TENDINITIS

TENDINITIS -vs- TENDINOSIS

The first thing you need to know about Tendinitis is that you will see it spelled two different ways: “Tendinitis” and / or “Tendonitis”.  Who really cares?  Either way you slice it, it’s the same ugly stuff! (the same is true with the alternative spellings “Tendinosis” / “Tendonosis”).

Tendons are the tough, white, “cords” that connect muscles to bones, and are the least elastic of the Elastic, Collagen-Based Connective Tissues. Government statistics tell us that overuse injuries of the body’s various muscle tendons is a leading reason for doctor visits. Although tendon problems are often referred to generically as “tendinitis”, tendinitis is actually an incorrect and outdated term in the vast majority of cases.

Over the past decade, medical research has shown conclusively that the major cause of “tendinitis” is not inflammation (aka “itis“).  But this is not really not anything new. For decades, the scientific research has been leading medical researchers to the conclusion that although the chemicals that we refer to collectively as “inflammation” are probably present in tendinopathies; inflammation itself is rarely the primary culprit. 

So, if “itis” (inflammation) is not the primary cause of most tendon problems, what is?  Research has shown us that the primary culprit is something called “osis”.   Thus the name, “tendon – osis”(tendinosis).  But what the heck is osis?

The suffix “osis” indicates that there is a derangement and subsequent deterioration of the collagen fibers that make up the tendon. The truth is, even though doctors (self included) still use the term “tendinitis” with their patients (I’m working on correcting this), their AMA-mandated ICD-9 Diagnosis Codes almost always indicate that the problem is “tendinosis” or “tendinopathy” (tendinopathy indicates an unspecified tendon problem).

Is this differentiation between “tendinits” and “tendinosis” really that important, or am I simply “splitting hairs” and making a big deal out of nothing?  Instead of answering that question myself, I will let one of the world’s preeminent orthopedic surgeons and tendon researchers answer it for me.

“Tendinosis, sometimes called tendinitis, or tendinopathy, 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 micro-tears in the connective tissue in and around the tendon, leading to an increased number of tendon repair cells. This may lead to reduced tensile strength, thus increasing the chance of repetitive injury or even tendon rupture. Tendinosis is often misdiagnosed as tendinitis due to the limited understanding of tendinopathies by the medical community.” Tendon researcher and orthopedic surgeon, Dr. GA Murrell from an article called, “Understanding Tendinopathies” in the December 2002 issue of The British Journal of Sports Medicine.

The information in the preceding paragraph (which, by the way, was not “new” when it was published nearly a decade ago) is so important as to be considered revolutionary.  The problem is that most of the medical community has, as Dr. Murrell stated above, “a limited understanding of tendinopathies“.  Why?  Why do more doctors not grasp what is going on with the majority of Tendinopathies?  Why does most of the medical community continue to ignore their own profession’s scientific data — over two decades worth of data and continue to treat tendinopathies with drugs and surgery?  Could it have anything to do with money?  More on this shortly?

The real question is how does this affect you, the Chronic Pain sufferer?  It means that if you are dealing with a chronic tendinopathy, you are probably being treated using a model that is at least 25-30 years behind the times as far as the medical research is concerned!  You think not?  Read what Dr. Warren Hammer, board certified Chiropractic Orthopedist (in practice since the late 1950′s), had to say about the subject in a 1992 column from Dynamic Chiropractic:

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The American Academy of Orthopedic Surgeons has provided a new classification of tendon injuries….  In the microtraumatic tendon injury the main histologic features represent a degenerative tendinopathy thought to be due to an hypoxic [diminished oxygen] degenerative process. The similarity to the histology [study of the cells] of an acute wound repair with inflammatory cell infiltration as in macrotrauma seems to be absent.  A new classification of tendon injury called “tendinosis” is now accepted.

“Tendinosis” is a term referring to tendinous degeneration due to atrophy (aging, microtrauma, vascular compromise). Histologically there is a non-inflammatory tendinous degeneration due to atrophy (aging, microtrauma, vascular compromise), as well as a non-inflammatory intratendinous collagen degeneration with fiber disorientation, hypocelluarity, scattered vascular ingrowth, and occasional local necrosis or calcification.

People; if your doctor is still treating you for “tendinitis” and not tendinosis, he / she is caught in a time warp. Plainly stated, tendinosis is not an inflammatory condition (itis)!  It is a degenerative condition (osis)! Not only is there debate over whether or not tendinitis actually exists, as you will see in a moment, the (anti-inflammation) medications that you are being prescribed are actually creating more degeneration.

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Best Treatment for Tendinosis?

???Anti-Inflammatory Medications???

Even though medical research has conclusively shown us for over two decades that tendinopathies have as their primary cause of pain and dysfunction; tissue derangement ——- not inflammation; anti-inflammation drugs are still the medical profession’s treatment of choice for tendon problems. It’s not difficult to see why this is (still) not working:

• Although there is undoubtedly a certain amount of inflammation present with tendinosis, research has conclusively shown that the problem is not primarily inflammation.
• Scientific studies have actually shown that non-steroidal anti-inflammatory medications (NSAID’s) such as Tylenol, Nuprin, Ibuprofen, Naproxen, Celebrex, Vioxx (oops — one of the #1 drugs in America for 10 years running, is off the market because it was found to be KILLING PEOPLE), & numerous others, actually cause injured collagen-based tissues like tendons, ligaments, muscles, fascia, etc, to heal up to 33% weaker, with as much as 40% less tissue elasticity.

Cortico-steroid injections are even worse. The dirty little secret of treating tissue injuries with steroids is that among their multitude of well known and ugly side effects, cortico steroids actually deteriorate or “eat” collagen based connective tissue, including bone!

Hold on a minute. Isn’t collagen the very tissue that is deranged in an “osis” and needs to heal? Of course it is! This is why corticosteroids are a known cause of degenerative arthritis and osteoporosis, not to mention a whole host of easily-verified systemic side effects. The fact that steroid injections are ridiculously degenerative is why doctors “ration” or limit the number of steroid injections a person can receive —- even if these injections seem to be easing your pain (which they often do — temporarily).

The Journal of Bone and Joint Surgery has reported that cortico-steroids are so degenerative that if you have more than one injection in the same joint over the course of your lifetime; your chance of premature degeneration is (GULP) 100%!  Ultimately, the problem of cortico-steroids (or NSAID’s for that matter) being used to treat tendons or other collagen-based tissues, is that short term relief is being traded for long term (and often permanent) damage.  In other words, tomorrow is being traded for today.  Kind of reminds you of our government’s short-sighted fiscal policies, doesn’t it?

Collagen is the building block of all connective tissues, including tendons (you should have learned a great deal about collagen on our FASCIAL ADHESION PAGE). If one looks at normal collagen fibers from tendons or other elastic connective tissues under a microscope, each individual cell must line up parallel to the surrounding cells.  This allows for maximum tissue flexibility (sort of like well-combed hair).

With tendinopathies (whether traumatic or repetitive — yes, trauma can cause tendinosis), the tissue uniformity becomes disrupted and unorganized, causing tissue restriction and a severe loss of function. This in turn, causes a loss of flexibility, increased rigidity, and stiffness in the tissue (sort of like knotted hair or a hairball  — or gristle in a bite of steak).

This leads to a loss of strength and function, which ultimately means that you end up with pain and dysfunction of the affected joint or area.  As we have already shown, loss of normal function is the known cause of joint deterioration. Anyone who has suffered through Chronic Tendinosis knows that it can be debilitating.

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AREAS

MOST COMMONLY AFFECTED

BY TENDINOSIS

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Sometimes Tendionosis is impossible to distinguish from FASCIAL ADHESIONS and microscopic scar tissue.  They must both be broken.  Sometimes there is excess calcium build up at the point where the tendon anchors to the bone.  This must be broken up as well.  Because the models for understanding the elastic, collagen-based tissues (ligaments, tendons, muscles, and fascia), are virtually identical to each other; the models for treating these tissues are likewise identical. 

As you might imagine, this is fantastic news for the patient.  Bear in mind that I have not included each and every specific area you can get tendinopathy.  You can get tendinopathy anywhere that you have a tendon.  The following list happens to be the areas that I treat most frequently in my clinic.

IMPORTANT:  Please note that some muscles only cross one joint.  However, many muscles cross two joints.   muscles that act on more than one joint have a greater propensity for problems.  It also means that one muscle has the potential to give you problems (including tendinosis) at two different joints. 

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• ROTATOR CUFF TENDINOSIS:  The Rotator Cuff is made up of four muscles that surround the shoulder.
  

• SUPRASPINATUS TENDINOSIS:  The Supraspinatus Tendon is not only the most commonly injured of the Rotator Cuff Muscles, it is the most common to find tendinopathy in as well.
  

• TRICEP TENDINOSIS: Tricep Tendinosis is rare.  About the only people I ever find it in is carpenters (hammering) and weightlifters.  However, here is the webpage.
  

• BICEPS TENDINOSIS: Because both heads of the bicep muscle have attachment points in the front of the shoulder, Biceps Tendinosis is frequently mistaken for Bursitis or a Rotator Cuff problem.
  

• LATERAL EPICONDYLITIS (Tennis Elbow): Although I have never seen anyone who got this problem playing tennis (hey, I live in the Ozarks), it is nonetheless extremely common.

• MEDIAL EPICONDYLITIS (Golfer’s Elbow): Not quite as common as Tennis Elbow above.

• WRIST / FOREARM FLEXOR TENDINOSIS: This is tendinopathy on the palm side of the forearm and wrist.

• WRIST / FOREARM EXTENSOR TENDINOSIS: This is tendinopathy on the backhand side of the forearm and wrist.

• THUMB TENDINOSIS: This extremely common problem can be debilitating.  You will frequently hear it referred to as DeQuervain’s Syndrome.

• GROIN (Hip Adductor) TENDINOSIS: I have included Tendinosis of the Groin under “Hip Flexor Tendinosis” below.
  

• HIP FLEXOR TENDINOSIS: Hip Flexor Tendinosis will manifest in the upper front thigh or groin area.

• PIRIFORMIS TENDINOSIS: This problem is related to PIRIFORMIS SYNDROME, and causes pain in the butt (sometimes with sciatica as well).

• SPINAL TENDINOSIS: Although most people never think of it, the potential for developing Spinal Tendinosis is greater than you ever imagined possible.
  

• KNEE TENDINOSIS: This is arguably the single most common reason that people visit a Sports Physician.

• QUADRICEPS / PATELLAR TENDINOSIS: A form of Knee Tendinosis

• HAMSTRING TENDINOSIS: Hamstring Tendinosis can cause knee, hip, and buttock problems.

• ACHILLES TENDINOSIS: Achilles Tendinosis is found in the large tendon in the very back of the lower leg / ankle.
  

• ANKLE TENDINOSIS: This common Tendinosis can typically be dealt with by following a few simple procedures.

• TIBIALIS ANTERIOR TENDINOSIS: This is related to the category above, and is typically found in the front of the ankle.

• POSTERIOR TIBIAL TENDINOSIS: This is related to the category above, and is typically found near the bony knob on the inside of the ankle.

• APONEUROSIS / APONEUROTICA TENDINOSIS: Although you have probably never heard the word before, “Aponeurosis” are flattened out tendons.  They are almost always referred to as fascia, but technically this is incorrect.

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As I said earlier, this list is in no way considered “comprehensive”.  It is simply a list the most common areas that I treat.  The truth is that Tendinopathies can be found virtually anywhere that there is a tendon —- including the spine.

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TENDINOSIS

CAN WE FIX IT?

Let me begin by saying that I cannot help everyone’s Tendinopathy.  And yes, I am very aware that there are thousands of websites out there giving all sorts of “free” do-it-yourself advice on how to fix these problems without going to a doctor.   Most of this advice concerns “common sense” treatments that everyone should try before seeking medical care. 

These lists frequently include things like stretching, icing, resting, special exercises, eating an anti-inflammatory diet, drinking enough water, special supplements, etc.  All of these are great, and highly recommended by me!  The truth is, websites like this are going to save a lot of time and money by helping a significant portion of the population get over minor tendinopathies on their own without jumping on the Medical Merry-Go-Round. 

This is not the group of people that I created this website for.

There is a significant portion of the tendinosis-suffering population who have tried all of these things.  They have also tried things like NSAIDS, cortico-steroid injections, cortico-steroid pills, pain pills, muscle relaxers, antibiotics (believe it or not, I have seen this several times — some of which, like Cipro, actually cause tendon weakness and rupture), TENS, braces & supports of all kinds, blood-transfusion-platelet-injection-therapy, high powered ultrasound (a form of litho-tripsy called arthro-tripsy), prolo-therapy (sugar water injections), all sorts of surgeries, and heaven only knows what else! 

Hey; if all that stuff actually worked, would you be sitting here wasting your time reading a website about Chronic Pain caused by Tendinosis?

The bottom line is that if your pain is being caused by adhesions, restrictions, and microscopic “scarring” in the collagen fibers that make up the affected tendon (or the fascial membranes that attach to the tendon), you are going to have a hard time dealing with it using S.M.O.P. (Standard Medical Operating Procedures).

Although these various treatments may cover the symptoms for awhile, standard medical therapies such as those listed previously, are not likely to help with tendinosis —- especially on a long-term basis. And although stretching and specific exercise can be of tremendous benefit, most clinicians tend to put the cart in front of the horse. Those things will not be effective until after the tissue adhesion has been removed (broken), except in the most minor cases.

Be aware that because of its microscopic nature, the collagen derangement associated with tendinopathies will frequently not show up with even advanced diagnostic imaging (this is true even for MRI, unless your doctor is using a brand new machine with an extra large magnet, or your problem is especially severe). And whether it shows on the MRI or not, will not really change the way that your doctor treats the problem.

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EFFECTIVELY TREATING TENDINOSIS

AT ITS SOURCE

If tendinopathies do not always show up well on the diagnostic tests that are run by your doctor, how in the world can a hillbilly chiropractor practicing in the Ozarks of rural Missouri, determine whether or not this micro-derangement of a tendon’s collagen fibers is present and potentially causing your pain and dysfunction?

I use something called I.I.R.E.C-B.C.T.

I.I.R.E.C-B.C.T. stands for Instrument Induced Remodeling of Elastic, Collagen-Based Connective Tissues. Although it has only been around for a couple of decades in its present form, the Chinese have used something similar for several thousand years.  This specific treatment enables the treating physician to “break” the microscopic adhesions and collagen derangements that make up injured, abused, or overused tendons.

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WARNING       WARNING

BRUISING

AHEAD

Because our “Tissue Remodeling” consists of actually breaking the adhesions / restrictions that cause so many symptoms, there is often some bruising associated with the technique.  Microscopic scarring is dense, inelastic, random, and unorganized tissue —– not what anyone really wants. But nonetheless, scars (even the microscopic kind) are living tissue with a blood supply.

This means that when I “break” the adhesion, there will be some internal leaking of red blood cells from the scar’s capillary bed, into the surrounding tissue. In plain English, this means that you will have a bruise. When I break FASCIAL ADHESIONS, it is not uncommon that this bruising can be really really ugly. With tendinopathies, the bruising is not usually usually so noticeable (Bear in mind, however, that many TENDINOPATHIES have FASCIAL ADHESIONS associated with them).  See our BRIUSING PAGE.

Let me go on record by saying that not all patient’s “tendinitis” is due to overuse.  A few years ago, I actually caused an elbow tendinitis by lifting a child’s bike out of the back of my truck with one hand.  I felt it “pop” and within a couple days, had enough pain that it limited my ability to function normally, until I had a TISSUE REMODELING TREATMENT.

I have also seen many tendinopathies that were actually caused by getting a muscle or tendon hit or bumped hard.   If you got hit hard enough to disrupt collagen-based fibers in ligaments, tendons, or fascia; you very well may have a problem that we can help with.

As you are beginning to see, the most up-to-date models for treating virtually all connective tissues are surprisingly similar.   This allows us to successfully treat an extremely wide variety of problems (including tendinopathies of all sorts) using similar methods.

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