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August/September 2002


Breaking With Tradition

By Louis C. Almekinders, MD

Chronic tendon problems are extremely common and are seen in primary care, rehabilitation, occupational health, and orthopedic practices. Although tendon problems generally do not affect the patient’s overall health, they can be disabling and are often chronic. As a result, they account for a significant portion of lost time from work and play. Diagnosis and treatment during the past decades were generally based on anecdotal data without a scientific basis. Recent research has yielded new information on this problem and has questioned our traditional approach.



ETIOLOGY

Chronic tendon problems are frequently lumped together as tendinitis, which suggests inflammatory changes within the tendons. Tendinitis is frequently considered an overuse injury. Many authors have suggested that repetitive mechanical loads on the tendon, as a result of physical activity, cause microtrauma to the tendon.1,2 Excessive exercise with repeated microtrauma is thought to overwhelm the reparative capabilities of the tendon, thereby resulting in a macroinjury. As the body frequently responds to injury with inflammation, the concept of “overuse tendinitis” was developed.

Biopsy studies of involved tendon have not confirmed the concept of an inflammatory response.3,4 The histology generally shows degenerative features within the tendon, and inflammatory mediators have not been detected. The correlation with excessive exercise is also far from clear. However, the frequency of chronic tendon problems is correlated with age. Many tendon problems are most common in the fourth and fifth decade of life. This finding suggests that age-related degenerative tendon change is a major predisposing factor. In addition, aging tendon may be less vascularized and not able to generate a strong healing response.


 Table 1. Common forms of tendinopathy.
It appears that a tendon can be affected in different parts. Chronic problems can be found within the mid-substance of the tendon, in the tendon sheath, or near the bone insertion site. Each of these appears to be a different chronic tendon problem and should not all be diagnosed as tendinitis. With the absence of inflammation, the term tendinopathy is more appropriate. Different forms of tendinopathy are mid-substance tendinopathy, peritendinopathy for tendon sheath problems, and insertional tendinopathy for insertion site problems (see Table 1).

DIAGNOSING TENDINOPATHY

The diagnosis of tendinopathy is generally not difficult. Most forms of tendinopathy develop clear symptomatology in the area where the tendon is affected. Local pain is by far the most common complaint. The pain tends to be most pronounced after a period of rest, eg, upon arising in the morning, and actually may ease some with continued use.

Physical examination can confirm the presence of tendinopathy. Tendons that are accessible to palpation display focal tenderness to palpation in the affected area. Peritendinopathy can develop some edema in the tendon sheath whereas mid-substance and insertional tendinopathy may be associated with thickening of the tendon itself. If the diagnosis is not clear, imaging studies can help. This is particularly necessary for tendons that are not easily accessible for physical examination such as the rotator cuff tendons. MRI and diagnostic ultrasound are the imaging modalities of choice. Apart from recognizing tendinopathy, it is also important not to label chronic pain as tendinitis or tendinopathy.

TREATING TENDINOPATHY

Counseling the patient may very well be the most important next step, once the diagnosis of tendinopathy is made. Frustration on the part of the patient as well as the health care professional is frequently due to the chronic nature of tendinopathy. It is not uncommon for patients to expect chronic tendon pain to respond to treatment within days or weeks. However, natural history studies indicate that it may take several months or even more than a year for tendinopathy to resolve.5 Explaining to patients that tendinopathy is a chronic, but still temporary condition will avoid unrealistic expectations and possibly stimulate compliance with the recommended treatment.

It is important to determine the relative contribution of mechanical overload to the tendinopathy. If there clearly is a pattern of overuse of the tendon, activity modification will be an important part of the initial intervention. If not, then further decreasing the activity level may mean complete immobilization. Complete immobilization through casting or splinting is generally not advisable since clear detrimental effects have been shown with immobilization of collagenous tissues. In these patients, it may be more important to find ways to stimulate healing rather than avoid further injury with immobilization.

Drug treatment of tendinopathy remains popular. Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally the first choice as the traditional view of tendinitis includes a clear component of inflammation. Due to the lack of evidence for inflammation as well as several controlled, clinical studies on NSAIDs, it appears that NSAIDs are more than likely not able to affect the natural history of tendinopathy.6,7 They may have an analgesic effect. However, there is no scientific evidence that they promote tendon healing. This should be weighed against the cost and risk of side effects. Only peritendinopathy has sometimes clear inflammatory features with edema of the tendon sheath. NSAIDs may be an appropriate choice for those patients.

Physical therapy is frequently used in tendinopathy. Both modalities and exercise therapy may be used. Ice, heat, ultrasound, and electrical stimulation all have theoretical beneficial effects on tendon tissue. Unfortunately, no controlled clinical studies are available that document their efficacy in tendinopathy.

Exercise therapy is a controlled mechanical stimulation of the tendon, which can consist of static stretching and/or active strengthening of the muscle-tendon unit. Studies on low-grade mechanical stimulation have shown beneficial effects on tendon tissue.8 More recently, research has shown that eccentric strengthening is particularly effective in lower extremity tendinopathy.9 Both Achilles and patellar tendinopathy have responded better with eccentric programs compared to more traditional strengthening in controlled studies.9-11

Corticosteroids continue to be used, particularly in upper extremity tendinopathy. Controlled studies suggest that they can result in a rapid relief of pain when used as a local injection.12 However, recurrences are frequent and ultimately corticosteroids may not alter the overall recovery rate. In addition, the concern of tendon rupture as a result of corticosteroid use remains unresolved. Judicious use of injectable corticosteroids for upper extremity tendinopathy, such as rotator cuff tendinopathy and lateral epicondylitis, may be appropriate if the pain is severe.

Surgical treatment traditionally has been a last resort for chronic resistant tendinopathy. Generally, this involves a debridement of the involved tendon tissue. Surgery may be effective, since it converts a chronic, nonhealing tendon lesion into an acute tendon injury. The response to this acute surgical trauma may evoke a vigorous healing response. The healing process even after surgical treatment is often slow, often taking 3 to 4 months.

NEW DEVELOPMENTS

The most recent addition to our treatment modalities is extra-corporeal shock wave treatment (ESWT). Powerful ultrasound waves, similar to those used in lithotripsy, are used to treat the affected tendon. Reported uses of ESWT include treatment for lateral epicondylitis, rotator cuff tendinopathy, and plantar fasciitis. The initial studies have shown improvement over placebo treatment.13 Its exact mechanism of action has not been determined. It is possible that ESWT works similarly to surgery. Most patients notice some increased, temporary pain following ESWT, which may suggest that by creating a controlled injury, a healing response is evoked.

The use of growth factors is currently in its experimental phase. Growth factors are naturally occurring proteins that can regulate cellular proliferation and matrix production. If the appropriate growth factors can be identified, they could be delivered to the involved tendon and start a healing response. Theoretically, this would be a more effective way of treating the tendon than with the use of NSAIDs or corticosteroids. NSAIDs and corticosteroids mostly treat the symptoms, whereas growth factors may act directly on the essential lesion in the tendon.

References
  1. 1. James SL, Bates BT, Osterning LR. Injuries to runners. Am J Sports Med. 1978;6:40-49.
  2. 2. Renstrom P. Sports traumatology today: a review of common current sports injury problems. Ann Chir Gynaecol. 1991;80:81-93.
  3. 3. Astrom M, Rausing A. Chronic Achilles tendinopathy, a survey of surgical and histopathologic findings. Clin Orthop. 1995;316:151-164.
  4. 4. Jozsa L, Reffy A, Kannus P, Demel S, Elek E. Pathological alterations in human tendons. Arch Orthop Trauma Surg. 1990;110:15-21.
  5. 5. Almekinders LC, Almekinders SV. Outcome of chronic overuse sports injuries: a retrospective study. J Orthop Sports Phys Ther. 1994;19:157-161.
  6. 6. Almekinders LC, Temple JD. Etiology, diagnosis and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc. 1998;30:1183-1190.
  7. 7. Astrom M, Westlin N. No effect of piroxicam on achilles tendinopathy: a randomized study of 70 patients. Acta Orthop Scand. 1992;63:631-634.
  8. 8. Viidik A. Tensile properties of Achilles tendon systems in trained and untrained rabbits. Acta Orthop Scand. 1969;40: 261-272.
  9. 9. Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2001;9:42-47.
  10. 10. Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendonitis. Clin Orthop. 1986;208:65-68.
  11. 11. Jensen K, DiFabio RP. Evaluation of eccentric exercise in treatment of patellar tendinitis. Phys Ther. 1989;69:700-702.
  12. 12. Adebajo AO, Nash P, Hazleman BL. A prospective double blind dummy placebo con-trolled study comparing triamcinolone hexacetonide injection with oral diclofenac 50 mg TDS in patients with rotator cuff tendinitis. J Rheumatol. 1990;17:1207-1210.
  13. 13. Hammer DS, Rupp S, Ensslin S, Kohn D, Seil R. Extracorporal shock wave therapy in patients with tennis elbow and painful heel. Arch Orthop Trauma Surg. 2000;120:304-307.
Louis C. Almekinders, MD, is a professor in the Department of Orthopedic Surgery, Sports Medicine Section, at the University of North Carolina at Chapel Hill.

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