Features November 2018 Issue

New Approach to Tendon Trouble

Painful tendon problems may be tendinitis. They may also be a less well-known condition-tendinosis.

Have you ever been diagnosed with tendinitis-whether in the elbow, shoulder, knee, hip or heel-and a corticosteroid shot didn't work? The "itis" in tendinitis refers to inflammation, and corticosteroids are powerful anti-inflammatory medications. It seems logical they shouldwork.

Anti-inflammatory remedies, whether in the form of pills (nonsteroidal anti-inflammatory drugs [NSAIDs]) or injections, do help some people with painful tendons, but they don't work for everyone. "We have observed that there's more to tendon problems than just inflammation," says Cleveland Clinic physician Dominic King, DO. He and his colleague Jason Genin, DO, of Orthopaedic Surgery, have proposed a new system for classifying tendon issues.

More than Inflammation

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© Steve Debenport | Getty Images

To get the right treatment for a tendon problem, you first must have the correct diagnosis.

Cleveland Clinic is at the forefront of new ways of thinking about tendon problems, which are called tendinopathies. Research using musculoskeletal ultrasound, which shows images of muscles and tendons, has revealed that tendinitis is not the only cause ofsymptoms.

Over time, a degenerative process can damage the normally resilient tendon fiber, thickening it. At this point, the problem is not inflammation, it is degeneration, and the condition is called tendinosis. Anti-inflammatories generally don't resolve theissue.

Inflammation or Degeneration?

Tendons are structures that connect muscle to bone. "They are like a bundle of stretchy rubber bands," Dr.King explains.

Problems with tendons are very common. You've probably heard of tennis elbow, golfers elbow, and rotator cuff problems in the shoulder. Tendinitis and tendinosis also commonly affect the tendons in the knee, hip, heel and foot.

Tendons can get injured in several ways. It can be from a sudden trauma, but more often it's from repetitive motion or overuse over time. Each tendon has subtle differences. But the overall concept is the same.

"Overloading a tendon, either from one large injury or several small injuries over time, can start you down the road to inflammation," says Dr. King. Inflammation that goes unchecked or is not properly treated can develop into degeneration.

The degeneration process causes tendons to thicken. They're less elastic and don't function properly. "If there's continued stress on the tendon you can end up with inflammation on top of that," says Dr. King. This can explain why some people with tendon problems who are treated with NSAIDs or a corticosteroid injection may get better for just a couple of weeks. "The pain came back because there was an underlying degenerative problem within the tendon," says Dr.King.

Eventually, a tendon can partially tear, which may lead to a tear of the entire tendon, called a rupture.

Get the Right Diagnosis

Tendonitis Problems

To get the right treatment for a tendon problem, you first need to know whether you have inflammation (tendinitis), degeneration (tendinosis), a combination of the two, or a tear. To make the diagnosis, your doctor will ask questions about the history of your symptoms and conduct a physicalexamination.

If a problem with a tendon is suspected, a musculoskeletal ultrasound can be performed to distinguish between the inflammation of tendinitis and the degenerative changes of tendinosis. Some physicians have the ultrasound equipment in their office, while others will order the test to be done by a radiologist. Treatment will depend on the results.

Dr. King emphasizes that there are three cornerstones to successful management of tendon problems. First, get evaluated and treated without delay. Second, have a good diagnosis that includes ultrasound. Third, be willing to accept that there won't be a quick fix.

"It took a while for this problem to develop, and it might take some time for it to go away," says Dr. Genin. "Patients who understand this are most likely to get the longest relief."

Treating Tendinitis

Treating tendinitis starts with resting from the activity that caused the problem. Your doctor might also recommend using a brace for a short period of time. For example, a tennis elbow strap takes pressure off an inflamed tendon in the elbow. A wrist brace immobilizes it at night. Other types of braces and straps are used for tendinitis in other locations, such as the knee or heel.

Because inflammation is present, you can take a short course of an over-the-counter NSAID, such as ibuprofen (Motrin®, Advil®) or naproxen (Aleve®). Physical therapy can also help. This might be all you need to get back to normal functioning.

However, if pain persists, your doctor can give you a corticosteroid injection. Another option is a platelet-rich plasma (PRP) injection. Platelets are components of blood that contain particles that aid in healing and tissue repair. A small sample of blood is taken. The platelets are separated out and then injected to the site of tendinitis.

PRP treatments are often not covered by insurance (they cost $500 or more per injection), but they can be an effective way to decrease pain when other conservative treatments have failed.

Treating Tendinosis

"Tendinosis is more of a mechanical problem," says Dr. King. Treatment involves a physical therapy program to stretch the tendon and strengthen surrounding muscles. "The aim of physical therapy is to stretch the tendinosis like a piece of taffy so it becomes more compliant," he says.

If that doesn't work, a procedure called ultrasound-guided percutaneous tenotomy is available. It's an office-based, FDA-approved procedure, which is covered by most insurance plans. Athin metal probe is inserted into the area, and high-pressure saline is used to break up and remove damaged tendon tissue.

The full benefit of the procedure usually takes about two to three months. The last resort if tenotomy doesn't take care of the problem is a surgical procedure to remove the hardened tendon tissue.

Treating a Tendon Tear

For a partial tear of a tendon, treatments called orthobiologics may be used. This is a term for therapies that use cells or tissues to stimulate the body's own healing mechanisms. PRP injections and placental tissue matrix (a collagen product harvested from placental tissue, which helps the tendon repair itself) are examples. "They have a role early on for tendinitis and also for partial tears," says Dr. King.

The best way to avoid a tendon tear is to get treated early for tendinitis.

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