How to treat tendonitis
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Tendons are sections of fibrous tissue that connect muscle to bone.
When a muscle contracts (shortens), the tendon is pulled. This leads to movement of a limb. An example would be the biceps tendon.
This tendon originates from the shoulder blade at one end. The other end is attached to the biceps muscle which is attached to the forearm. When the biceps muscle is contracted, the forearm flexes.
Tendonitis occurs when acute or chronic overloading of the tendon takes place. When the tendon cannot sustain the overload, it will become injured and inflamed.
Tendonitis is painful because, when inflammation or injury does occur, inflammatory cells enter the region. Inflammatory cells release a number of enzymes that promote healing but which also produce pain. The blood supply to tendons is generally poor. When a tendon is injured, the inflammatory process (and thus the healing process), which depends on blood flow, is lengthy.
Tendonitis is treated a bit differently depending on the location, severity of problem, and the length of time the problem has been going on. However, some basic principles are the same.
For acute tendon injuries, ice is mandatory.
Tendonitis in the shoulder usually is treated with a combination of anti inflammatory medicines, rest (using a sling), physical therapy, and injections of glucocorticoid (anti inflammatory medicine).
Tendonitis in the elbow is usually treated with the same regimen. Instead of a sling, a brace of some type is used. Ditto for the wrist.
In the hand, tendonitis is usually treated with injection first. Rest is still advised.
Tendonitis in the hip and knee may be treated with physical therapy, anti inflammatory medicines, rest, ice or moist heat, and injections.
Tendonitis in the ankle is usually treated with a splint, anti inflammatory medicines, ice, and physical therapy. Injections are sometimes required. However the tendency is to delay injections in this region because of the danger of tendon rupture. The amount of force applied to the ankle and foot- since these are the areas that take the most pounding- is tremendous compared with other areas. Tendonitis in the foot is treated similar to the way it is treated in the ankle. Sometimes
orthotics and wedges inside shoes are used as well.
On rare occasions when tendonitis remains symptomatic despite conservative management, surgery is required.
Fortunately, there is a relatively new option that appears to be having surprisingly good results.
Since tendonitis is due to inflammation, the old thinking has been that reducing inflammation is the best approach. As a result, anti-inflammatory drugs, steroid injections, and so forth have been the mainstays of the “old school” of treatment.
Unfortunately, inflammation is also the body’s attempt to heal the damage to the tendon. The problem is that inflammation is not always accompanied by the increased blood flow required to bring new nutrients to the area to help with the healing processes.
So, new techniques have been devised to actually try to temporarily increase blood flow through carefully and selectively injuring the tendon at the area of concern, and then stimulating the body’s normal healing mechanisms to spring into action. While this seems paradoxical, it works.
The first part of this process involves the use of ultrasound guided percutaneous tenotomy (UGPT). Ultrasound is employed to diagnose the problem and then to guide the insertion of a needle to selectively injure the tendon at the site where tissue repair needs to occur.
The second part of the process is to inject a small amount of platelet rich plasma. Platelets are small blood cells that are rich in various growth factors. These growth factors stimulate the growth and proliferation of new tissue. In essence, the platelet rich plasma helps regenerate new tendon fibers.
The procedure goes like this…
When the patient arrives at the clinic, the physician sits down and explains the procedure including risks and benefits.
The patients, if they agree to proceed, are taken to the laboratory and approximately 60 cc’s of blood is drawn and then spun in a special centrifuge. After the specimen is spun, the layer containing platelets is drawn off using a special syringe.
The patient is positioned in a comfortable manner.
The area of tendon pathology is then identified using diagnostic ultrasound. Often other problems that aggravate tendonitis such as bone spurs and arthritis are also demonstrated.
After informed consent is obtained, the area is steriley prepared and anesthetized with a local anesthetic. A special needle of suitable gauge and length is inserted through the anesthetized skin and soft tissue and advanced to the tendon at the site of injury. Bone spurs, if present are gently chiseled away using the needle. Using carefully placed movements, multiple small holes are then placed in the tendon.
Since local anesthetic has been administered previously, a minimal amount of discomfort is experienced.
After the needling procedure, a small amount of platelet rich plasma (also called “autologous tissue grafting material”) is slowly injected into the area.
The needle is then removed and a bandage is placed over the needle hole.
Post-procedure care consists of absolute rest for three days followed by modified rest for another four days, then slow and careful resumption of activity.
Analgesics such as tramadol (Ultram) may be used. However, anti-inflammatory drugs and immunosuppressive drugs should be held for approximately a week before and a week after the treatment.
Ultrasound guided percutaneous tenomy and autologous tissue grafting often prevents the need to perform an open surgical procedure. This outpatient procedure is done using only local anesthetic.
A course of physical therapy may be initiated after the period of rest with the goals of improving function, decreasing pain, and increasing strength.
In some cases, a second course may be required. However, the long term results are extraordinary with very few patients requiring open surgery.
So who is a candidate for this procedure? Any patient with a history of chronic tendonitis that hasn’t responded to other measures is a good candidate. This includes people with arthritis who also have tendonitis (sometimes the distinction is not always easy to make and the arthritis pain may actually be tendon-related pain). Patients with tendon rupture are not good candidates.
For more information on tenotomy and platelet rich plasma, contact the Arthritis Treatment Center at (301) 694-5800 or reach us on the web at www.arthritistreatmentcenter.com.
For more information on tendonitis, visit our sister site:
Tendonitis and PRP
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