Tendonitis

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Practice Essentials

Tendonitis is an inflammatory condition characterized by pain at tendinous insertions into bone. The term tendinosis refers to the histopathologic finding of tendon degeneration. The term tendinopathy is a generic term used to describe a common clinical condition affecting the tendons, which causes pain, swelling, or impaired performance. Because of the fact that most pain from tendon conditions is not actually inflammatory in nature, tendinopathy may be a better term than tendonitis.

Common sites of tendinopathy include the following:

Pathophysiology

Tendons transmit the forces of muscle to the skeleton. As such, they are subjected to repeated mechanical loads, which are felt to be a major causative factor in the development of tendinopathy. Pathologic findings include tendon inflammation, mucoid degeneration, and fibrinoid necrosis in tendons. Microtearing and proliferation of fibroblasts have also been reported. However, the exact pathogenesis of tendinopathy is unclear.

Epidemiology

Middle-aged adults are most susceptible to the development of tendinopathy.

Prognosis

In general, the prognosis is very good with rest and conservative therapy. Chronic tendinopathy can lead to weakening of the tendon and subsequent rupture. Complications of tendonitis may include chronic disability, tendon rupture, and adhesive capsulitis (ie, frozen shoulder).

Patient Education

Quadriceps strengthening exercises is helpful for patellar tendinopathy and change in training routine and/or equipment, if indicated. Runners with Achilles tendinopathy should wear proper footwear, run on softer surfaces, and avoid hills. Patients with tennis elbow should maintain proper backhand technique, use a less tightly strung racket, and play on slower surfaces. Range-of-motion exercises are recommended for patients with rotator cuff tendinopathy to avoid complication of adhesive capsulitis.

For patient education information, see Tendinitis and Tennis Elbow.

History

The history in patients with tendonitis varies with the specific disorder, as follows:

Physical Examination

Findings on physical examination vary with the specific disorder, as follows:

Lateral epicondylitis

Medial epicondylitis

Supraspinatus tendinopathy (rotator cuff tendinopathy)

Bicipital tendinopathy

Patellar tendinopathy 

Popliteus tendinopathy

Iliotibial band syndrome

Shin splints

Achilles tendinopathy

Imaging Studies

Radiographs may be indicated if a history of trauma is present, but findings usually are negative with tendinopathy.

Further imaging studies, such as ultrasonography and magnetic resonance imaging (MRI), are usually reserved for when the diagnosis is unclear or the patient's condition fails to improve with conservative management.

Ultrasonography is a rapid, noninvasive, and portable method to evaluate for tendinopathy.

MRI is also accurate in accessing tendon pathology.

Approach Considerations

The goal of treatment is to reduce pain and to return to activity. Nonpharmacologic treatments of tendinopathy are as follows:

Low-intensity pulsed ultrasound was shown to be no more effective than placebo in the treatment of patellar tendinopathy.[5] Transcutaneous electrical nerve stimulation (TENS) provided no benefit over primary care management in a randomized trial in 241 adults with tennis elbow.[6]

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in relieving tendinopathy pain, and may be administered topically or orally. However, because the vast majority of tendinopathies are not inflammatory, whether NSAIDs are more effective than other analgesics is unclear.

Corticosteroid injection may be considered for patients with tendonitis in whom conservative therapy with rest, immobilization, and anti-inflammatory agents has failed.The corticosteroid (eg, triamcinolone) is typically combined with a local anesthetic (eg, lidocaine) to provide prompt analgesia; in addition, pain relief confirms the diagnosis and accurate placement of the corticosteroid.

The efficacy of locally injected steroids is debated. A systematic review concluded that steroid injections provide short-term pain relief but may not have long-term efficacy.[7] Response to injection therapy may vary with the anatomic site of tendinopathy.

A randomized, controlled trial in 165 patients with unilateral lateral epicondylalgia of longer than 6 weeks' duration found that although results at 4 weeks favored corticosteroid injection, at 1 year the rate of much improvement or complete recovery was lower with corticosteroid injection than with placebo injection (83% vs 96%, respectively; relative risk [RR], 0.86; P = 0.01)). One-year recurrence was also higher with corticosteroid versus placebo (54% vs 12%; RR, 0.23; P< 0.001).[8]

Never use injections for Achilles tendonitis, because cases of Achilles tendon rupture have been reported following a single injection of corticosteroid. Avoid repetitive corticosteroid injections in any site, as well as injection directly into a tendon, because of the risk of tendon rupture. The use of ultrasound to direct these treatments improves accuracy and performance by facilitating visualization of the target and relevant adjacent structures.[9]

In patients with calcific tendonitis of the shoulder, a systematic review concluded that ultrasound (US)-guided needling and lavage has a high success rate and low complication rate.[10] In a randomized controlled study in 48 patients with calcific tendonitis of the rotator cuff that compared the combination of barbotage and US-guided corticosteroid injection in the subacromial bursa with subacromial bursa injection alone, both treatment groups demonstrated improvement at 1-year follow-up, but clinical and radiographic results were significantly better in the barbotage group.[11] After US-guided treatment, recovery may be enhanced by use of a rehabilitation protocol that focuses on mobility, strength, and function.[12]

A retrospective evaluation of double-needle US-guided percutaneous fragmentation and lavage (DNL) in 147 patients with rotator cuff calcific tendinitis found DNL to be safe and effective, with prompt relief of pain and function restoration.[13] However, a systematic review of the efficacy of US-guided needle lavage in treating calcific tendinitis found a lack of high-quality evidence to determine the relative efficacy.[14]

Surgical therapy

Patients with symptoms resistant to conservative therapy may benefit from arthroscopic or open surgical treatment for tendon decompression and tenodesis. A Japanese study in 23 patients with chronic lateral epicondylitis who underwent arthroscopic surgery found that the procedure provided significant improvement in pain and functional recovery up to 3 months after surgery. However, the visual analog scale (VAS) for pain and satisfaction criteria during activity did not fall below 10 points until 6 months postoperatively.[15]

Isolated gastrocnemius recession has been shown to provide significant and sustained pain relief for chronic Achilles tendinopathy. Good function can be expected for activities of daily living, however ankle plantarflexion power and endurance deficits were noted.[16, 17]

Platelet-rich therapies

Platelet-rich therapies represent an experimental approach to treatment of tendinopathies and other musculoskeletal soft tissue injuries. In this technique, a quantity of the patient's blood is centrifuged and the active, platelet-rich fraction is extracted and applied to the injured tissue (eg, by injection). In theory, the growth factors produced by platelets should enhance tissue healing.

Although platelet-rich therapies are gaining wider use, however, few level one studies exist demonstrating a clear benefit.[18, 19]   Systematic reviews of the literature have concluded that evidence of benefit for the use of protein-rich plasma (PRP) as a treatment for tendinopathies varies by site. There is evidence to support PRP injections for the treatment of lateral elbow and patellar tendinopathy, whereas there remains insufficient evidence to support PRP for Achilles tendon or rotator cuff pathology.[20]  [21]

Medication Summary

The goals of pharmacotherapy are to control pain and decrease inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in relieving tendinopathy pain, and may be administered topically or orally. Corticosteroids may be considered when conservative therapy has failed.

Ibuprofen (Motrin, Advil, Ibuprin, Nuprin)

Clinical Context:  Usually DOC for treatment of mild to moderate pain if no contraindications are present.

Inhibits inflammatory reactions and pain, probably by decreasing activity of the enzyme cyclooxygenase, which results in inhibition of prostaglandin synthesis.

Naproxen (Naprosyn, Aleve)

Clinical Context:  For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which results in decrease of prostaglandin synthesis.

Indomethacin (Indocin, Indochron E-R)

Clinical Context:  Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis.

Class Summary

These agents are used for the relief of mild to moderate pain. Although the effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen usually is the drug of choice (DOC) for initial therapy. Other options include naproxen and indomethacin.

Dexamethasone acetate (Decadron, AK-Dex, Alba-Dex, Dexone)

Clinical Context:  Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. Dosage varies with degree of inflammation and size of affected area.

Methylprednisolone acetate (Solu-Medrol, Depo-Medrol, Medrol)

Clinical Context:  Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Use 0.5-1 mL (40 mg/mL) mixed with equal or double volume of 1% local anesthetic (ie, lidocaine). Dosage varies with degree of inflammation and size of affected area.

Hydrocortisone acetate (Solu-Cortef, Cortef)

Clinical Context:  Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Use 0.5-1 mL (25 or 50 mg/mL) mixed with equal or double volume of 1% local anesthetic (ie, lidocaine). Dosage varies with degree of inflammation and size of affected area.

Class Summary

These agents have both anti-inflammatory (glucocorticoid) and salt-retaining (mineralocorticoid) properties. Glucocorticoids have profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

Author

Mark Steele, MD, Professor, Department of Emergency Medicine, Chief Medical Officer, Truman Medical Center, University of Missouri-Kansas City School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey G Norvell, MD, MBA, RDMS, Associate Professor, Program Director, Department of Emergency Medicine, University of Kansas Medical Center

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Gino A Farina, MD, FACEP, FAAEM, Professor of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine at Hofstra University; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Disclosure: Nothing to disclose.

Additional Contributors

Richard S Krause, MD, Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

Disclosure: Nothing to disclose.

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The proximal patellar tendon is most commonly affected in jumper's knee.

Iliotibial band at the lateral femoral condyle, with the posterior fibers denoted.

Hawkins test. The examiner forward flexes the arms to 90° and then forcibly internally rotates the shoulder. This movement pushes the supraspinatus tendon against the anterior surface of the coracoacromial ligament and coracoid process. Pain indicates a positive test result for supraspinatus tendonitis.

Yergason test.

Speed test.

The Ober test.

Hawkins test. The examiner forward flexes the arms to 90° and then forcibly internally rotates the shoulder. This movement pushes the supraspinatus tendon against the anterior surface of the coracoacromial ligament and coracoid process. Pain indicates a positive test result for supraspinatus tendonitis.

Speed test.

Yergason test.

The proximal patellar tendon is most commonly affected in jumper's knee.

Iliotibial band at the lateral femoral condyle, with the posterior fibers denoted.

The Ober test.