TENDINITIS

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”).   It is important to remember however, that the two problems are different from each other — very different.

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. And although tendon problems are often referred to generically as “tendinitis”, tendinitis is actually an incorrect and outdated term in virtually all cases.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 Immune System 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 calledosis”.   Thus the name, “tendon – osis”(tendinosis).  But what in the world 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 because it is what they’re used to and understand (I’m working on correcting this), their AMA-mandated 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 over 13 years 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 do most of the medical community continue to ignore their own profession’s scientific data — over two decades worth of data — and insist on treating tendinopathies with drugs and surgery?  Could it have anything to do with money?  Although I probably do not have to answer this for you, in a moment I will.

The real question we need to be asking is how this issue affects 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:

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.

f

f

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 du jour 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.  In other words, the problem is not cause by 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 cortisome and other steroids is that among their multitude of well-known and ugly side effects, corticosteroids actually deteriorate or “eat” collagen based connective tissue, including bone (HERE).

Hold on a minute. Isn’t collagen the very tissue that is deranged in an “osis” and needs to heal in the first place? 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 — at least 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.

d

 

AREAS

MOST COMMONLY AFFECTED

BY TENDINOSIS

t

Sometimes Tendionosis is impossible to distinguish from Fascial Adhesion and microscopic scar tissues / fibrosis that occur in the body.  They must both be broken down so they can be remodeled.  Sometimes there is excess calcium build up at the point where the tendon anchors to the bone (Calcific Tendinosis).  This must be broken 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. 

d

  • SUPRASPINATUS TENDINOSISThe 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.
  • THUMB TENDINOSIS: This extremely common problem can be debilitating.  You will frequently hear it referred to as DeQuervain’s Syndrome (in 15 years, I have never seen a case of DQS we could not solve).
  • SPINAL TENDINOSIS: Although most people never think of it, the potential for developing Spinal Tendinosis is greater than you ever imagined possible.
  • KNEE TENDINOSIS: Often referred to as “Patellar Tracking Syndrome,” this condition is arguably the single most common reason that people visit a Sports Physician.
  • 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.
  • 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.

d

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.

f

f

f

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 these are going to save a lot of people, a lot of time and money by helping a significant number of them 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 http://www.DestroyTendinitis.com 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 benefit to a significant number of patients, 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 (in fact, sometimes they are the very reason that people get worse with therapy).

Be aware that because of its microscopic nature, the collagen derangement associated with tendinopathies will rarely 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.

f

f

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 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 I call 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 this sort of treatment method 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.

f

f

WARNING       WARNING

BRUISING

AHEAD

Because our “Tissue Remodeling” consists of actually breaking the adhesions / restrictions that cause so many of the symptoms associated with tendinosis, 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 will frequently have Fascial Adhesions associated with them).

Let me go on record by saying that not all patient’s “tendinitis” (Tendinosis) is due to overuse.  A few years ago, I actually caused an elbow tendinosis in myself 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.  If you want more information on this subject, go to my TENDINOSIS pictures and research page.   If not, continue on to…..

OTHER PROBLEMS WE HELP WITH

25 responses to “TENDINITIS

  1. gavin

    Hey Dr. Russ. 21 year old male. diagnosed with tendinosis in both wrists on the ulnar side via mri (bad weightlifting technique+guitar+computer). took it easy for awhile and iced vigorously but a year later and i have not been able to fix it. have recently been having similar “tendinitis” pain in my elbows and Achilles despite doing no physical activity that could have caused these . It is strange to me that these injuries have effected both sides equally. Im beginning to wonder if i have a food allergy causing these effects or some nutrient deficiency. Any ideas?

  2. Judith

    I was diagnosed with addhesive capsulitis of the hip. Where do I go from here. I live in Vancouver Canada. Which doctor or treatment you recomend me. Your recomendation is really much appreciated.

    Thanks

    Judith

  3. Dianne Korber

    I have a sudden onset after starting a new job of wrist pain which started first only on palm side of wrists and then had a trigger thumb and pain in hands. This has been since the end of March and OT is not helping. I have been told I have flexor tendonitis and possibly CTS. Never prior to this new job which had horrible ergonomics have I had wrist or hand pain. Both wrists on the top and bottom and all fingers hurt, burn and tingle which is a wandering type pain… moves around. I am desperate to get relief… any ideas. Pain also changes in severity throughout day. Heat and compression feel good on hands. Ice no longer does but haven’t done that in a while.

  4. Vee

    Hello, I am a pianist, although I have not played much in the past 2 years except for a little demonstration in lessons with my students. I don’t type a lot but do answer email everyday. Two years ago, I worked in a carwash squeeging the floor for 3 weeks straight. Needless to say, I could barely move my hands after and suffered a lot of pain in both palms and forearms. I’ve been to several physiotherapists who all believe I have nerve entrapment because I have burning pain in my palms – no tingling or numbness though. I either have a lot of pain or burning, sometimes the burning becomes so strong I can’t move my hands. I’ve had a lot of physio (treating nerve entrapment) and chiro for soft tissue manipulation in my forearms – which I think did help as my forearms don’t usually get sore any more. Saw a neurologist and hand specialist who said I do not have nerve entrapment or carpal tunnel – that the burning I now feel should go away if I let myself rest and stop massaging my hands as I’m reinforcing a memory of my injury. My forearms certainly aren’t as tight as they use to be. But I still suffer from burning in the palm, my thumb muscles do cramp a little and I can’t really play the piano or type for very long. Could I have tendinosis in the palm of my hands?

  5. Jannice

    I’ve been reading your articles online and they have been very fascinating. I am a runner (I have to admit I am one of the worst offenders out there) and am 35 years old of age. I’ve have never had tendonitis and didn’t know realize how serious this injury was until seeing how long it is taking me to heal.

    It started in the beginning of November 2013 when I was just walking and I felt a slight tinge (kind of like something popped out of place) on my left ankle and kept walking no problem. The next morning, it bothered me a bit but I didn’t think anything of it so I went for a 5 mile run. Needless to say I was limping afterwards and couldn’t bear any weight on my left foot so I made an appointment with an Orthopaedic thinking I maybe broke something. He ruled out fracture and said that I had “insertional tendonitis” He recommended an ankle brace, which I thought I can just tough through this. I continued running for a few weeks and the problem got worse to the point where it was really really painful for me to walk. I went back and he recommended an air cast that goes up to the knee which I wore for about 3 days (which by the way put my back completely out of wack) so I compensated by wearing wedge heels on the other foot.

    Well….needless to say my other foot started bothering me and it was the same kind of pain, so I banned my aircast and stopped wearing it and went to 2 sessions of acupuncture, which kind of helped. Later I found out that I had “posterial tibial tendonitis.” My left foot is about 95 %of the way healed but my right foot is still bothering me! I have been battling this off and on for quite some time. There is some inflammation/puffiness on the inside of my ankle right under my ankle bone and some on the inside of my foot along with some tingling sensations from time to time and a dull ache. In the meantime, I’ve been to a foot and ankle doctor and got custom orthotics made (which are superhard) but I’ve noticed that has helped in the healing process ( I can stand longer w/o pain). My foot and ankle doc told me that I’m bowlegged so I pronate. I’ve also been seeing a chiropractor and physical therapist. It is just a stubborn injury that is taking forever to go away. I have not been exercising at all other than the exercises my PT gives me since I’ve been seeing him for the past month which are mostly core and ankle strengthening exercises.

    I definitely think it maybe muscular in nature as I get muscle spasms and tightness in my calves and I think about the pain all the time. How can I make this injury heal faster? I’m so scared that this is going to be permanent since it has been going on so long. If this is permanent I think I’m going to shoot myself. (not really) Everyone tells me that this will heal and it just takes time but I think 5 months is too long. Do you think rest at this point given that I didn’t rest initially will help? And if that is the case, what kind of rest. Should I stay completely off the foot and maybe go back to wearing the aircast? My fear is that this will bother my left foot. I was even thinking about a wheelchair at one point, which is going to not work unfortunately. Any help/advice/recommendations would be really really appreciated. I’m desperate at this point!!

    • Hello Janice,

      There are a couple of things that catch my eye here. Firstly, while I have occasionally seen bowlegged folks who are pronators, this is rarely the case. Bowed legs are almost always indicative of supination — a problem that has the potential to be every bit as severe as pronation, but must be dealt with in a totally different fashion (don’t ask me how I know). As always, when it comes to feet, Shawn Eno of Xtreme Footwerks is the man to see. He is a biomechanical genius who literally saved my life and career a number of years ago. You almost certainly need some Tissue Remodeling done in this area as well (this is a large part of the thrust of this site). COLD LASER is a wonderful modality for helping any healing process, including Tendinosis. I would also recommend that in the future, you back way off the cardio, take up sprinting (when you are able), and begin engaging in some strength training. Numerous articles on this on my http://www.DoctorSchierling.com website.

      Sincerely,
      Dr. Russ

  6. stuart wemyss

    Very interesting indeed! I have had a knee injury for over 3 years now and it has been ultrasound scanned on many occasions. Every time my right knee shows a patellar tendon that is much thicker then my left and there is always a lot of blood vessels showing up. I feel strong pain where the patellar tendon joins the knee cap, when on stairs hills or ladders and discomfort when walking normally. I had an MRI scan and it didn’t show any sign of tendinosis but did have prepatellar bursitis showing up. I have been telling the dooctor that isn’t where the pain is. So now they seem intent on treating bursitis rather than where my pain is just because the tendinosis isn’t on the MRI!

  7. Jessi

    I have what Im being told is acute tendonitis. I have severe pain and swelling. Sometimes in the shoulder, sometimes my elbow and even my wrists. I take Celebrex daily. It is no help to me. The pain is so severe that for a few days I cant even move those joints. Do I have any other options?

  8. Roark

    Obviously not ideal, but it sounds like one way to recover from tendinosis is to eventually tear the tendon and allow it to heal back together with new collagen? I was told by my ortho that a lot of times the tear is a result of slowly progressing tendinopathy anyways. But I hope after it is healed up with newly arranged fibers and cells, that will fix the original tendinopathy.

    • Hello Roark,

      That is one way. Just be aware that tendons heal extremely slow. Tissue Remodeling is like a controlled form of trauma that breaks down old and tangled tissue, causing fibroblastic activity to create new tissue. When aligned by the proper stretching and then strengthened by exercises, it can work quite nicely.

      sincerely,
      Dr. Russ

  9. Anita Yenigalla

    I have been diagnosed with a high grade torn supraspinatus torn tendon in my right shoulder, pl help. Thanks . Anita

  10. Professor / Dr Brian A Rothbart

    Excellent blog on the differences between tendinosis and tendonitis. Very salient if you are a researcher in the area of chronic pain. Less important (or of no importance) if you are a chronic pain sufferer looking for a solution to end your chronic muscle and joint pain.

    Both tendinosis and tendonitis are symptoms (just like pain is a symptom). In order to eliminate the symptom you must first determine the cause and then treat that cause directly.

    Professor/Dr Brian A Rothbart

  11. Hi I have just been diagnosed with patella tendonosis in my right knee, unfortunately it was not diagnosed for three years. Its in the proximal pattelar tendon and also the distal quadrangle tendon and, “proximal and patellar tendonosis is quite extensive over full thickness of tendon” it’s bloody painful. I have been declined surgery and have now fallen through the gaps of my countries health system. I don’t know what to do to go about fixing my knee other than stop working as a mechanic. I broke my left tibia 7 years ago and it turned into after having a rod inserted turned in a complete disaster. Bone infection and 4 oeratipns to save it. It took around a 14 months to be able to walk properly again. All the while favoring my good leg, which unfortunately now, and has done for at least three years developed tendonosis. The only way I can receive funding for correct medical treatment is to prove the tendonosis is a direct result of my accident seven years ago. Or as you pointed out tendonosis can be sustained in an accident. It’s possible I didn’t notice tendonosis in my right leg when my left leg continued to sustain trauma after trauma. I would love for you to comment on this and possibly point me in some kind of direction. Thanks heaps

  12. Wayne Bauer

    Hi, I have been a PT for 25 years and have been a tendinosis sufferer for about 20 years. Recently I have begun deep tissue and transverse friction massage to my subscapularis tendon with promising results. I have seen so much “Anti-inflammatory ” treatments fail it is silly anyone would still try them. I really found your website informative and believe everything you state. Keep up the good work!

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s