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.
Click here: Second Opinion Arthritis Treatment Kit
Tendons are bands or cords that connect a muscle to a bone.
Some tendons glide through a sheath lined with synovium, the same tissue that lines joints. As a result of repetitive m otion or trauma, the sheath can become inflamed. This is called tendonitis.
Other tendons don't have a synovial lined sheath. As a result of repetitive motion or trauma, these tendons undergo degeneration with microscopic tearing. This is referred to as tendinosis.
Tendon injury can be caused by three things: over-use of a tendon, injury or aging. In a small number of cases, it can be associated with other inflammatory diseases such as rheumatoid arthritis or lupus.
One of the most common forms of tendonitis among people who engage in high-impact sports is Achilles tendonosis, which is inflammation of the tendon connecting the calf muscle to the heel.
The main symptoms of tendonitis or tendinosis are pain and stiffness. Symptoms may be more apparent at night, or after vigorous exercise. There may also be swelling and tenderness in the affected area.
Tendonitis/tendinosis is usually diagnosed on the basis of the history and physical exam. An MRI scan or diagnostic ultrasound can reveal any weakening of the tendon itself or changes in the tendon sheath or covering.
Although anti-inflammatory drugs may be administered to reduce swelling and inflammation, the most important form of treatment for tendonitis is: rest, ice, immobilize and elevate. Tendonitis/tendinosis will get worse with continued use of the injured tendon, so rest is vital. Temporary use of a splint may also help to rest the tendon.
For those engaged in sport, it may be useful to get some form of physical therapy such as massage or ultrasound for the affected area. Exercises which stretch and strengthen the muscles are also helpful.
Tendonitis/tendinosis can recur with a return to physical activity, and prolonged bouts of this painful condition can lead to rupture of the tendon itself. Those who suffer from tendonitis on a regular basis should avoid taking part in any form of exercise, where there is excessive repetitive motion. This would include high-impact aerobics, stepping, skipping or running on a hard surface.
In repeated cases of chronic tendonitis/tendinosis, surgery may be considered.
The injured shoulder should be rested from the activities that caused the problem and from activities that cause pain. Ice packs applied to the shoulder and non-steroidal anti-inflammatory drugs will help reduce inflammation and pain.
Physical therapy to strengthen the muscles of the rotator cuff should be started. If the pain persists or if therapy is not possible because of severe pain, a steroid injection may reduce pain and inflammation enough to allow effective therapy.
If a patient does not respond to conservative (non-surgical) measures, ultrasound-guided needle tenotomy with injection of platelet-rich plasma (PRP) should be considered. This is a physiologic approach to healing tendon tissue since PRP contains many growth and healing factors. Surgery should be avoided if possible.
If the rotator cuff is already torn and symptoms persist, the tendon will most likely need to be repaired surgically. This is done using arthroscopic technique.
The program after surgery depends greatly on the severity of the injury. A sling is typically worn immediately following surgery for at least a day to allow healing of the soft tissues. Range of motion exercises follow this, and then strengthening, particularly of the rotator cuff. For a completely torn rotator cuff that was treated surgically, it may take at least six months for the muscles to regain their function and for full range of motion to be restored. The pain itself is usually relieved much sooner that this, however, and normal activities of daily living are often achieved within 2-3 months even for completely torn rotator cuffs.
Proximal Biceps Tendon Rupture. Rupture is usually transverse and either within the shoulder joint or within the proximal part of intertubercular groove. The biceps muscle bunches up in the distal arm. There is minimal loss of function.
Patients can be treated conservatively as most will become asymptomatic after 4-6 weeks. Operative treatment may be indicated for cosmetic reasons or if shoulder reconstruction is required for other reasons.
Distal Biceps Tendon Rupture. Usually caused by a single traumatic event involving flexion against resistance, with the elbow at a right angle. Most often occurs in a 50-60 year old active male. A sudden sharp tearing sensation results in a painful swollen elbow with weakness of flexion and supination. In a partial rupture, the biceps tendon will still be palpable in the antecubital fossa.
Surgery must be performed early in order to avoid scarring of biceps.
Refractory cases of lateral epicondylitis- meaning cases where the patient has not responded to exercise, physical therapy, splinting, anti-inflammatory medicines, and steroid injections may need to undergo surgery. Ultrasound-guided needle tenotomy with PRP should be tried first, though.
Wrist and Hand
The goal is to relieve the pain caused by the irritation and swelling. Swelling around the flexor tendon and tendon sheath must be reduced to allow smooth gliding of the tendon. Wearing a splint may help. Anti-inflammatory medication taken by mouth or injected into that tendon compartment may help reduce the swelling and relieve the pain. In some cases, simply resting may allow the symptoms to go away on their own. Treatment may also include changing activities to reduce swelling.
Ultrasound guided needle hydrodissection can open up the inflamed tendon sheath much like an angioplasty does for a blocked coronary artery.
When symptoms are severe or do not improve, surgery may be recommended. The surgery opens the compartment (covering) to make more room for the irritated tendons. Normal use of the hand can usually be resumed once comfort and strength have returned.
Patellar Tendon Rupture. Usually unilateral and due to a sports injury in patients younger than 40 years. Bilateral ruptures, with more minor trauma can occur in patients with systemic conditions such as inflammatory disease, diabetes mellitus, or chronic renal failure. There is an immediate onset of pain with a tearing sensation. Diffuse tender swelling with bruising develops in the anterior knee. A defect at the level of the rupture may be palpable. Active extension may be completely lost and the patient unable to maintain the passively extended knee against gravity.
Immediate surgical repair of the ruptured patella tendon is recommended for optimal return of function.
Quadriceps Tendon Rupture. Relatively infrequent and usually occurs in patients older than 40 years. Are most often unilateral and bilateral ruptures usually result from systemic disease and prior degenerative changes. Patients typically present with acute knee pain, swelling, and functional loss following a stumble, fall, or a giving way of the knee. There may be no history of prior knee pain. Swelling above the patella, bruising and tenderness are present. There is also variable loss of knee extension.
Early surgical repair yields the best results for complete quadriceps tendon ruptures. Partial tears can be treated conservatively.
Ankle and Foot
Achilles tendonitis. The best treatment of Achilles tendonosis is prevention. Stretching the Achilles tendon before exercise, even at the start of the day, will help to maintain flexibility in the ankle joint. Problems with foot mechanics can also be treated with devices inserted into the shoes. Products such as heel cups, arch supports, and custom orthotics can be used to correct for abnormalities such as overpronation and help prevent Achilles tendonitis.
Other conservative measures used to treat Achilles tendonosis include icing the injury, anti-inflammatory medications, and physical therapy.
Resting the painful Achilles tendon will allow the inflammation to be minimized and allow for healing. Therefore, cross-training is an important aspect of recovery. Steroid injections should not be used because they increase the incidence of Achilles tendon rupture.
Achilles tendon rupture is generally treated surgically to reattach the tendon to its normal position. The blood supply to the Achilles tendon is poor. In some individuals, generally people who live sedentary lifestyles, surgery may be avoided by casting the Achilles tendon rupture for several months. However, the rate of re-rupture is much higher in the non-surgical patients. In patients who have surgery for an Achilles tendon rupture, less than 3% experience a re-rupture of the tendon.
The surgery to treat an Achilles tendon rupture involves an incision along the back of the ankle. Usually the incision is made just to the side of midline so shoes will not rub on the site of the scar. The most common complication following an Achilles tendon repair is problems with wound healing. The skin lying over the Achilles tendon sometimes does not heal well. Therefore, careful wound management is important following surgical repair of an Achilles tendon rupture.
Usually patients are placed in a cast following the surgery for a period of 4-8 weeks. After the cast is removed, a walking boot can be used. Often the cast will be placed with the toes pointing slightly downwards--this eases the tension on the Achilles tendon to allow healing. There are many variations and particular physician preferences regarding how long to cast, use crutches, etc.
Posterior Tibial Tendon Rupture. The posterior tibial tendon maintains the arch of the foot and rupture is one of the most common causes of acquired flat foot in adults. The foot may become so deformed that severe ankle arthritis develops. Pain frequently begins just behind the medial malleolus. The foot rolls inwards and becomes flat. Treatment of posterior tibial tendonitis begins with a good supportive arch support. The arch support is useful because it supports the arch and takes some of the stress off the tendon. You may need to decrease your activity, mainly the time up on your feet to rest the tendon. Anti-inflammatory medications may be prescribed. Cortisone injection in this condition is usually not indicated, due to the increased risk of rupture of the tendon following injection. Ultrasound-guided needle tenotomy with PRP is an excellent treatment for this condition.
If this fails to resolve the process, surgery may be required to remove the thickened tissue around the tendon. This is done to try and decrease the symptoms of pain and to prevent rupture of the tendon.
If the tendon has ruptured, surgery may be required to either repair the ruptured tendon - or to replace it with a tendon graft. Most tears will not simply be repairable, unless they have only recently occurred. Usually, another tendon in the foot, such as the tendon that flexes the four lesser toes (bends them down) is used as a tendon graft to replace the function of the posterior tibial tendon.
Finally, in cases which have been neglected, and a fixed flatfoot deformity is present, a fusion (or arthrodesis) of the foot may be required. Usually, several joints must be fused to control the flatfoot deformity occurring after posterior tibial tendon rupture.
Peroneal Tendon Rupture. Most ruptures are longitudinal tears of the peroneus brevis tendon and this usually occurs as the result of a lateral ankle sprain. The longer the injury takes to heal, the greater the suspicion of a tendon rupture.
Most peroneal brevis tendon ruptures do not heal and require surgical repair.
However, as mentioned above, a more physiologic treatment for tendonosis may be more effective and prevent the need for surgery with many cases of chronic tendonitis. Percutaneous needle tenotomy is a technique where a small gauge needle is introduced using local anesthetic and ultrasound guidance. The needle is used to poke several small holes in the fascia. This procedure is called "tenotomy." Tenotomy induces an acute inflammatory response. Then, platelet rich plasma, obtained from a sample of the patient's whole blood is injected into the area where tenotomy has been performed. Platelets are cells that contain multiple healing and growth factors. The result? Normal good quality fascial tissue is stimulated to grow with natural healing.
For more information about this procedure, visit our sister site:
Tendonitis TendonitisandPRP.com provides reliable, accurate, and useful information on tendonitis treatment written by a board-certified rheumatologist. Learn more about how to get tendonitis relief using the most up-to-date methods.
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