Tendinosis
Encyclopedia
Tendinosis, sometimes called chronic tendinitis, tendinosus, chronic tendinopathy
or chronic tendon injury, is damage to a tendon
at a cellular level (the suffix "osis" implies a pathology of chronic degeneration without inflammation). It is thought to be caused by microtears in the connective tissue in and around the tendon, leading to an increase in tendon repair cells. This may lead to reduced tensile strength
, thus increasing the chance of tendon rupture. Tendinosis is often misdiagnosed as tendinitis due to the limited understanding of tendinopathies by the medical community.
. Increased water content and disorganized collagen matrix in tendon lesion
s may be detected by ultrasonography
or magnetic resonance imaging
.
Symptoms can vary from an ache or pain and stiffness
to the local area of the tendon, or a burning that surrounds the whole joint
around the inflamed tendon. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiffer the following day as swelling impinges on the movement of the tendon. Many patients report stressful situations in their life in correlation with the beginnings of pain which may contribute to the symptoms.
, which is weaker than normal tendon. Recurrence of injury in the damaged region of tendon is common.
Standard treatment of tendon injuries is largely palliative. Use of non-steroidal anti-inflammatory drug
s combined with Physical Therapy
, rest and gradual return to exercise is a common therapy, although there is evidence to suggest that tendinosis is not an inflammatory disorder, and that anti-inflammatory drugs are not an effective treatment and that inflammation does not cause tendon dysfunction. There are a variety of treatment options, but more research is necessary to determine their effectiveness. Initial recovery is usually within 2 to 3 months and full recovery is within 3 to 6 months. About 80% of patients will fully recover.
are currently being researched as possible treatments for tendinosis. One study found both modalities to be equally effective in treating tendinosis of the Achilles tendon and more effective than a 'wait and see' approach. Other treatments for which research is on-going includes vitamin E
, vitamin B6
, nitric oxide
and stem cell
injections.
that has been shown in studies on rats to speed the healing of tendons by increasing fibroblast activity. One case study showed ASTM resulting in full recovery in the case of an athlete suffering from chronic ankle pain and fibrosis, after an unsuccessful course of surgery and conventional physical therapy.
in controlling or preventing pathology to the synovial membrane of affected tendons, which commonly occurs in many cases of chronic tendinitis.
(SWT) may be effective in treating calcific tendinosis in both humans and rat
s. In rat subjects, SWT increased levels of healing hormones
and proteins
leading to increased cell proliferation and tissue regeneration in tendons. Another study found no evidence that SWT was useful in treating chronic pain
in the Achilles tendon.
has been found to increase the activity of fibroblast
s, leading to increased collagen fibrils and synthesis, which seems to speed up the regeneration and increase the regenerative capacity of tendons.
(NO) also appears to play a role in tendon healing and inhibition of NO synthesis impairs tendon healing. Supplementing with arginine
, the amino acid
that the body uses to form NO, may be useful in tendon healing. The use of a NO delivery system (glyceryl trinitrate patches) applied over the area of maximal tenderness was tested in three clinical trials for the treatment of tendinopathies and was found to significantly reduce pain and increase range of motion and strength.
Tendinopathy
Tendinopathy refers to a disease of a tendon. More specifically, it can refer to:* Tendinitis* TendinosisTendon injury arise from a combination of intrinsic and extrinsic factors; acute tendon injuries may be predominantly caused by extrinsic factors, whereas in overuse syndromes as in the case of...
or chronic tendon injury, is damage to a tendon
Tendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
at a cellular level (the suffix "osis" implies a pathology of chronic degeneration without inflammation). It is thought to be caused by microtears in the connective tissue in and around the tendon, leading to an increase in tendon repair cells. This may lead to reduced tensile strength
Tensile strength
Ultimate tensile strength , often shortened to tensile strength or ultimate strength, is the maximum stress that a material can withstand while being stretched or pulled before necking, which is when the specimen's cross-section starts to significantly contract...
, thus increasing the chance of tendon rupture. Tendinosis is often misdiagnosed as tendinitis due to the limited understanding of tendinopathies by the medical community.
Diagnosis
Swelling in a region of micro damage or partial tear can be detected visually or by touchPalpation
Palpation is used as part of a physical examination in which an object is felt to determine its size, shape, firmness, or location...
. Increased water content and disorganized collagen matrix in tendon lesion
Lesion
A lesion is any abnormality in the tissue of an organism , usually caused by disease or trauma. Lesion is derived from the Latin word laesio which means injury.- Types :...
s may be detected by ultrasonography
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...
or magnetic resonance imaging
Magnetic resonance imaging
Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...
.
Symptoms can vary from an ache or pain and stiffness
Stiffness
Stiffness is the resistance of an elastic body to deformation by an applied force along a given degree of freedom when a set of loading points and boundary conditions are prescribed on the elastic body.-Calculations:...
to the local area of the tendon, or a burning that surrounds the whole joint
Joint
A joint is the location at which two or more bones make contact. They are constructed to allow movement and provide mechanical support, and are classified structurally and functionally.-Classification:...
around the inflamed tendon. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiffer the following day as swelling impinges on the movement of the tendon. Many patients report stressful situations in their life in correlation with the beginnings of pain which may contribute to the symptoms.
Treatment
Tendons are very slow to heal if injured, and rarely regain their original strength. Partial tears heal by the rapid production of disorganized type-III collagenType-III collagen
Collagen alpha-1 chain is a protein that in humans is encoded by the COL3A1 gene, which is located on chromosome 2.- Function :Collagen alpha-1 chain is a fibrillar collagen that is found in extensible connective tissues such as skin, lung, and the vascular system, frequently in association with...
, which is weaker than normal tendon. Recurrence of injury in the damaged region of tendon is common.
Standard treatment of tendon injuries is largely palliative. Use of non-steroidal anti-inflammatory drug
Non-steroidal anti-inflammatory drug
Nonsteroidal anti-inflammatory drugs, usually abbreviated to NSAIDs or NAIDs, but also referred to as nonsteroidal anti-inflammatory agents/analgesics or nonsteroidal Anti-inflammatory medicines , are drugs with analgesic and antipyretic effects and which have, in higher doses, anti-inflammatory...
s combined with Physical Therapy
Physical therapy
Physical therapy , often abbreviated PT, is a health care profession. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, diagnosis, treatment/intervention,and rehabilitation...
, rest and gradual return to exercise is a common therapy, although there is evidence to suggest that tendinosis is not an inflammatory disorder, and that anti-inflammatory drugs are not an effective treatment and that inflammation does not cause tendon dysfunction. There are a variety of treatment options, but more research is necessary to determine their effectiveness. Initial recovery is usually within 2 to 3 months and full recovery is within 3 to 6 months. About 80% of patients will fully recover.
On-going research
Both eccentric loading and extracorporeal shockwave therapyExtracorporeal shockwave therapy
Extracorporeal Shockwave Therapy or ESWT is a method of treatment for multiple tendonopathies.Presently this technology is only approved in the US by the Food and Drug Administration for treatment of plantar fasciitis and tennis elbow...
are currently being researched as possible treatments for tendinosis. One study found both modalities to be equally effective in treating tendinosis of the Achilles tendon and more effective than a 'wait and see' approach. Other treatments for which research is on-going includes vitamin E
Tocopherol
Tocopherols are a class of chemical compounds of which many have vitamin E activity. It is a series of organic compounds consisting of various methylated phenols...
, vitamin B6
Pyridoxine
Pyridoxine is one of the compounds that can be called vitamin B6, along with pyridoxal and pyridoxamine. It differs from pyridoxamine by the substituent at the '4' position. It is often used as 'pyridoxine hydrochloride'.-Chemistry:...
, nitric oxide
Nitric oxide
Nitric oxide, also known as nitrogen monoxide, is a diatomic molecule with chemical formula NO. It is a free radical and is an important intermediate in the chemical industry...
and stem cell
Stem cell
This article is about the cell type. For the medical therapy, see Stem Cell TreatmentsStem cells are biological cells found in all multicellular organisms, that can divide and differentiate into diverse specialized cell types and can self-renew to produce more stem cells...
injections.
Soft Tissue Mobilization
Augmented Soft Tissue Mobilization (ASTM) is a form of manual therapyManual therapy
Manual therapy, manipulative therapy, or manual & manipulative therapy is a physical treatment primarily used by physiotherapists, chiropractors, osteopaths to treat musculoskeletal pain and disability; it most commonly includes massage therapy, joint mobilization and joint...
that has been shown in studies on rats to speed the healing of tendons by increasing fibroblast activity. One case study showed ASTM resulting in full recovery in the case of an athlete suffering from chronic ankle pain and fibrosis, after an unsuccessful course of surgery and conventional physical therapy.
Vitamin B6
Various studies have supported the efficacy of vitamin B6Vitamin B6
Vitamin B6 is a water-soluble vitamin and is part of the vitamin B complex group. Several forms of the vitamin are known, but pyridoxal phosphate is the active form and is a cofactor in many reactions of amino acid metabolism, including transamination, deamination, and decarboxylation...
in controlling or preventing pathology to the synovial membrane of affected tendons, which commonly occurs in many cases of chronic tendinitis.
Eccentric loading
Perhaps the most promising avenue of therapy is indicated in a line of research finding dramatic rates of recovery including complete remodeling of chronically damaged tendon tissue with eccentric loading.Inflatable brace
The use of an inflatable brace (AirHeel) was shown to be as effective as eccentric loading in the treatment of chronic Achilles tendinopathy. Both modalities produced significant reduction in pain scores, but their combination was no more effective than either treatment alone.Shock-wave therapy
Shock-wave therapyExtracorporeal shockwave therapy
Extracorporeal Shockwave Therapy or ESWT is a method of treatment for multiple tendonopathies.Presently this technology is only approved in the US by the Food and Drug Administration for treatment of plantar fasciitis and tennis elbow...
(SWT) may be effective in treating calcific tendinosis in both humans and rat
Rat
Rats are various medium-sized, long-tailed rodents of the superfamily Muroidea. "True rats" are members of the genus Rattus, the most important of which to humans are the black rat, Rattus rattus, and the brown rat, Rattus norvegicus...
s. In rat subjects, SWT increased levels of healing hormones
Insulin-like growth factor 1
Insulin-like growth factor 1 also known as somatomedin C is a protein that in humans is encoded by the IGF1 gene. IGF-1 has also been referred to as a "sulfation factor" and its effects were termed "nonsuppressible insulin-like activity" in the 1970s.IGF-1 is a hormone similar in molecular...
and proteins
TGF beta 1
Transforming growth factor beta 1 or TGF-β1 is a polypeptide member of the transforming growth factor beta superfamily of cytokines. It is a secreted protein that performs many cellular functions, including the control of cell growth, cell proliferation, cell differentiation and apoptosis...
leading to increased cell proliferation and tissue regeneration in tendons. Another study found no evidence that SWT was useful in treating chronic pain
Chronic pain
Chronic pain has several different meanings in medicine. Traditionally, the distinction between acute and chronic pain has relied upon an arbitrary interval of time from onset; the two most commonly used markers being 3 months and 6 months since the initiation of pain, though some theorists and...
in the Achilles tendon.
Tendon Bioengineering
The future of non-surgical care for tendinosis is likely bioengineering. Ligament reconstruction is possible using mesenchymal stem cells and a silk scaffold. These same stem cells were capable of seeding repair of damaged animal tendons.Vitamin E
Vitamin ETocopherol
Tocopherols are a class of chemical compounds of which many have vitamin E activity. It is a series of organic compounds consisting of various methylated phenols...
has been found to increase the activity of fibroblast
Fibroblast
A fibroblast is a type of cell that synthesizes the extracellular matrix and collagen, the structural framework for animal tissues, and plays a critical role in wound healing...
s, leading to increased collagen fibrils and synthesis, which seems to speed up the regeneration and increase the regenerative capacity of tendons.
Nitric oxide
Nitric oxideNitric oxide
Nitric oxide, also known as nitrogen monoxide, is a diatomic molecule with chemical formula NO. It is a free radical and is an important intermediate in the chemical industry...
(NO) also appears to play a role in tendon healing and inhibition of NO synthesis impairs tendon healing. Supplementing with arginine
Arginine
Arginine is an α-amino acid. The L-form is one of the 20 most common natural amino acids. At the level of molecular genetics, in the structure of the messenger ribonucleic acid mRNA, CGU, CGC, CGA, CGG, AGA, and AGG, are the triplets of nucleotide bases or codons that codify for arginine during...
, the amino acid
Amino acid
Amino acids are molecules containing an amine group, a carboxylic acid group and a side-chain that varies between different amino acids. The key elements of an amino acid are carbon, hydrogen, oxygen, and nitrogen...
that the body uses to form NO, may be useful in tendon healing. The use of a NO delivery system (glyceryl trinitrate patches) applied over the area of maximal tenderness was tested in three clinical trials for the treatment of tendinopathies and was found to significantly reduce pain and increase range of motion and strength.