Khan, K. M., Cook, J. L., Taunton, J. E., & Bonar, F. (2000). Overuse tendinosis, not tendinitis - Part 1: A new paradigm for a difficult clinical problem. Physician Sportsmed, 28(5), 38+.

BACKGROUND

Ask anyone who is involved with the healthcare professions what tendinitis is and chances are they will say it is a condition that involves inflammation of the tendons. This inflammation is most often considered to be the result of tendon fiber tearing associated with overuse. However, there have been a number of recent studies that have indicated that many of us hold a common misconception about this problem. This article is the latest to suggest that tendinitis is frequently misunderstood and may, in fact, be quite different than we had previously supposed.

Overuse tendon pathologies are common in active populations. Most prevalent are tendon injuries such as Achilles tendinitis, patellar tendinitis, lateral humeral epicondylitis, and rotator cuff tendinitis. However, several recent studies have indicated that the nature of the pathology in these conditions is not tendon fiber tearing or inflammation. Since the term tendinitis indicates an inflammation of the tendon, the term tendinosis was suggested to be a more accurate description of the common overuse tendon pathologies. Tendinosis means abnormal condition of the tendons and is more appropriate.

The authors of this paper cited numerous studies that had used light microscopy to investigate the cellular structure of damaged tendons. In each of these studies it was found that there was a significant amount of collagen degeneration associated with the injury, but not an inflammatory reaction in the tissues. The degeneration is primarily a result of overuse and fatigue of the connective tissue in the tendon. In addition there was an increase in fibroblast cells, but not inflammatory cells. The increase in fibroblast cells is indicative of the body’s attempt to repair the tendon tissue that has degenerated.

While tearing of the tendon tissue may occur under certain circumstances, the authors stated that the actual occurrence of this is quite rare. Most overuse tendon pathologies are clearly not inflammatory, but they do involve tendon fiber damage. Therefore, as clinical practitioners, we need to rethink how we approach treatment of these problems.

DISCUSSION

Because tendinosis is a condition involving gradual degeneration of the tendon tissue, attention needs to be focused on those elements that may have led to the tendon overload in the first place. Strong emphasis should be placed on correcting any biomechanical errors that may have contributed to the problem. Significant periods of rest from any offending activities are also strongly encouraged. This treatment approach does not differ from the currently practiced conservative treatment of these tendon complaints. However, some other commonly used treatments may need to be seriously reconsidered.

Because tendinitis was thought to be an inflammatory condition, use of anti-inflammatory medication has been advocated for quite some time. However, the authors in this study indicated that there is little evidence to support the continued use of NSAIDS (Non-Steroidal Anti-Inflammatory Drugs) for these types of tendon pathologies. Since NSAIDS are primarily acting as anti-inflammatory medications, and there is not a significant inflammatory component to these injuries, there does not seem to be a strong reason for their continued use.

Corticosteroid injections have been used to treat tendinitis, although their use has been declining recently due to indications of connective tissue damage associated with this treatment. Once again, based on the findings of these studies about the cellular nature of most overuse tendon disorders, there seems to be a lack of evidence supporting their continued use for these complaints. In fact, since corticosteroid injections have been found to limit collagen synthesis, they may impair the tissue rebuilding and healing process.

The authors in this study stated that changes in treatment strategies would be necessary in order to more accurately address common tendinosis problems. Use of massage for treatment of these problems is strongly indicated. Several studies we have reported on recently have indicated that massage has a significant effect on increasing fibroblast activity in the region of damaged tendon tissue. For that reason, massage for these tendon complaints is certainly indicated. Some practitioners may have avoided working on tendinitis complaints in the past because it was perceived to be an inflammatory condition. However, now it is evident that this condition is one that would certainly benefit from specific massage applications such as deep friction massage.

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