the tissue.
Swelling in a region of micro damage or partial tear can be detected visually or by touch. Increased water content and disorganized collagen matrix in tendon
lesions may be detected by ultrasonography or magnetic resonance imaging.
Symptoms can vary from an ache or pain and
stiffnessto the local area of the tendon, or a burning that surrounds the whole jointaround the inflamed tendon. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiffer the following day as swelling impinges on the movement of the tendon. Many patients report stressful situations in their life in correlation with the beginnings of pain which may contribute to the symptoms.
Due to their highly specialised ultrastructure, low level of vascularization and slow collagen turnover, tendons and
ligamentsare very slow to heal if injured, and rarely regain their original strength. Partial tears heal by the rapid production of disorganized type-III collagen, which is weaker than normal tendon. Recurrence of injury in the damaged region of tendon is common.
Standard treatment of tendon injuries is largely
palliative. Use of non-steroidal anti-inflammatory drugs combined with rest and gradual return to exercise is a common therapy, although there is evidence to suggest that tendinitis is not an inflammatory disorder, and that anti-inflammatory drugs are not an effective treatment [cite journal | last =Khan | first =K.M. | coauthors =Cook, J.L., Kannus, P., Maffulli, N., Bonar, S.F. | title =Time to abandon the "tendinitis" myth: Painful, overuse tendon conditions have a non-inflammatory pathology | journal =British Medical Journal | volume =324 | pages =626–627 | date =2002-03-16 | url =http://bmj.bmjjournals.com/cgi/content/full/324/7338/626 | doi =10.1136 | accessdate = 2007-04-02 | pmid =11895810 | doi_brokendate =2008-06-28 ] and that inflammation does not cause tendon dysfunction. [cite journal|author=Marsolais D, Duchesne E, Côté CH, Frenette J. |title=Inflammatory cells do not decrease the ultimate tensile strength of intact tendons in vivo and in vitro: protective role of mechanical loading |journal=J Appl Physiol |year=2007 |issue=1 |volume=102 |pages=3–4 |pmid =16916923 ]
Both eccentric loading and
extracorporeal shockwave therapyare currently being researched as possible treatments for tendinitis. One study found both modalities to be equally effective in treating tendinosisof the Achilles tendon and more effective than a 'wait and see' approach. [cite journal|author=Rompe JD, Nafe B, Furia JP, Maffulli N |title=Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial |journal=Am J Sports Med |year=2007 |issue=35 |volume=3 |pages=374–83 |pmid =17244902 | url = http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17244902 | accessdate = 2007-06-06 ] Other treatments for which research is on-going includes vitamin E, nitric oxideand stem cellinjections.
Perhaps the most promising avenue of therapy is indicated in a line of research finding dramatic rates of recovery including complete remodeling of chronically damaged tendon tissue with eccentric loading. [cite journal | last =Alfredson Tom , MD | first =Håkan | coauthors =Pietilä, T., Jonsson, P. & Lorentzon, R. | title =Heavy-Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis | journal =The American Journal of Sports Medicine | volume =26 | pages =360–366 | publisher =American Orthopaedic Society for Sports Medicine | date =1998 | url =http://ajs.sagepub.com/cgi/content/abstract/26/3/360 | accessdate = 2007-04-02 | pmid =9617396 ] [cite journal | last =Mafi | first =N. | coauthors =Lorentzon R. & Alfredson H. | title =Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis | journal =Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA | volume =9 | issue =1 | pages =42–47 | publisher =Springer International | date =2001 | url =http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=11269583 | id =11269583 | accessdate = 2007-04-02 | doi =10.1007/s001670000148 ] [cite journal | last =Fahlstrom . | first =M. | coauthors =Jonsson P., Lorentzon R. & Alfredson H. | title =Chronic Achilles tendon pain treated with eccentric calf-muscle training | journal =Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA | volume =11 | issue =5 | pages =327–333 | publisher =Springer International | date = 2003 | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=12942235 | id = 12942235 | accessdate = 2007-04-02 | doi =10.1007/s00167-003-0418-z ] [cite journal | last =Roos | first =E.M. | coauthors =Engstrom M., Lagerquist A. & Soderberg B. | title =Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy -- a randomized trial with 1-year follow-up | journal = Scandinavian Journal of Medicine & Science in Sports | volume = 14 | issue = 5 | pages = 286–295 | publisher = Munksgaard International Publishers | date = 2004 | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=15387802 | id = 15387802 | accessdate = 2007-04-02 | doi =10.1111/j.1600-0838.2004.378.x ] [cite journal | last =Öhberg | first =L. | coauthors =Lorentzon R. & Alfredson H. | title =Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up | journal =British Journal of Sports Medicine | volume =38 | pages =8–11 | publisher = BMJ Publishing Group Ltd. | date =2004 | doi = 10.1136/bjsm.2001.000284 | accessdate = 2007-04-02 | pmid =14751936 ] [>cite journal | last =Jonsson | first =P. | coauthors = Alfredson H. | title =Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study | journal =British journal of sports medicine | volume =39 | issue =11 | pages =847–850 | publisher =BMJ Publishing Group | date =2005 | url =http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16244196 | id =16244196 | accessdate = 2007-04-02 | doi =10.1136/bjsm.2005.018630 | pmid =16244196] [cite journal | last =Wilson | first =J.J. | coauthors =Best, T.M. | title =Common overuse tendon problems: A review and recommendations for treatment | journal =American Family Physician | volume =72 | issue =5 | pages =811–818 | publisher =American Academy of Family Physicians. | date =2005 | url =http://www.aafp.org/afp/20050901/811.pdf |format=PDF | accessdate = 2007-04-02 ] [cite journal | last =Rees | first =J.D. | coauthors =Wilson A.M. & Wolman R.L. | title =Current concepts in the management of tendon disorders | journal =Rheumatology | volume =45 | issue =5 | pages =508–521 | publisher =Oxford University Press | date =2006 | url =http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16490749 | id =16490749 | accessdate = 2007-04-02 | doi =10.1093/rheumatology/kel046 | pmid =16490749 cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17062655 | accessdate = 2007-06-06 |doi=10.1136/bjsm.2006.029769 ]
The use of an inflatable brace (AirHeel) was shown to be as effective as eccentric loading in the treatment of chronic Achilles tendinopathy. Both modalities produced significant reduction in pain scores, but their combination was no more effective than either treatment alone. [cite journal|author=Petersen W, Welp R, Rosenbaum D |title=Chronic Achilles Tendinopathy: A Prospective Randomized Study Comparing the Therapeutic Effect of Eccentric Training, the AirHeel Brace, and a Combination of Both |journal=Am J Sports Med |year=June 14, 2007 |pmid =17569792 ]
Shock-wave therapy (SWT) may be effective in treating
calcific tendinitisin both humans [cite journal|author=Cacchio A, Paoloni M, Barile A, Don R, de Paulis F, Calvisi V, Ranavolo A, Frascarelli M, Santilli V, Spacca G |title=Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study |journal= Phys Ther |year=2006 |issue=86 |volume=5 |pages=672–82 |pmid =16649891 | url = http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16649891 | accessdate = 2007-06-06 ] and rats.cite journal|author=Chen YJ, Wang CJ, Yang KD, Kuo YR, Huang HC, Huang YT, Sun YC, Wang FS |title=Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinitis and increase TGF-beta1 and IGF-I expression |journal=J Orthop Res |year=2004 |issue=4 |volume=22 |pages=854–61 |pmid =15183445 | url = http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15183445 | accessdate = 2007-06-06 |doi=10.1016/j.orthres.2003.10.013] In rat subjects, SWT increased levels of healing hormones and proteins leading to increased cell proliferation and tissue regeneration in tendons. Another study found no evidence that SWT was useful in treating chronic painin the Achilles tendon. [cite journal|author=Costa ML, Shepstone L, Donell ST, Thomas TL |title=Shock wave therapy for chronic Achilles tendon pain: a randomized placebo-controlled trial |journal= Clin Orthop Relat Res |year=2005 |issue=440 |pages=199–204 |pmid =16239807 | url = http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16239807 | accessdate = 2007-06-06|doi=10.1097/01.blo.0000180451.03425.48|volume=440 ]
Vitamin E has been found to increase the activity of
fibroblasts, leading to increased collagen fibrils and synthesis, which seems to speed up the regeneration and increase the regenerative capacity of tendons. [cite journal | last =Gonzalez | first =Santander R | coauthors =Plasencia Arriba MA, Martinez Cuadrado G, Gonzalez-Santander Martinez M & Monteagudo de la Rosa M. | title =Effects of "in situ" vitamin E on fibroblast differentiation and on collagen fibril development in the regenerating tendon | journal =The International Journal of Developmental Biology | volume =1 | issue =Supplemental | pages =181–182 | publisher =University Of The Basque Country Press | date =1996 | pmid =9087752 | accessdate = 2007-04-02 ] [cite journal | last =Plasencia. | first =M.A. | coauthors = Ortiz C., Vazquez B., San Roman J., Lopez-Bravo A., Lopez-Alonso A. | title =Resorbable polyacrylic hydrogels derived from vitamin E and their application in the healing of tendons | journal =Journal of Materials Science. Materials in Medicine | volume =10 | issue =10/11 | pages =641–648 | publisher =Kluwer Academic Publishers | date =1999 | pmid =15347979 | accessdate = 2007-04-02 | doi =10.1023/A:1008991825657 ]
Nitric oxide(NO) also appears to play a role in tendon healing [cite journal | last =Xia | first =W. | coauthors =Szomor Z., Wang Y. & Murrell G.A. | title =Nitric oxide enhances collagen synthesis in cultured human tendon cells | journal =Journal of Orthopaedic Research : Official Publication of the Orthopaedic Research Society | volume =24 | issue =2 | pages =159–172 | publisher =Wiley | date =2006 | url =http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16435353 | id =16435353 | accessdate = 2007-04-02 | doi =10.1002/jor.20060 ] and inhibition of NO synthesis impairs tendon healing. [cite journal
last =Darmani | first =H. | coauthors = Crossan J.C. & Curtis A. | title =Single dose of inducible nitric oxide synthase inhibitor induces prolonged inflammatory cell accumulation and fibrosis around injured tendon and synovium | journal =Mediators of Inflammation | volume =13 | issue =3 | pages =157–164 | publisher =Hindawi Pub. Corp. | date =2004
url =http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15223606 | id =15223606 | accessdate = | doi =10.1080/09511920410001713556 ] Supplementing with
arginine, the amino acidthat the body uses to form NO, may be useful in tendon healing.cite web | last =Erickson | first =Laurie | title =Future Treatments | date =2002-07-01 | url =http://www.tendinosis.org/future.html | accessdate = 2007-04-02 ] The use of a NO delivery system (glyceryl trinitrate patches) applied over the area of maximal tenderness was tested in three clinical trials for the treatment of tendinopathies and was found to significantly reduce pain and increase range of motion and strength. [cite journal|author=Murrell GA. |title=Using nitric oxide to treat tendinopathy |journal=Br J Sports Med |year=2007 |issue=4 |volume=41 |pages=227–31 |pmid =17289859 |doi=10.1136/bjsm.2006.034447]
Common tendinitis injuries
Tendinous injuries are common in the upper and lower limbs (including the
rotator cuffattachments), and are less common in the hips and torso. Individual variation in frequency and severity of tendinitis will vary depending on the type, frequency and severity of exercise or use; for example, rock climbers tend to develop tendinitis in their fingers, swimmers in their shoulders. Achilles tendinitisis a common injury, particularly in sports that involve lunging and jumping while Patellar tendinitis is a common among basketballand volleyballplayers owing to the amount of jumping and landing. [cite web |last = Mayo Clinic | url = http://www.mayoclinic.com/health/patellar-tendinitis/DS00625 | title = Patellar tendinitis | authorlink = Mayo Clinic | accessdate = 2007-06-04 | year = 2007 ]
A veterinary equivalent to Achilles tendinitis is
bowed tendon, tendinitis of the superficial digital flexor tendon of the horse.
Repetitive strain injury
Tension myositis syndrome
* [http://www.healthtouch.com/bin/EContent_HT/showAllLfts.asp?lftname=ACR035&cid=HT Tendinitis/Bursitis provided by the American College of Rheumatology]
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