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Tendinopathy, a type of
tendon A tendon or sinew is a tough, high-tensile-strength band of dense fibrous connective tissue that connects muscle Skeletal muscles (commonly referred to as muscles) are organs An organ is a group of tissues with similar functions. Plant ...

tendon
disorder that results in pain, swelling, and impaired function. The pain is typically worse with movement. It most commonly occurs around the shoulder (
rotator cuff tendinitis Shoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed. ...
,
biceps tendinitis The biceps ( la, musculus biceps brachii, "two-headed muscle of the arm") is a large muscle that lies on the front of the upper arm between the shoulder and the elbow. Both heads of the muscle arise on the scapula and join to form a single muscle ...
), elbow (
tennis elbow Tennis elbow, also known as lateral epicondylitis, is a condition in which the outer part of the elbow The elbow is the visible joint between the upper and lower parts of the arm. It includes prominent landmarks such as the olecranon, the ...

tennis elbow
,
golfer's elbow Golfer's elbow, or medial epicondylitis, is tendinosis Tendinopathy, also known as tendinitis or tendonitis, is a type of tendon A tendon or sinew is a tough band of fibrous connective tissue that connects muscle to bone A bone is a Stif ...
), wrist, hip, knee (
jumper's knee Patellar tendinitis, also known as jumper's knee, is an overuse injury of the tendon that straightens the knee. Symptoms include pain in the front of the knee. Typically the pain and tenderness is at the lower part of the kneecap, though the upper ...
,
popliteus tendinopathy The popliteus muscle in the leg is used for unlocking the knees when walking, by laterally rotating the femur on the tibia during the closed chain portion of the bipedal gait cycle, gait cycle (one with the foot in contact with the ground). In ope ...
), or ankle (
Achilles tendinitis Achilles tendinitis, also known as achilles tendinopathy, occurs when the Achilles tendon The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon A tendon or sinew is a tough, high-tensile-strength band of dense fi ...
). Causes may include an injury or repetitive activities. Groups at risk include people who do manual labor, musicians, and athletes. Less common causes include
infection An infection is the invasion of an organism's body tissues by disease-causing agents, their multiplication, and the reaction of host A host is a person responsible for guests at an event or for providing hospitality during it. Host may ...

infection
,
arthritis Arthritis is a term often used to mean any disorder that affects joints A joint or articulation (or articular surface) is the connection made between bone A bone is a Stiffness, rigid tissue (anatomy), tissue that constitutes part of th ...
,
gout Gout is a form of inflammatory arthritisInflammatory arthritis is a group of diseases which includes: rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results i ...

gout
,
thyroid disease Thyroid disease is a medical condition that affects the function of the thyroid gland. The thyroid gland is located at the front of the neck and produces thyroid hormones that travel through the blood to help regulate many other organs, meaning t ...
, and
diabetes Diabetes mellitus, commonly known as just diabetes, is a group of metabolic disorder A metabolic disorder is a disorder that negatively alters the body's processing and distribution of macronutrients such as proteins, fats, and carbohydrate ...

diabetes
. Diagnosis is typically based on symptoms,
examination Examination may refer to: * Physical examination, a medical procedure * Questioning and more specific forms thereof, for example in law: ** Cross-examination ** Direct examination * Test (assessment), informally "exam", "exams", "evaluation" ** Civ ...
, and occasionally
medical imaging Medical imaging is the technique and process of imaging Imaging is the representation or reproduction of an object's form; especially a visual representation (i.e., the formation of an image). Imaging technology is the application of materi ...
. A few weeks following an injury little
inflammation Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogen In biology Biology is the natural science that studies life and living organisms, including their anato ...
remains, with the underlying problem related to weak or disrupted tendon
fibrils Fibrils (from the Latin Latin (, or , ) is a classical language belonging to the Italic languages, Italic branch of the Indo-European languages. Latin was originally spoken in the area around Rome, known as Latium. Through the power of the Roman ...
. Treatment may include rest, NSAIDs, splinting, and
physiotherapy Physical therapy (PT), also known as physiotherapy, is one of the allied health professions Allied health professions are health care Health care, health-care, or healthcare is the maintenance or improvement of health via the preventive h ...
. Less commonly
steroid injections Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involved ...
or surgery may be done. About 80% of patients recover completely within six months. Tendinopathy is relatively common. Older people are more commonly affected. It results in a large amount of missed work.


Signs and symptoms

Symptoms includes tenderness on palpation, swelling, and
pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain The International Association for the Study of Pain (IASP) is an international learned society A learned societ ...
, often when exercising or with a specific movement.


Cause

Causes may include an injury or repetitive activities. Groups at risk include people who do manual labor, musicians, and athletes. Less common causes include
infection An infection is the invasion of an organism's body tissues by disease-causing agents, their multiplication, and the reaction of host A host is a person responsible for guests at an event or for providing hospitality during it. Host may ...

infection
,
arthritis Arthritis is a term often used to mean any disorder that affects joints A joint or articulation (or articular surface) is the connection made between bone A bone is a Stiffness, rigid tissue (anatomy), tissue that constitutes part of th ...
,
gout Gout is a form of inflammatory arthritisInflammatory arthritis is a group of diseases which includes: rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results i ...

gout
,
thyroid disease Thyroid disease is a medical condition that affects the function of the thyroid gland. The thyroid gland is located at the front of the neck and produces thyroid hormones that travel through the blood to help regulate many other organs, meaning t ...
, and
diabetes Diabetes mellitus, commonly known as just diabetes, is a group of metabolic disorder A metabolic disorder is a disorder that negatively alters the body's processing and distribution of macronutrients such as proteins, fats, and carbohydrate ...

diabetes
. Despite the injury of the tendon there is poor healing.
Quinolone antibiotic A quinolone antibiotic is a member of a large group of broad-spectrum bacteriocidal A bactericide or bacteriocide, sometimes abbreviated Bcidal, is a substance which kills bacteria Bacteria (; common noun bacteria, singular bacterium) ar ...
s are associated with increased risk of tendinitis and tendon rupture.FDA May 12, 201
FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur
/ref> A 2013 review found the incidence of tendon injury among those taking fluoroquinolones to be between 0.08 and 0.2%. Fluoroquinolones most frequently affect large load-bearing tendons in the lower limb, especially the Achilles tendon which ruptures in approximately 30 to 40% of cases.


Types

*
Achilles tendinitis Achilles tendinitis, also known as achilles tendinopathy, occurs when the Achilles tendon The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon A tendon or sinew is a tough, high-tensile-strength band of dense fi ...
*
Calcific tendinitis Calcific tendinitis is a form of tendinitis Tendinopathy, also known as tendinitis or tendonitis, is a type of tendon disorder that results in pain, swelling, and impaired function. The pain is typically worse with movement. It most commonly oc ...

Calcific tendinitis
*
Patellar tendinitis Patellar tendinitis, also known as jumper's knee, is an overuse injury A repetitive strain injury (RSI) is an injury to part of the musculoskeletal or nervous system caused by repetitive use, vibrations, compression or long periods in a fixed po ...
(jumper's knee)


Pathophysiology

As of 2016 the
pathophysiology Pathophysiology ( physiopathology) – a convergence of pathology with physiology – is the study of the disordered physiological processes that cause, result from, or are otherwise associated with a disease or injury. Pathology is ...
of tendinopathy is poorly understood. While
inflammation Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogen In biology Biology is the natural science that studies life and living organisms, including their anato ...
appears to play a role, the relationships among changes to the structure of tissue, the function of tendons, and pain are not understood and there are several competing models, none of which have been fully validated or falsified. Molecular mechanisms involved in inflammation includes release of inflammatory cytokines like IL-1β which reduces the expression of type I collagen mRNA in human tenocytes and causes extracellular matrix degradation in the tendon. There are multifactorial theories that could include: tensile overload, tenocyte related collagen synthesis disruption, load-induced ischemia, neural sprouting, thermal damage, and adaptive compressive responses. The intratendinous sliding motion of fascicles and shear force at interfaces of fascicles could be an important mechanical factor for the development of tendinopathy and predispose tendons to rupture.
Obesity Obesity is a medical condition A disease is a particular abnormal condition that negatively affects the structure or function (biology), function of all or part of an organism, and that is not due to any immediate external injury. ...

Obesity
, or more specifically,
adiposity Adipose tissue, body fat, or simply fat is a loose connective tissue Connective tissue is one of the four basic types of animal tissue (biology), tissue, along with epithelial tissue, muscle tissue, and nervous tissue. It develops from the mesod ...
or fatness, has also been linked to an increasing incidence of tendinopathy. The most commonly accepted cause for this condition however is seen to be an overuse syndrome in combination with intrinsic and extrinsic factors leading to what may be seen as a progressive interference or the failing of the innate healing response. Tendinopathy involves cellular apoptosis, matrix disorganization and neovascularization. Classic characteristics of "tendinosis" include degenerative changes in the collagenous matrix, hypercellularity, hypervascularity, and a lack of inflammatory cells which has challenged the original misnomer "tendinitis". Histological findings include granulation tissue, microrupture, degenerative changes, and there is no traditional inflammation. As a consequence, "lateral elbow tendinopathy or tendinosis" is used instead of "
lateral epicondylitis Tennis elbow, also known as lateral epicondylitis, is a condition in which the outer part of the elbow The elbow is the visible joint between the upper and lower parts of the arm. It includes prominent landmarks such as the olecranon, the ...
". Examination of tennis elbow tissue reveals noninflammatory tissue, so the term "angiofibroblastic tendinosis" is used. Cultures from tendinopathic tendons contain an increased production of
type III collagen Type III Collagen is a homotrimer, or a protein composed of three identical peptide chains (monomers), each called an alpha 1 chain of type III collagen. Formally, the monomers are called collagen type III, alpha-1 chain and in humans are encoded b ...
. Longitudinal sonogram of the lateral elbow displays thickening and heterogeneity of the common extensor tendon that is consistent with tendinosis, as the ultrasound reveals calcifications, intrasubstance tears, and marked irregularity of the lateral epicondyle. Although the term "epicondylitis" is frequently used to describe this disorder, most histopathologic findings of studies have displayed no evidence of an acute, or a chronic inflammatory process. Histologic studies have demonstrated that this condition is the result of tendon degeneration, which causes normal tissue to be replaced by a disorganized arrangement of collagen. Therefore, the disorder is more appropriately referred to as "tendinosis" or "tendinopathy" rather than "tendinitis". Colour Doppler ultrasound reveals structural tendon changes, with vascularity and hypo-echoic areas that correspond to the areas of pain in the extensor origin. Load-induced non-rupture tendinopathy in humans is associated with an increase in the ratio of collagen III:I proteins, a shift from large to small diameter collagen fibrils, buckling of the collagen fascicles in the tendon extracellular matrix, and buckling of the tenocyte cells and their nuclei.


Diagnosis

Symptoms can vary from aches or pains and local
joint stiffness Joint stiffness may be either the symptom of pain on moving a joint, the symptom of loss of range of motion or the Sign (medicine), physical sign of reduced range of motion. * Pain on movement is commonly caused by osteoarthritis, often in quite m ...
, to a burning that surrounds the whole
joint A joint or articulation (or articular surface) is the connection made between bone A bone is a Stiffness, rigid tissue (anatomy), tissue that constitutes part of the skeleton in most vertebrate animals. Bones protect the various organs of th ...

joint
around the inflamed tendon. In some cases, swelling occurs along with heat and redness, and there may be visible knots surrounding the joint. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiff the following day as muscles tighten from the movement of the tendon. Many patients report stressful situations in their life in correlation with the beginnings of pain which may contribute to the symptoms.


Medical imaging

Ultrasound imaging can be used to evaluate tissue strain, as well as other mechanical properties. Ultrasound-based techniques are becoming more popular because of its affordability, safety, and speed. Ultrasound can be used for imaging tissues, and the sound waves can also provide information about the mechanical state of the tissue.


Treatment

Treatment of tendon injuries is largely conservative. Use of
non-steroidal anti-inflammatory drug Nonsteroidal anti-inflammatory drugs (NSAIDs) are members of a drug class A drug is any chemical substance A chemical substance is a form of matter In classical physics and general chemistry, matter is any substance that has mass a ...
s (NSAIDs), rest, and gradual return to exercise is a common therapy. Resting assists in the prevention of further damage to the tendon. Ice, compression and elevation are also frequently recommended.
Physical therapy Physical therapy (PT), also known as physiotherapy, is one of the allied health professions Allied health professions are health care Health care, health-care, or healthcare is the maintenance or improvement of health via the preventive h ...

Physical therapy
,
occupational therapy Occupational therapy (OT) is a profession within healthcare Health care, health-care, or healthcare is the maintenance or improvement of health via the prevention, diagnosis, treatment, recovery, or cure of disease, illness, injury, an ...
, orthotics or braces may also be useful. Initial recovery is typically within 2 to 3 days and full recovery is within 3 to 6 months. Tendinosis occurs as the acute phase of healing has ended (6–8 weeks) but has left the area insufficiently healed. Treatment of tendinitis helps reduce some of the risks of developing tendinosis, which takes longer to heal. There is tentative evidence that
low-level laser therapy Low-level laser therapy (LLLT) is a form of medicine that applies low-level (low-Power (physics), power) Laser, lasers or Light-emitting diode, light-emitting diodes (LEDs) to the surface of the body. Whereas high-power lasers are used in laser m ...
may also be beneficial in treating tendinopathy. The effects of deep transverse friction massage for treating tennis elbow and lateral knee tendinitis is unclear.


NSAIDs

NSAIDs may be used to help with pain. They however do not alter long term outcomes. Other types of pain medication, like
paracetamol Paracetamol, also known as acetaminophen, is a medication used to treat fever and mild to moderate pain. At a standard dose, paracetamol only slightly decreases body temperature; it is inferior to ibuprofen in that respect, and the benefits of ...
, may be just as useful.


Steroids

Steroid injections have not been shown to have long term benefits but have been shown to be more effective than NSAIDs in the short term. They appear to have little benefit in tendinitis of the rotator cuff. There are some concerns that they may have negative effects.


Other injections

There is insufficient evidence on the routine use of injection therapies (autologous blood, platelet-rich plasma, deproteinised haemodialysate, aprotinin, polysulphated glycosaminoglycan, skin derived fibroblasts etc.) for treating Achilles tendinopathy. As of 2014 there was insufficient evidence to support the use of platelet-rich therapies for treating musculoskeletal soft tissue injuries such as ligament, muscle and tendon tears and tendinopathies.


Prognosis

Initial recovery is usually within 2 to 3 months, and full recovery usually within 3 to 6 months. About 80% of people will fully recover within 12 months.


Epidemiology

Tendon A tendon or sinew is a tough, high-tensile-strength band of dense fibrous connective tissue that connects muscle Skeletal muscles (commonly referred to as muscles) are organs An organ is a group of tissues with similar functions. Plant ...

Tendon
injury and resulting tendinopathy are responsible for up to 30% of consultations to sports doctors and other musculoskeletal health providers. Tendinopathy is most often seen in tendons of athletes either before or after an injury but is becoming more common in non-athletes and sedentary populations. For example, the majority of patients with Achilles tendinopathy in a general population-based study did not associate their condition with a sporting activity. In another study the population incidence of Achilles tendinopathy increased sixfold from 1979-1986 to 1987-1994. The incidence of rotator cuff tendinopathy ranges from 0.3% to 5.5% and annual prevalence from 0.5% to 7.4%.


Terminology

Tendonitis is a very common, but misleading term. By definition, the suffix "-itis" means "inflammation of". Inflammation is the body's local response to tissue damage which involves red blood cells, white blood cells, blood proteins with dilation of blood vessels around the site of injury. Tendons are relatively avascular. Corticosteroids are drugs that reduce inflammation. Corticosteroids can be useful to relieve chronic tendinopathy pain, improve function, and reduce swelling in the short term. However, there is a greater risk of long-term recurrence. They are typically injected along with a small amount of a numbing drug called lidocaine. Research shows that tendons are weaker following corticosteroid injections. Tendinitis is still a very common diagnosis, though research increasingly documents that what is thought to be tendinitis is usually tendinosis. Anatomically close but separate conditions are: *
Enthesitis Enthesitis is inflammation of the entheses, the sites where tendons or ligaments insert into the bone. It is an enthesopathy, a pathologic condition of the entheses. Early clinical manifestations are an aching sensation akin to "working out ...
, wherein there is inflammation of the
entheses The enthesis (plural entheses) is the connective tissue between tendon or ligament and bone. There are two types of entheses: ''Fibrous entheses'' and ''fibrocartilaginous entheses''. In a fibrous enthesis, the collagenous tendon or ligament direc ...
, the sites where tendons or ligaments insert into the bone. It is associated with HLA B27 arthropathies such as
ankylosing spondylitis Ankylosing spondylitis (AS) is a type of arthritis Arthritis is a term often used to mean any disorder that affects joints A joint or articulation (or articular surface) is the connection made between bone A bone is a Stiffness, ri ...

ankylosing spondylitis
,
psoriatic arthritis Psoriatic arthritis is a long-term inflammatory arthritisInflammatory arthritis is a group of diseases which includes: rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typi ...
, and
reactive arthritis Reactive arthritis, formerly known as Reiter's syndrome, is a form of inflammatory Inflammatory may refer to: * Inflammation, a biological response to harmful stimuli * The word ''inflammatory'' is also used to refer literally to fire and flammabil ...
. * Apophysitis, inflammation of the bony attachment, generally associated with overuse among growing children.


Research

The use of a
nitric oxide Nitric oxide (nitrogen oxide or nitrogen monoxide) is a colorless gas with the formula . It is one of the principal oxides of nitrogen. Nitric oxide is a free radical: it has an unpaired electron, which is sometimes denoted by a dot in its che ...

nitric oxide
delivery system ( glyceryl trinitrate patches) applied over the area of maximal tenderness was found to reduce pain and increase range of motion and strength. A promising therapy involves eccentric loading exercises involving lengthening muscular contractions.


Other animals

Bowed tendon Tendinitis/tendonitis is inflammation of a tendon. Many times, the tendon tissue is torn. A bowed tendon is a horseman's term for a tendon after a horse has sustained an injury that caused the tendon fibers to be torn, and then healed with "bowed" a ...
is a horseman's term for tendinitis (inflammation) and tendinosis (degeneration), most commonly seen in the superficial digital flexor tendon in the front leg of horses.
Mesenchymal stem cell Mesenchymal stem cells (MSCs) also known as mesenchymal stromal cells or medicinal signaling cells are multipotent Cell potency is a Cell (biology), cell's ability to Cellular differentiation, differentiate into other cell types. The more cell ...

Mesenchymal stem cell
s, derived from a horse's bone marrow or fat, are currently being used for tendon repair in horses.


References


External links


Questions and Answers about Bursitis and Tendinitis
nbsp;- US National Institute of Arthritis and Musculoskeletal and Skin Diseases {{Authority control Disorders of fascia Inflammations Overuse injuries Pain Wikipedia medicine articles ready to translate