Tendonitis is inflammation of the cord-like structure located where a muscle narrows down to join a bone, usually in the shoulder, elbow, wrist, hip, knee and ankle. Tendons come in many shapes and sizes. Some are very small, like the ones that cause movements of the fingers and some are much larger, such as the Achilles Tendon in the heel. Tendons are fibrous cords that attach muscle to bone. It is through tendons that the muscles of the foot and ankle act enable us to perform the different motions necessary for walking. This structure, the tendon, is more fibrous and dense than the elastic and fleshy muscle. It transmits the pull of the muscle to the bone to cause movement. When functioning normally, these tendons glide easily and smoothly as the muscle contracts.
Sometimes the tendons become inflamed for a variety of reasons, and the action of pulling the muscle becomes irritating. If the normal smooth gliding motion of the tendon is impaired, the tendon will become inflamed and movement will become painful. This is called tendonitis, and literally means inflammation of the tendon. There are several types of tendonitis including:
Wrist Tendonitis — a common problem that can cause pain and swelling around the wrist. Wrist tendonitis is due to inflammation of the tendon sheath. Treatment of wrist tendonitis usually does not require surgery.
Achilles Tendonitis — causes pain and swelling in the back of the heel.
Patellar (Kneecap) Tendonitis — often called Jumper’s Knee, treat with rest and anti-inflammatories
Rotator Cuff Tendonitis — many patients are told by their doctor they have rotator cuff tendonitis
Inflammation of the tendon is caused by overuse of, or increased stress on the tendon resulting in an increased blood flow through the area with warmth, swelling, pain and loss of function. Commonly, individuals begin an exercise program, or increase their level of exercise, and begin to experience symptoms of tendonitis. The tendon is unaccustomed to the new level of demand, and this overuse will cause inflammation and tendonitis.
Another common cause of symptoms of tendonitis is due to age-related changes of the tendon. As people age, the tendons loose their elasticity and ability to glide as smoothly as they used to. With increasing age, individuals are more prone to developing symptoms of tendonitis. The cause of these age-related changes is not entirely understood, but may be due to changes in the blood vessels that supply nutrition to the tendons.
Sometimes, there is an anatomical cause for tendonitis. If the tendon does not have a smooth path to glide along, it will be more likely to become irritated and inflamed. In these unusual situations, surgical treatment may be necessary to realign the tendon.
Tendons can become irritated quickly, as in acute tendonitis. Or, they can become irritated after repetitive injuries, termed chronic tendonitis, or overuse syndrome. The pain of tendonitis can be severe and should be treated quickly. Failure to rest the inflamed limb or the joint, at least temporarily, will usually result in longer-term problems and can lead to a tear within the tendon or a complete rupture of the tendon.
Tendonitis can be caused by sudden intense injury, but is most often the result of a repetitive, minor injury of the affected area. For example, a middle-aged sedentary man who spends four hours painting a ceiling may develop a tendonitis in the shoulder. A typist who spends long hours at a keyboard with poorly positioned hands and wrists may develop tendonitis. The early season game of tennis can result in a backhand which strains the tendon on the outside of the elbow.
Incorrect posture at work or home, or poor stretching or conditioning before exercise or playing sports, also increases a person’s risk. Other risk factors for tendonitis include:
- An abnormal or poorly placed bone or joint (such as length differences in the legs or arthritis in a joint) that stresses soft-tissue structures.
- Stresses from other conditions, such as rheumatoid arthritis, gout, psoriatic arthritis, thyroid disorders, or unusual medication reactions.
If properly treated early with rest, activity modifications, physical therapy and appropriate medication, the problem can be resolved completely. If untreated, in addition to pain, long term structural abnormalities, such as flat foot, can result. Occasionally, surgery may be necessary in order to regain the normal pain free function.
Treatment options include the following:
- Refrain from activity that caused the inflammation, or modify your workout.
- Splint the affected area.
- Apply ice or heat.
- Take anti-inflammatory medications to reduce inflammation and pain.
- Stretching/strengthening exercises in physical therapy.
Diagnosis of tendonitis requires a medical history and careful physical examination. On physical examination, there will often be tenderness along the involved tendon or its sheath (outer covering) or at one particular point within the tendon and pain when the muscle to which the tendon is attached is worked against resistance. X-rays do not show tendons, but may be useful in excluding other bone or joint problems. Blood tests, as well as MRI and diagnostic ultrasound which may be useful in the detection of these conditions, are generally not required.
Not infrequently, shoulder x-rays show the presence of a calcium deposit within a tendon sheath or around the shoulder joint. Tendonitis in the shoulder can most often be resolved without any specific attention to the calcium deposit. Many people have calcium deposits in the shoulder that do not produce any symptoms.
Treatment is based on the underlying cause. In overuse or injury, reduction of the causing force or stress is mandatory. A typist may need to review the ergonomic position that is used on a daily basis. Resting a painful hip from strengthening exercises may be required to allow the problem to settle prior to resumption of the strengthening program.
Failure to rest invariably will result in continuing symptoms. Splints or braces for the affected part are a means of achieving rest and reduction of stress on the part, especially in the hand and wrist area. Off the shelf supports may be sufficient, or custom fashioned braces may be required. Treatments, particularly ice, may help to reduce inflammation and pain. Ultrasound is often of benefit. The ultrasound referred to here is “treatment ultrasound” as distinct from diagnostic ultrasound and is most commonly administered by a physical therapist.
In the lower limb, stressful weight bearing activities may need to be reduced on a temporary basis to allow the inflammation to lessen. The use of a cane in the opposite hand can assist a painful hip. Orthotics may be required to reduce the stress at the ankle or within the foot. An orthotic is an adaptive device that is placed inside the shoe between the foot and the shoe, which serves to change the support and the angle of the foot, to improve foot mechanics and relieve pain or pressure. They can be custom made or off the shelf.
If an infection is present, there is usually an intense inflammation present with redness, warmth and swelling (a blood test will contribute to this diagnosis). Treatment with an appropriate antibiotic is necessary and serial aspiration (withdrawal of fluid with a needle) or surgical debridement of the tendon may be required. A potentially serious complication of tendonitis is rupture of a tendon with the most common being a tear of the Achilles tendon in the lower calf, which usually requires surgical intervention to repair. A limited number of tendon problems do not settle with the usual conservative measures and may require surgical intervention.
Warming up and stretching prior to strenuous exercise will help to prevent these problems from occurring. Therefore, activities should be begun slowly prior to expending maximum effort. For example, golfers should warm up at the driving range before driving the ball on the first tee.
Typists who spend long hours at the keyboard should ensure that the keyboard is at an appropriate height. Wrists rests should not be used; instead typing should be done with wrists extended in a neutral or slightly flexed position. Typists should also take breaks. Stretching and strengthening are very helpful to address any areas of muscle imbalance. At work or when exercising, proper posture and body mechanics are important. Proper conditioning of involved muscles is another component of treatment.
It is important to complete a daily range of motion exercise program to preserve mobility, particularly in the shoulder joint, as a tendonitis in the shoulder not infrequently becomes a greater problem if the shoulder becomes stiff. A “frozen shoulder” is preventable if the tendonitis, which is its usual precursor, is addressed early on. Lying down, on the back, clasp the fingers together and use the non painful arm to assist bringing the painful arm above the head to the fullest extent. Full shoulder movement will be bringing the upper arm up alongside the ear. Lower and repeat 5 times. In standing, walk the fingers of the involved arm up the wall to the highest tolerated position and then stretch the shoulder to the fullest extent by holding it in this stretched position for 20 seconds and then lowering. Repeat 5 times.
The cr17 Hurricane is a groundbreaking pain management device that can be used to treat tendonitis. A unique physical therapy technology, the cr17 incorporates a concentrated level of vibration and percussion in a single device. When combined with the Camara Myofascial Method, a series of protocols designed to facilitate positive change in the physiological, neurological and biomechanical aspects of the body, these tools can significantly enhance chiropractic treatments.