Tender Tendons

Tendon problems can affect many areas of the body such as the elbows (tennis elbow and golfer’s elbow), hips, knees (runner’s knee), ankles (Achilles tendon) and feet (policeman’s heel). In the past these problems went by the name of tendonitis. The suffix “itis” was used because it was thought that inflammation was present. Imaging techniques like ultrasound and MRI scans have revealed that there is in fact very little inflammation (except possibly in the very early stages) but instead degenerative changes were found. This led to the replacement of tendonitis by tendinosis. The suffix “osis” means degeneration. Recently however, studies have found that the imaging findings are not directly related to symptoms:

• some people are symptom-free even though they have structural tendon pathology
• as symptoms improve, structural pathology doesn’t change
• structural pathology is not necessarily a good predictor of recovery

This has led to a yet another word being used…tendinopathy. The “pathy” simple means problem…something is wrong but we’re not exactly sure what it is! It’s thought that past experience, emotion and adverse pain beliefs could lead to a hypersensitive nervous system.

That being said, it’s believed that tendon overload plays a crucial role, whereby the rate of wear is greater than the rate of repair. Therefore, inciting factors tend to fall under 2 categories.

1) Factors that increase the rate of tear:

• repetitive impact activities
• tendon compression
• sudden increase in training volume, intensity or frequency
• muscle weakness
• faulty biomechanics
• obesity

2) Factors that decrease the rate of repair:

• menopause
• age
• rheumatoid arthritis
• type II diabetes
• high cholesterol
• statins
• smoking

After a thorough clinical assessment the probable causative factors should be addressed when possible. The aim of treatment is to decrease pain, promote healing and improve function. There are several different treatments that are used. The choice usually depends on the site, severity of symptoms and the stage of presentation. In the early stages when there is possibly some inflammation present, NSAIDs, rest, ice, wedges, taping or splinting can be used. Obviously, physiotherapy and acupuncture are useful and corticosteroid injections are helpful (especially when performed around the tendon rather than in it). Surgery is a last resort and results can sometimes be disappointing. Some of the best evidence is for the use of extracorporeal shock-wave therapy or a progressive exercise programme. In fact, a progressive exercise programme should be part of all treatment packages particularly alongside treatments that are successful at decreasing pain but that don’t improve healing or function. A graduated exercise programme can ensure the long-term success of treatment.