At a glance:
- Tendons are bands of strong fibrous tissue made of collagen that connect muscles to bones or other parts of the body
- Tendons transmit the forces exerted by a muscle to the bone or attached body part to facilitate movement
- Tendinopathy is any disease or disorder of a tendon
- Depending on the pathology of a tendinopathy it may be referred to by a number of different names, including tendinitis, tendinosis, paratenonitis, tenosynovitis or a rupture
- Tendinopathies typically cause pain, muscle weakness and stiffness or loss of motion in the affected area. Depending on which part of the tendon structure is involved, it may also cause inflammation, a sensation of heat in the affected area, or bruising
- Severe tendinopathy may require surgical intervention, but tailored and controlled exercise offers the best results for long term recovery
What is Tendon?
Tendons are bands of strong fibrous tissue that connect muscles to other parts of the body. These attachments are typically to bones, but some tendons attach muscles to organs or other structures, such as the eye.
Composed mostly of collagen, tendon tissue has a high tensile strength. This is necessary for them to serve their purpose - transmitting force from the muscles to the bones (or other attachment points) to achieve movement. Each muscle has two attached tendons, one proximal (closer to the centre of the body) and one distal (distant from the centre of the body).
Each of these tendons has two attachment points - one to the bone or organ, and another to the muscle. While the essential biology of the tendon and attachments is the same across the different muscles in the body, the tendons themselves vary in size and shape depending on the purpose of the muscle.
Tendons attached to muscles that exert a great deal of force tend to be shorter and thicker to help transfer that energy without causing damage. Tendons attached to muscles dedicated to fine or delicate movements, such as the fingers or eyes tend to be long and thin, as they are not required to carry a great deal of force.
The connection between tendon and muscle is known as the musculotendinous junction (MTJ), and the connection to the bone is known as the osteotendinous junction (OTJ). Problems with tendons may occur at either the MTJ or OTJ or in the tendon itself.
What is the Difference Between Tendinitis, Tendinosis, Paratenonitis and Tendinopathy?
Some specialists use the term tendinopathy to describe a chronic condition in which a tendon fails to heal, most use the term to describe any tendon disorder. The “pathy” suffix is derived from the ancient Greek and means disorder or disease, so the word literally means tendon disease or disorder and so it is used as a blanket term for all tendon problems.
There are a number of more specific terms for diseases or disorders of the tendons that fall under the umbrella of tendinopathy, each with different pathologies.
- Tendinitis - once used in an umbrella manner similar to tendinopathy, tendinitis now refers to acute inflammation of a tendon due to tears and micro-traumas. The cause of tendinitis is typically injury (falls, sprains, etc) or repeated microtrauma to a tendon or group of tendons (running on hard surfaces or uneven ground, jumping, bearing excess weight, etc).Recent research suggests that actual inflammation of tendons is fairly uncommon, so some cases of tendinitis are actually misdiagnosed tendinosis. Given that part of a tendinitis treatment may include corticosteroids and NSAIDs, two treatments contraindicated for tendinosis, correct diagnosis is extremely important.
- Tendinosis - non-inflammatory degeneration of a tendon is referred to as tendinosis. It can be further classified into phases of reactive, dysrepair and degenerative tendinosis. The condition is typically caused by repeated microtrauma to tendons at a load level over the capacity of the tendon, which leads to structural or compositional changes within the tendon. As a result of these changes, tendinosis typically takes longer to treat than tendinitis. Tendinosis is most common in people that take part in high intensity or high impact sports or activities.
- Paratenonitis and Tenosynovitis - some tendons are sheathed in a thin layer of tissue that helps reduce the friction between the tendon and surrounding tissue. The sheath surrounding the achilles tendon is called the paratenon. The sheaths surrounding the tendons in the hands are referred to as synovial sheaths.Inflammation of the paratenon or synovial sheath are referred to as paratenonitis and tenosynovitis respectively. The inflammation restricts the movement of the tendon.
- Partial and Complete Tendon Ruptures - a tear in a tendon is often referred to as a rupture. A complete rupture describes when a tendon completely tears in two. A partial rupture occurs when a tendon partially tears but remains intact.
Ruptures are classified as either acute or chronic. Acute ruptures typically result from impact or injury, whereas partial ruptures slowly worsen over time or result from acute ruptures that are left unrepaired.
What Causes Tendinopathy?
Tendiopathy may result from a number of different factors, including:
- Bone spurs in the heel, which are in fact commonly caused by an untreated tendinopathy, may lead to gait disorders, further putting pressure on tendons or aggravating the paratenon
- Calcium deposits around the osteotendinous junction (OTJ)
- High impact sports or activities, such as those that require a great deal of running and jumping (jumpers knee)
- Improper technique such as using/holding tools or sporting equipment incorrectly
- Incorrect sporting equipment such as gear that is too heavy or shoes that are too big or too tight
- Intensive and regular physical exertion, such as extreme workout routines, professional dance schedules or sports training programs
- Obesity may lead to increased pressure on the tendons of the legs and feet
- Overexertion such as exercising for too long or lifting weights that are too heavy
- Overuse injuries to a tendon or group of tendons through repetitive movement such as those required by a job (production line work, typing, etc)
- Neglecting a recovery period between training sessions
- Not warming up properly before exercise
- Physical exertion in cold temperatures
- Poor posture, bad ergonomics or other situations that place the body in an awkward position for a long period of time
- Running on hard or uneven surfaces
Symptoms of Tendinopathy
While the cause of the tendinopathy may vary, as may the proper diagnosis, most tendon issues feature similar symptoms, such as:
- Inflammation
- Muscle weakness
- Pain
- Stiffness or reduced range of motion in the affected area
In addition to these general symptoms, different symptoms may indicate the type of tendinopathy present. A sudden onset of pain, inflammation and bruising may indicate a complete or partial rupture, whereas pain that gets worse after activity involving the affected tendon points more towards tendonitis or tendinosis. Another typical presentation of tendinosis, is pain in the morning or at the beginning of exercise, that then improves with warm up, but returns following a period of rest. The different forms of tendinopathy may also require different techniques for diagnosis. Although the treatment of the conditions is essentially the same, diagnosis of tenosynovitis can be performed through non-invasive diagnostic testing whereas paratenonitis requires a biopsy for definitive diagnosis.
Don’t risk debilitating damage or injury - schedule and appointment with a physiotherapist or a consultation with your GP to have the problem diagnosed and treated professionally.
Treatment for Tendinopathy
Depending on the cause of the tendinopathy, the treatment may vary. If inflammation is present, corticosteroid injections or other anti inflammatory medications may be used. A growing school of thought theorises that corticosteroids may hinder a tendon’s ability to self-repair, so these medications may not always be used.
In the case of partial or complete ruptures, surgery may be required to repair the damage.
In most cases, some of the most successful nonsurgical treatments include controlled exercise and unloading the tendon through bracing. Controlled exercise allows a physiotherapist or other healthcare professional to gradually increase the loading of a tendon, enabling it to strengthen, increase its capacity, and repair naturally over time. This is known as progressive overload. Exercise therapy for tendinopathy is typically a long term endeavour, and can initially be a matter of trial and error to find the appropriate load, but the lasting benefits typically overshadow the investment.
Another form of exercise therapy, known as “eccentric exercise”, where the muscle is lengthened, whilst contracting, may be utilised to strengthen the muscle around the affected tendon and promote the remodelling of tendons.
During exercise, or during a recovery period, restricting the load placed on the affected tendon is important. This is typically achieved through taping or bracing.
If you experience pain in a tendon after exercise, sport or repetitive physical activity, you may have tendinopathy. Don't ignore the problem - book an appointment today!