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What is tendinopathy?

What is tendinopathy?

Tendinopathy is an umbrella term that refers to a disease of a tendon, such examples include tennis elbow and achillies tendinopathy. Tendon injuries are usually a result of increased load and overuse, and over the past few years research and new insights into tendon pathology has seen our understanding grow.

Historically therapist referred to all tendon injuries as a form of tendonitis. The problem with this is that tendonitis infers that there is inflammation of the tendon. The problem with this is that tendons have a poor blood supply and lack of inflammatory cells, and therefore chronic tendon injuries can simply not be caused by inflammation alone. 

Tendonosis a relatively new term is defined as damage to a tendon at cellular level, it is thought to be caused by micro tears in the connective tissue in and around the tendon, leading to an increase in tendon repair cells. The ‘osis’ implies a pathology of chronic degeneration without inflammation.

trait

tendonosis

tendonitis

Time to recovery (early presentation)

6-10 weeks

Days to 2 weeks

Time to recovery (chronic presentation)

3-6 months

4-6 weeks

prevalence

common

rare

So strictly speaking tendonitis should only be reserved for tendon injuries that involve larger-scale acute injuries accompanied by inflammation. If a condition lasts for only a few weeks or less then it can be argued that inflammation was the primary cause that was impacting on an individual’s recovery.

 

So what is the relevance to all of this?

In short the treatment and management is different, to treat a degenerative tendon with methods that would usually be associated with an inflammatory condition is likely to see poor results. Therefore the word tendonopathy has been adopted and accepted by the medical community as it has abandoned the old school of thought that all chronic tendon injuries are a result of inflammation.

It is important to note as well that people of different ages will often present with varying degrees of pain and ability to function. This is why applying a “blanket treatment” to all presentations of tendinopathy is unlikely to be effective in all cases.

 

The Continuum of Tendinopathy

It is proposed that under periods of excessive load a tendon will pass through the following continuum.  

Normal Tendon

↓ (reversible)

Reactive Tendinopathy

↓ (reversible)

Tendon Dysrepair (Failed Healing)

↓ (reversible)

Degenerative Tendinopathy

↓ (irreversible)

Rupture/Tear

Each of the components of this continuum is further explained below.

 

Reactive Tendinopathy

This is a non-inflammatory proliferative response. A Proliferative response is where new cells and tissues are rapidly produced. This is a short-term adaptive thickening in an attempt to reduce stresses. This takes place in the short-term to allow the tendon to cope with loads through thickening and stiffening. The tendon can revert back to normal structure if overload is reduced or sufficient time is given between loading.

Clinical Manifestations: This will generally follow a burst of acute overload ; an individual who has done a burst of unaccustomed activity. It is typically seen with younger athletes and individuals who have begun training at a high level of intensity and progression though there were previously living quite sedentary lifestyles.

 

Tendon Dysrepair

Similar to reactive tendinopathy this is an attempt at tendon healing, however there is greater matrix breakdown. There are also possible increases in vascularity and associated neuronal ingrowth (neovascularisation).

On Ultrasound and MRi there will be evident swelling and increased matrix disorganisation.

Clinical Manifestations: This stage appears in chronically overloaded tendons. This has the potential to appear over a range of ages and loading environments. On examination, these tendons are thickened with more localised changes in one area of the tendon.

 

Degenerative Tendinopathy

In this stage there is progression of both matrix and cell changes, there are even some areas of cell death. Large areas of the matrix are disordered, filled with vessels (neovascularisation) and breakdown.

Extensive compromise of the tendon can be seen on ultrasound and MRI

Clinical Manifestations: More commonly seen in the older patient/athlete, but can also be seen in younger patients with a chronically overloaded tendon. Therefore, there is real potential to see this in a young, elite athlete. However, the more classic presentation is the middle-aged recreation athlete, with focal swelling and pain. They often describe repeated bouts of tendon pain. If allowed to progress this stage can inevitably lead to rupture. Analysis of ruptured tendons has shown these degenerative changes in 97% of cases.

 

The treatment and its implications:

It is very difficult to determine what stage of the continuum an individual is at as pain levels vary considerably at all stages, and as such other clinical information is needed to determine what stage the pathology is in. To make things more confusing variable stages of the pathology may co-exist in different localities of a single tendon.

Strictly speaking if the injury is identified in the early stages then the best outcomes can be expected. The most important aspect of the treatment for the early stages is simply rest. If we look at reactive tendinopathy and tendon dysrepair then exercises that continue to overload the tendon such as eccentric lowering should be completely avoided.  Deep soft tissue work particularly in the form of deep transverse frictions would be of benefit as it would increase blood flow to the area and promote healing. Deep soft tissue work would also help break down by products of the injury cycle such as the adhesions that are produced which would reduce pain and possible stiffness. Also  NSAIDs (non-steroid anti-inflammatory drugs)may be beneficial at this stage, as their ability to impede healing can reduce abnormal adaptation.

In degenerative stages frictions should be continued due to the ability to stimulate cell activity. ultrasound and laser may also be used but evidence for this can be somewhat conflicting. In a degenerative state the tendon can be progressively overloaded, as there is evidence to suggest eccentric strengthening results in stimulations of the mechanoreceptors in the tendon cells to produce collagen and thereby help reverse the tendonosis cycle. Exercise appears to be a positive stimulus for tendon restructuring, but only in the degenerative stage. However the problem with progressively overloading the tendon is that variable stages of the pathology may co-exist in different localities of a single tendon, and therefore exercise may trigger further irritation.

Other treatment modalities that could be of benefit include the use of cyrotherapy, heat therapy, steroid injections and biomechanical reduction techniques to relieve stress around the tendon, though all of these modalities need to be discussed in much more detail .

Disclaimer: This is a simplified text into the understanding of tendinopathy. The entire process is far more complex but this should give therapists a basic understanding so more appropraite treatment options are selected. This will ultimately enhance the overall effectiveness of treatment programs and athlete outcomes.


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