Search My Blog

Tuesday, February 14, 2012

Tendonitis and Tendinosis

Tendonitis and Tendinosis

Tendonitis is an inflammatory condition characterized by pain at tendinous insertions into bone. The term tendinosis refers to the histopathologic finding of tendon degeneration. The term tendinopathy is a generic term used to describe a common clinical condition affecting the tendons, which causes pain, swelling, or impaired performance. Because of the fact that most pain from tendon conditions is not actually inflammatory in nature, tendinopathy may be a better term than tendonitis.

Common sites of tendinopathy include the following:

  • Rotator cuff of the shoulder (ie, supraspinatus) and bicipital tendons
  • Insertion of the wrist extensors (ie, lateral epicondylitis, tennis elbow) and flexors (ie, medial epicondylitis) at the elbow
  • Patellar and popliteal tendons and iliotibial band at the knee
  • Insertion of the posterior tibial tendon in the leg (ie, shin splints)
  • Achilles tendon at the heel


From Wikipedia, the free encyclopedia
Classification and external resources
MeSH D052256

Tendinosis, sometimes called chronic tendinitis, tendinosus, chronic tendinopathy or chronic tendon injury, is damage to a tendon at a cellular level (the suffix "osis" implies a pathology of chronic degeneration without inflammation). It is thought to be caused by microtears in the connective tissue in and around the tendon, leading to an increase in tendon repair cells. This may lead to reduced tensile strength, thus increasing the chance of tendon rupture. Tendinosis is often misdiagnosed as tendinitis due to the limited understanding of tendinopathies by the medical community.[1]



[edit] Diagnosis

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 stiffness to the local area of the tendon, or a burning that surrounds the whole joint around 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.

[edit] Treatment

Tendons are 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 Physical Therapy, rest and gradual return to exercise is a common therapy, although there is evidence to suggest that tendinosis is not an inflammatory disorder, and that anti-inflammatory drugs are not an effective treatment[2] and that inflammation does not cause tendon dysfunction.[3] There are a variety of treatment options, but more research is necessary to determine their effectiveness. Initial recovery is usually within 2 to 3 months and full recovery is within 3 to 6 months. About 80% of patients will fully recover.[4]

[edit] On-going research

Both eccentric loading and extracorporeal shockwave therapy are currently being researched as possible treatments for tendinosis. One study found both modalities to be equally effective in treating tendinosis of the Achilles tendon and more effective than a 'wait and see' approach.[5] Other treatments for which research is on-going includes vitamin E, vitamin B6, nitric oxide and stem cell injections.

[edit] Soft Tissue Mobilization

Augmented Soft Tissue Mobilization (ASTM) is a form of manual therapy that has been shown in studies on rats to speed the healing of tendons by increasing fibroblast activity.[6][7] One case study showed ASTM resulting in full recovery in the case of an athlete suffering from chronic ankle pain and fibrosis, after an unsuccessful course of surgery and conventional physical therapy.[8]

[edit] Vitamin B6

Various studies have supported the efficacy of vitamin B6 in controlling or preventing pathology to the synovial membrane of affected tendons, which commonly occurs in many cases of chronic tendinitis.[9]

[edit] Eccentric loading

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.[10][11][12][13][14][15][4][16]

[edit] Inflatable brace

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.[17]

[edit] Shock-wave therapy

Shock-wave therapy (SWT) may be effective in treating calcific tendinosis in both humans[18] and rats.[19] 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 pain in the Achilles tendon.[20]

[edit] Tendon Bioengineering

The future of non-surgical care for tendinosis is likely bioengineering. Ligament reconstruction is possible using mesenchymal stem cells and a silk scaffold.[21] These same stem cells were capable of seeding repair of damaged animal tendons.[22]

[edit] Vitamin E

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.[23][24]

[edit] Nitric oxide

Nitric oxide (NO) also appears to play a role in tendon healing[25] and inhibition of NO synthesis impairs tendon healing.[26] Supplementing with arginine, the amino acid that the body uses to form NO, may be useful in tendon healing.[27] 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.[28]

[edit] See also

[edit] References

  1. ^ Murrell GA (December 2002). "Understanding tendinopathies". Br J Sports Med 36 (6): 392–3. doi:10.1136/bjsm.36.6.392. PMC 1724561. PMID 12453831.
  2. ^ Khan, K.M.; Cook, J.L., Kannus, P., Maffulli, N., Bonar, S.F. (2002-03-16). "Time to abandon the "tendinitis" myth : Painful, overuse tendon conditions have a non-inflammatory pathology". British Medical Journal 324 (7338): 626–7. doi:10.1136/bmj.324.7338.626. PMC 1122566. PMID 11895810. Retrieved 2007-04-02.
  3. ^ Marsolais D, Duchesne E, Côté CH, Frenette J. (2007). "Inflammatory cells do not decrease the ultimate tensile strength of intact tendons in vivo and in vitro: protective role of mechanical loading". J Appl Physiol 102 (1): 3–4. doi:10.1152/japplphysiol.00162.2006. PMID 16916923.
  4. ^ a b Wilson, J.J.; Best, T.M. (2005). "Common overuse tendon problems: A review and recommendations for treatment" (PDF). American Family Physician (American Academy of Family Physicians.) 72 (5): 811–8. PMID 16156339. Archived from the original on 2007-09-29. Retrieved 2007-04-02.
  5. ^ Rompe JD, Nafe B, Furia JP, Maffulli N (2007). "Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial". Am J Sports Med 3 (35): 374–83. doi:10.1177/0363546506295940. PMID 17244902.
  6. ^ Craig J. Davidson et. al., "Rat tendon morphologic and functional changes resulting from soft tissue mobilization", Medicine & Science in Sports & Exercise, Mar. 1997, Vol. 29, No. 3, pp. 313-319.
  7. ^ Gale M. Gehlsen, "Fibroblast responses to variation in soft tissue mobilization pressure", Medicine & Science in Sports & Exercise, Apr. 1999, Vol. 31, No. 4, pp. 531-535.
  8. ^ Thomas J. Melham et. al., "Chronic ankle pain and fibrosis successfully treated with a new noninvasive augmented soft tissue mobilization technique (ASTM): a case report", Medicine & Science in Sports & Exercise, Jun. 1998, Vol. 30, No. 6, pp. 801-804.
  9. ^ Ellis, John M (1983). Free of Pain.
  10. ^ Alfredson Tom , MD, Håkan; Pietilä, T., Jonsson, P. & Lorentzon, R. (1998). "Heavy-Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis". The American Journal of Sports Medicine (American Orthopaedic Society for Sports Medicine) 26 (3): 360–6. PMID 9617396. Retrieved 2007-04-02.
  11. ^ Mafi, N.; Lorentzon R. & Alfredson H. (2001). "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". Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA (Springer International) 9 (1): 42–7. doi:10.1007/s001670000148. PMID 11269583.
  12. ^ Fahlstrom ., M.; Jonsson P., Lorentzon R. & Alfredson H. (2003). "Chronic Achilles tendon pain treated with eccentric calf-muscle training". Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA (Springer International) 11 (5): 327–33. doi:10.1007/s00167-003-0418-z. PMID 12942235.
  13. ^ Roos, E.M.; Engstrom M., Lagerquist A. & Soderberg B. (2004). "Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy -- a randomized trial with 1-year follow-up". Scandinavian Journal of Medicine & Science in Sports (Munksgaard International Publishers) 14 (5): 286–95. doi:10.1111/j.1600-0838.2004.378.x. PMID 15387802.
  14. ^ Öhberg, L.; Lorentzon R. & Alfredson H. (2004). "Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up". British Journal of Sports Medicine (BMJ Publishing Group Ltd.) 38 (1): 8–11. doi:10.1136/bjsm.2001.000284. PMC 1724744. PMID 14751936.
  15. ^ >Jonsson, P.; Alfredson H. (2005). "Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study". British journal of sports medicine (BMJ Publishing Group) 39 (11): 847–50. doi:10.1136/bjsm.2005.018630. PMC 1725058. PMID 16244196.
  16. ^ Rees, J.D.; Wilson A.M. & Wolman R.L. (2006). "Current concepts in the management of tendon disorders". Rheumatology (Oxford University Press) 45 (5): 508–21. doi:10.1093/rheumatology/kel046. PMID 16490749.
  17. ^ Petersen W, Welp R, Rosenbaum D (June 14, 2007). "Chronic Achilles Tendinopathy: A Prospective Randomized Study Comparing the Therapeutic Effect of Eccentric Training, the AirHeel Brace, and a Combination of Both". Am J Sports Med 35 (10): 1659–67. doi:10.1177/0363546507303558. PMID 17569792.
  18. ^ Cacchio A, Paoloni M, Barile A, Don R, de Paulis F, Calvisi V, Ranavolo A, Frascarelli M, Santilli V, Spacca G (2006). "Effectiveness of radial shock-wave therapy for calcific tendinosis of the shoulder: single-blind, randomized clinical study". Phys Ther 5 (86): 672–82. PMID 16649891.
  19. ^ Chen YJ, Wang CJ, Yang KD, Kuo YR, Huang HC, Huang YT, Sun YC, Wang FS (2004). "Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinosis and increase TGF-beta1 and IGF-I expression". J Orthop Res 22 (4): 854–61. doi:10.1016/j.orthres.2003.10.013. PMID 15183445.
  20. ^ Costa ML, Shepstone L, Donell ST, Thomas TL (2005). "Shock wave therapy for chronic Achilles tendon pain: a randomized placebo-controlled trial". Clin Orthop Relat Res 440: 199–204. doi:10.1097/01.blo.0000180451.03425.48. PMID 16239807.
  21. ^ Fan H, Liu H, Wong EJ, Toh SL, Goh JC (August 2008). "In vivo study of anterior cruciate ligament regeneration using mesenchymal stem cells and silk scaffold". Biomaterials 29 (23): 3324–37. doi:10.1016/j.biomaterials.2008.04.012. PMID 18462787.
  22. ^ Long JH, Qi M, Huang XY, Lei SR, Ren LC (June 2005). "[Repair of rabbit tendon by autologous bone marrow mesenchymal stem cells]" (in Chinese). Zhonghua Shao Shang Za Zhi 21 (3): 210–2. PMID 15996290.
  23. ^ Gonzalez, Santander R; Plasencia Arriba MA, Martinez Cuadrado G, Gonzalez-Santander Martinez M & Monteagudo de la Rosa M. (1996). "Effects of "in situ" vitamin E on fibroblast differentiation and on collagen fibril development in the regenerating tendon". The International Journal of Developmental Biology (University Of The Basque Country Press) 1 (Supplemental): 181–2. PMID 9087752.
  24. ^ Plasencia., M.A.; Ortiz C., Vazquez B., San Roman J., Lopez-Bravo A., Lopez-Alonso A. (1999). "Resorbable polyacrylic hydrogels derived from vitamin E and their application in the healing of tendons". Journal of Materials Science. Materials in Medicine (Kluwer Academic Publishers) 10 (10/11): 641–8. doi:10.1023/A:1008991825657. PMID 15347979.
  25. ^ Xia, W.; Szomor Z., Wang Y. & Murrell G.A. (2006). "Nitric oxide enhances collagen synthesis in cultured human tendon cells". Journal of Orthopaedic Research (Wiley) 24 (2): 159–72. doi:10.1002/jor.20060. PMID 16435353.
  26. ^ Darmani, H.; Crossan J.C. & Curtis A. (2004). "Single dose of inducible nitric oxide synthase inhibitor induces prolonged inflammatory cell accumulation and fibrosis around injured tendon and synovium". Mediators of Inflammation (Hindawi Pub. Corp.) 13 (3): 157–64. doi:10.1080/09511920410001713556. PMC 1781556. PMID 15223606.
  27. ^ Erickson, Laurie (2002-07-01). "Future Treatments". Retrieved 2007-04-02.
  28. ^ Murrell GA. (2007). "Using nitric oxide to treat tendinopathy". Br J Sports Med 41 (4): 227–31. doi:10.1136/bjsm.2006.034447. PMC 2658939. PMID 17289859.

[edit] External links


From Wikipedia, the free encyclopedia
Classification and external resources
ICD-10 M77.9
ICD-9 726.90
DiseasesDB 31624
eMedicine emerg/570
MeSH D052256

Tendinitis (informally also tendonitis), meaning inflammation of a tendon (the suffix -itis denotes diseases characterized by inflammation), is a type of tendinopathy often confused with the more common tendinosis, which has similar symptoms but requires different treatment.[1] The term tendinitis should be reserved for tendon injuries that involve larger-scale acute injuries accompanied by inflammation. 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).



[edit] Types

Tendinitis injuries are common in the upper and lower limbs (including the rotator cuff attachments), 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 or elbows, swimmers in their shoulders. Achilles tendinitis is a common injury, particularly in sports that involve lunging and jumping while Patellar tendinitis is a common among basketball and volleyball players owing to the amount of jumping and landing.[2] A veterinary equivalent to Achilles tendinitis is bowed tendon, tendinitis of the superficial digital tendon of the horse.

[edit] Diagnosis

Symptoms can vary from aches or pains and local stiffness, to a burning that surrounds the whole joint around the inflamed tendon. Swelling may happen along with heat and redness, but not in all cases, there may be visible knots surrounding joint. 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 muscles tighten from 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. If the symptoms of tendinitis last for several months or longer it is probably tendinosis.

[edit] Treatment

Treatment of tendon injuries is largely conservative. Use of non-steroidal anti-inflammatory drugs, rest, and gradual return to exercise is a common therapy. Resting assists in the prevention of further damage to the tendon. Ice, compression and elevation are also frequently recommended. Physical therapy, orthotics or braces may also be useful. Initial recovery is typically within 2 to 3 days and full recovery is within 4 to 6 weeks.[3] As tendinosis is more common than tendinitis, and has similar symptoms, tendinitis is often initially treated the same as tendinosis. This helps reduce some of the chronic long-term risks of tendinosis, which takes longer to heal.

Steroid injections have not been shown to have long term benefits and are equivalent to NSAIDs in the short term.[4] In chronic tendinitis laser therapy has been found to be better than conservative treatment at reducing pain; however, no other outcomes were accessed.[5]

[edit] Research

Autologous blood injection is a technique where the area of tendinitis is injected with the patient's own blood in order to stimulate tendon healing. The procedure does result in a pain flare for several days as the blood irritates the tendon; however, platelet-derived growth factor, which is contained in platelets, is thought to commence the healing process. The treatment has been tested in two small trials for tennis elbow.[6][7]

[edit] See also

[edit] References

  1. ^ Khan, KM; Cook JL, Kannus P, Maffulli N, Bonar SF (2002-03-16). "Time to abandon the "tendinitis" myth : Painful, overuse tendon conditions have a non-inflammatory pathology". BMJ 324 (7338): 626–7. doi:10.1136/bmj.324.7338.626. PMC 1122566. PMID 11895810.
  2. ^ Mayo Clinic (2007). "Patellar tendinitis". Retrieved 2007-06-04.
  3. ^ Wilson, JJ; Best TM (Sep 2005). "Common overuse tendon problems: A review and recommendations for treatment" (PDF). American Family Physician 72 (5): 811–8. PMID 16156339.
  4. ^ Gaujoux-Viala C, Dougados M, Gossec L (December 2009). "Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials". Ann. Rheum. Dis. 68 (12): 1843–9. doi:10.1136/ard.2008.099572. PMC 2770107. PMID 19054817.
  5. ^ "BestBets: Laser therapy in the treatment of tendonitis".
  6. ^ Edwards SG, Calandruccio JH. (2003). "Autologous blood injections for refractory lateral epicondylitis". J Hand Surg [Am]. 28 (2): 272–8. doi:10.1053/jhsu.2003.50041. PMID 12671860.
  7. ^ Connell DA, Ali KE, Ahmad M, Lambert S, Corbett S, Curtis M (June 2006). "Ultrasound-guided autologous blood injection for tennis elbow". Skeletal Radiol. 35 (6): 371–7. doi:10.1007/s00256-006-0081-9. PMID 16552606.

[edit] External links

Tendinitis (informally also tendonitis), meaning inflammation of a tendon
tendonitis - Google Search
Tendinitis - Wikipedia, the free encyclopedia
Tendinosis - Wikipedia, the free encyclopedia
vitamin e, vitamin b6, nitric oxide - Google Search
VITAMIN B12: Uses, Side Effects, Interactions and Warnings - WebMD
Nutrition Overview
antihistamine from Wonder Labs
Stimulin ™ w/Citrulline #1 Nitric Oxide Stimulator** More Potent Than L-Arginine
Vitamin E 400 IU Natural
B-12 - SUBLINGUAL B12 Vitamin B-12, B6, Folic Acid and Biotin Vegetarian
Muscle contraction - Wikipedia, the free encyclopedia
Extracorporeal shockwave therapy - Wikipedia, the free encyclopedia
Tocopherol - Wikipedia, the free encyclopedia
Pyridoxine - Wikipedia, the free encyclopedia
Nitric oxide - Wikipedia, the free encyclopedia
Nitric oxide - Wikipedia, the free encyclopedia
Tendinitis -
Tendinitis: Symptoms -

No comments: