Tendon conditions are a fairly common problem. Tendinopathies affect about 2-5% of people, but are much more common in athletic populations. Roughly 50% of sports injuries each year are tendon injuries.
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What is a tendon?
A tendon is a type of connective tissue in the body that connects muscles to bones. Tendons move our bones as our muscles tighten and relax. Tendons also help absorb some of the impact that muscles take during quick explosive movements, though they do not have as much elasticity as muscles do. This causes tendons to become injured when they are overstretched. Tendons are also commonly injured during repetitive activities, which causes tendonitis.
Common Tendon Conditions
There are several different conditions that can develop in tendons ranging from inflammation, degeneration, and tendon tears. The following are some of the most common tendon conditions:
Tendonitis and Tendonosis
Tendonitis means that there is inflammation in the tendon. This most commonly occurs in the elbow (tennis elbow), knee (patellar tendonitis), shoulder (rotator cuff tendonitis), wrist (De Quervain’s), and heel (achilles tendonitis). Tendonitis is an acute, short-term problem that is caused by overuse of the tendon.
When tendonitis becomes chronic, the tendon starts to show degenerative changes which is called tendonosis. The degenerative changes in the tendon include the death of tendon cells and disorganization of the tendon structure. These changes weaken the tendon and lead to long-term pain and functional loss.
When the attachment of a tendon to bone breaks off completely, it is called a rupture. This can happen due to trauma, sports injuries, or heavy lifting. The two most common tendons to rupture are the achilles in the heel and the proximal biceps tendon in the shoulder. Common symptoms of a tendon rupture include hearing a “pop” at the time of injury, pain, swelling, and functional loss. Tendon ruptures are diagnosed with imaging which may include an x-ray, MRI, or ultrasound. Surgery is required to repair the tendon in most cases of full tendon ruptures.
Tendon Sheath Inflammation
Every tendon is surrounded by a protective thin layer of tissue known as a tendon sheath. When the tendon sheath becomes inflamed, it is called tenosynovitis. Inflammation can develop between the tendon and the sheath with repetitive activities which causes pain, swelling, and stiffness. Tenosynovitis can also develop after an infection or injury. The hands, wrists, and feet are most commonly affected. Anti-inflammatory medication is usually required to treat tenosynovitis.
De Quervain’s Tenosynovitis
De Quervain’s is the most common form of tenosynovitis which occurs at the base of the thumb. This causes pain and swelling at the thumb side of your hand and wrist. De Quervain’s is caused by repetitive wrist and thumb use. One of the most common populations to get symptoms of De Quervain’s is new mothers who are repetitively lifting their newborns. Treatment consists of splinting and anti-inflammatory medications. In some cases, a cortisone injection may be used and rarely surgery is required.
Another form of tenosynovitis that affects the tendons that flex the fingers is called trigger finger. Swelling in the sheath of these tendons creates a sensation of locking or catching when you bend and straighten your finger. Other symptoms can include pain and stiffness in the fingers and thumb. The ring finger and thumb are the two most commonly affected digits. Trigger finger is most common in those with diabetes or rheumatoid arthritis, or those that perform forceful hand activities. Treatment involves a combination of anti-inflammatory mediation, splinting, corticosteroid injection, exercises, and surgery.
Rotator Cuff Strain
Partial tears are common in the muscles of the rotator cuff in the shoulder which is referred to as a rotator cuff strain. This leads to pain and difficulty raising your arm up, sleeping on the painful side, and lifting. Rotator cuff strains are most commonly caused by degeneration or overuse, but can also occur with trauma such as a fall or shoulder dislocation. Conservative treatment involves physical therapy and medication management. If conservative treatment is unsuccessful, surgery may be required to repair the tendon.
Patellar Tendonitis (Jumper’s Knee)
Tendonitis is common at the patellar tendon in the front of the knee which occurs frequently in sports that require jumping or running. Jumper’s knee is more common in adolescents and young adults, especially males. This condition is diagnosed clinically with a medical history and physical examination and can be confirmed with ultrasound imaging. Patellar tendonitis is treated conservatively with reducing activities that cause loading to the tendon and physical therapy. Surgery is only required in very rare cases and is used as a last resort.
When calcium deposits build up in tendons it is called calcific tendonitis. These deposits can become inflamed and cause pain. It an occur anywhere in the body but most commonly affects the shoulder joint. This condition is most common in people between the ages of 40-60 years and women are more likely to be affected than men. It is associated with aging and wear and tear, but the exact cause is not known. Calcific tendonitis is diagnosed with x-ray or MRI imaging and is treated with steroid injections and anti-inflammatory medications. In some cases, surgery may be required to remove the calcium deposits.
Summary: Common tendon conditions involve inflammation, degeneration, and tears and most commonly occur in the shoulder, knee, wrist, and heel.
You may have a tendon condition if you are experiencing pain or tenderness with some or all of the following symptoms:
- Difficulty moving your joint
- Feeling crackling or grating when moving your joint
- Muscle weakness and loss of strength
- Red, warm, skin in the painful area
Tendons are the most vulnerable to injury when they are tense or the attached muscle is maximally contracted or stressed and tension is applied quickly or obliquely. This makes it common for tendons to be injured during sporting activities. Tendons are also commonly injured with repetitive activities leading to tendonitis or tenosynovitis.
Some other factors that make it more likely to develop a tendon condition include:
- High-intensity training
- Muscle imbalances
- Incorrect training equipment or surfaces
- Lack of flexibility
- Lack of strength
- Too much weight on your tendon from lifting something heavy
There are many potential risk factors for the development of tendon conditions including medication side effects, co-morbidities, and repetitive activities. The following are the most common risk factors for tendon injuries:
- Age: with increasing age the elastic component of tendons tends to decrease which leads to the tendon being more easily injured.
- High cholesterol: when cholesterol is high, it can start to be deposited in the tendons which leads to a greater risk of injury(1)
- Higher BMI: obesity is associated with a higher risk of tendinopathy. tendon tear, tendon rupture, and complications after tendon surgery compared to non-obese people(2).
- Genetics: certain genes have been linked to the development of tendon conditions suggesting a genetic contribution to tendinopathy(3).
- Antibiotic treatment: fluoroquinolone antibiotics such as ofloxacin and levofloxacin have been reported to have a higher risk of tendon rupture as a potential side effect(4). Reports suggest that fluoroquinolone-associated tendon disorders are more common in people over the age of 60 years who are also taking corticosteroids.
- Kidney transplant: people who have history of a kidney transplant are at a higher risk of developing tendon disorders. This is possibly due to the medications required after the procedure.
- History of injured muscle: if a muscle is already injured, it is at a higher risk of complete rupture if the muscle continues to be subjected to high activity levels.
- Participation in strenuous activities: people who perform regular strenuous activities, including athletes, are at a higher risk for tendon injuries. The most common cause of tendon injuries in active people is a sudden increase in volume of activities.
Summary: There are several different risk factors for developing a tendon condition including age, weight, overall health, and medications.
Your doctor will discuss your health history and perform a physical examination when diagnosing a tendon condition. You will want to take note of the intensity of pain, what activities cause symptoms, the type of pain, how long symptoms have been occurring, and any recent changes in activity levels or new activities you have engaged in.
During the physical examination, your doctor will look at your range of motion and observe for signs of swelling and redness. Your doctor will also palpate the area to look for any tenderness.
If your doctor needs more information, they might order imaging tests. These could include:
- X-ray: your doctor might order an x-ray to rule out fracture or arthritis.
- Ultrasound: this type of imaging will show if there are any degenerative changes in the tendon suggesting tendinosis. It will also show if there are any tears or damage to the tendon.
- MRI: this shows the general health of your tendon and will reveal any injuries to the tendon if present.
Summary: Diagnosing a tendon condition involves taking a medical history, a physical examination, and imaging tests.
Treatment options depend on what type of tendon condition you have. If you are diagnosed with tendonitis or tenosynovitis your treatment options will likely be a combination of the following:
- Rest from aggravating activities
- Anti-inflammatory medication
- Corticosteroid injection
- Braces, splints, or orthotics
If you are diagnosed with tendinosis your treatment options will be different and include a combination of:
- Modifying activities that are aggravating, but not resting completely from activity
- Strengthening and stretching
- Physical therapy
If you are diagnosed with a tendon tear treatment typically involves medications and physical therapy and if not successful, surgery may be required. Tendon ruptures almost always need to be repaired surgically.
Summary: Treatment for tendon conditions depends on the diagnosis, but will involve a combination of activity modificaiton, medication management, exercise, and surgery.
Tendons connect muscles to bones and are injured when overstretched or overworked. Tendon injuries are most common in sports, but anyone can develop a tendon condition. Symptoms involve pain, swelling, difficulty moving, and stiffness. Diagnosis will involve a physical examination and imaging tests. Treatment options include activity modifications, medications, exercise, and surgery but depend on the type of tendon condition you have.