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Chronic Tendonitis - What's New In Treatment?

Mar 25, 2008
So, you've been diagnosed with tendonitis and you've gone through the usual types of treatment programs like physical therapy, anti-inflammatory drugs, and even cortisone shots.

What else is available?

Before we discuss the exciting new ways of managing chronic tendonitis, let's talk about what tendonitis is... and what it isn't.

Tendons are thick cords of fibrous tissue that connect muscles to bones. It is this connection that allows joint motion. When muscles contract, they pull on the tendons which cause the bones to move.

In order for tendons to glide they move inside a lubricated sheath of tissue that is lined with synovial tissue. This synovial tissue is the same type of tissue that lines the inside of joints. Tendonitis occurs when the sheath through which a tendon glides becomes inflamed. This leads to severe pain. The pain usually gets worse with use of the affected joint. However, when tendonitis becomes severe, there may be pain at rest, particularly at night.

Since muscles and tendons surround most joints, tendonitis is rather common. The diagnosis of tendonitis is relatively simple for the experienced clinician. Generally, the diagnosis is made by history and physical examination. In difficult diagnostic cases, diagnostic ultrasound or magnetic resonance imaging is helpful in confirming the diagnosis.

Some of the more common types of tendonitis are:

Shoulder tendonitis. The tendons in the shoulder that are most often affected are the rotator cuff and biceps tendons.

The rotator cuff consists of four tendons that sit on top of the upper arm bone. They are the supraspinatus, infraspinatus, subscapularis, and teres minor tendons. The location of these tendons and the muscles they attach to are what give the shoulder such a great range of motion.

Rotator cuff tendonitis may occur as a result of repetitive activity or tendon degeneration. Pain is felt with most movements and is usually located on the outside part of the shoulder. Certain movements such as reaching behind or to the side may be uncomfortable.

The biceps tendon permits the arm to be flexed at the elbow. Biceps tendonitis also occurs due to repetitive activity and pain is felt in the front of the shoulder.

Shoulder tendonitis can sometimes be treated successfully with anti-inflammatory medication, physical therapy, and occasionally glucocorticoid (cortisone) injection. These methods are most useful for acute tendonitis.

Tendonitis in the elbow is usually located either on the outside and is called lateral epicondylitis or tennis elbow. It may also occur along the inside part of the elbow- medial epicondylitis. This is called golfer's elbow.

Treatment for this condition consists of physical therapy, stretching and strengthening exercises, splints, and injections. While surgery is sometimes recommended for chronic case, I will discuss why that is inadvisable.

Tendonitis in the wrist arises because of repetitive motion. A peculiar form of tendonitis, called Dequervain's tendonitis, is felt on the outside of the thumb.

Tendonitis in this area is managed with glucorticoid injections and immobilization with a splint. Physical therapy modalities may be helpful. Rarely, if ever, is surgery required. Tendonitis in the fingers can lead to catching of the fingers. This is termed "trigger finger." Trigger finger usually responds to injection.

Tendonitis in the knee may affect the patellar tendon. This is the tendon that connects the knee cap to the tibia (lower leg bone). Patellar tendonitis usually occurs because of excessive jumping and is actually called "jumpers knee." This is treated with rest, anti-inflammatory medications, and physical therapy.

Tendonitis in the ankle can occur along the outside of the ankle (peroneal tendonitis), the inside of the ankle (posterior tibial tendonitis), or at the back of the ankle (Achilles tendonitis). The tendonitis that occurs along the outside or inside of the ankle can occur because of trauma or because of mechanical instability. Another potential cause is an underlying arthritis condition.

Achilles tendonitis often occurs as a result of excessive stress and loading of the tendon as well as repetitive motion. The Achilles tendon is the thick cord at the back of the ankle that connects the heel bone to the calf muscle. Treatment involves rest, elevation of the heel to take the tension off the Achilles tendon, and physical therapy. Glucocorticoid injection should be avoided because of the danger of Achilles tendon rupture. Anti-inflammatory medication may be helpful.

So what can be done to treat chronic tendonitis? What can you do if you've tried all of the above treatments and still have a problem?

The first new approach, particularly with tendons that are balky is to use hydrodissection. This is a form of treatment where a small gauge needle is introduced into the tendon sheath and a large volume of saline, glucocorticoid, and lidocaine are used to dissect the sheath away from the tendon. Often chronic inflammation causes the sheath and tendon to stick together and this can cause pain as well as loss of function. This type of therapy is particularly effective for the small tendons in the hand.

Another new form of therapy called tenotomy is now being used. This almost always negates the need for an open surgical procedure. With tenotomy, a small gauge needle is introduced with local anesthetic and used to "irritate" the insertion of the tendon where the site of inflammation is located. The needle is inserted using direct ultrasound visualization. After the needling, injection of a small amount of platelet rich plasma (PRP) is performed at the site of needling, again using direct ultrasound visualization. PRP is rich in growth factors that stimulate healing. The process of healing takes only a few days to weeks as opposed to the several weeks to months that an open surgical procedure takes.

Tenotomy can be performed at almost any site where there is chronic tendon inflammation. Results are usually excellent.

Both of these procedures are excellent for the aging athlete who wants to keep going.

For more information about hydrodissection and tenotomy, contact the Arthritis and Osteoporosis Center of Maryland at (301) 694-5800
About the Author
Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine. For more info: Arthritis Treatment
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