Tendons attach muscles to bones. The most common form of tendon injury is tendonitis, which is acute inflammation of the tendon. When the inflammation is chronic and there is continued stress on the tendon, the tendon may have tendinopathy. With tendinopathy, the tendon is “mushy”, not as able to tolerate forces through it, and gets irritated more easily.
Common types of tendinopathy
Certain types of tendon issues are more common. The patellar tendon is directly underneath your kneecap. Young athletes who irritate the patellar tendon, such as with jumping may get patellar tendinitis, which is also called runner’s knee or jumping knee. If the pain continues, it could develop into chronic patellar tendinopathy that makes it hard to bend the knee, do stairs, jump, run or do similar activities.
One of the most common areas in the shoulder for tendinopathy is in the biceps, with pain in the front part of the shoulder. People who work at a desk or do a lot of forward motion all day may develop this tendinopathy.
The Achilles tendon on the back of your heal may also have tendinopathy. Chronic tendon dysfunction will cause thickening and calcification in that region, and you may develop a bone spur or enthesophyte in that area. If you have a painful bump on the back of your foot, it may be due to this bone spur.
Finally, lateral epicondylitis is probably the most common issue. There’s typically no injury, but rather vague, achy pain on the outside of the elbow. It will hurt when you’re driving in the car or try to pick up a cup of coffee. Usually this tendinopathy happens after a lot of repetitive tasks such as hammering, mixing or holding a baby.
Tendinopathy symptoms
Usually there’s no drama to tendinopathy—it just hurts. There will be a gradual loss of function as well as pain and stiffness. Some people will say it feels like it pops. Often it will hurt as you stretch it out.
There may be an increase in activity for some types of tendinopathy, but Achilles tendinopathy tends to happen with no change in activity.
Tendinopathy risk factors
There are many risk factors associated with tendinopathy. Some risk factors you can control, while others you cannot control.
- A history of tendon dysfunction or tendinopathy puts you at risk for further tendon issues.
- Age over 35.
- Body mechanics. Since a female pelvis is wider, it mechanically puts additional stress on the side of the hip. I see many women with side of the hip pain related to gluteus tendinopathy.
- Muscular weakness, like general muscle atrophy or fatigue, increases the risk. We need a strong muscle to have a strong tendon. Our muscles atrophy unless we’re training them. People may hesitate to do an exercise because they worry about hurting themselves, but fear of using your muscles can cause pain.
- Genetic predispositions.
- Overtraining, both by endurance athletes or people who do a lot of repetitive motions in daily life such as cleaning, painting, or hammering.
- Poor ergonomics, such as constantly bending your head to look at your phone.
- Some medications. Statins for cholesterol and some antibiotics can increase your risk.
- Metabolic diseases such as diabetes, gout, or inflammatory bowel disease.
How is tendinopathy diagnosed?
Tendinopathy is generally diagnosed by pain over the tendon. Although some tendons are very deep or are hard to put pressure on, most of the time the tendon hurts when you touch it. There may be swelling, such as in the Achilles tendon. It will also hurt when you activate the muscle: if it’s on your shoulder, for example, it will hurt when you use the shoulder.
Sometimes we’ll take x-rays to see if anything else is happening in the joint. Many times on the x-ray you’ll find bone spurs. We may also do an ultrasound so you can see what happens in real time when you use the muscle.
You’ll see microscopic tearing in the tendon, and your body will put calcium deposits down within the tendon to stabilize it. Those deposits typically correlate with pain and inflammation. The chronic inflammation and irritation will cause the tendon to become thick and weakened.
What treatments are available for tendinopathy?
Activity modification is the first step of treatment, but may be difficult to do depending on which tendon is affected. Even if the activity cannot be avoided, correcting the mechanics on the way that you’re doing the activity can reduce pain. Bracing to restrict the motion through the tendon can help, as can treatments such as a walking boot or crutches.
The most important part is strengthening the muscle, so physical therapy is very critical. Making the muscle stronger makes the tendon more resilient and helps with overall pain, but it’s not a quick fix and can take six to twelve weeks of physical therapy.
Anti-inflammatories can be used in the short term to temporarily help with pain.
Steroid injections may also help with pain, but for chronic tendinopathy the pain relief is relatively short-lived and often wears off after a couple of weeks. If physical therapy isn’t done, the pain comes right back when the steroid injection wears off. Additionally, certain tendons cannot have steroid injections since steroids can increase your risk of tendon rupture.
Tendon fenestration is another technique that may be used, where a needle stabs the tendon to bring blood flow to the area and encourage healing. A local anesthetic is used to reduce pain.
Additionally, platelet-rich plasma (PRP) treatment may be used, where your platelets are injected into the diseased tendon.
If the tendon is not responding to the non-surgical options, especially if it ruptures, surgery may be considered.
Frequently asked questions
Is plantar fasciitis a type of tendinopathy?
Fascia is more fibrous than tendon tissue, but it is very, very similar in a few ways. The plantar fascia is very closely related to the Achilles. In many cases, both the plantar fascia and the Achilles tendon are involved. The initial exercises to treat both are very similar as well.
Would dry needling help treat tendinopathy?
Dry needling is very similar to the tendon fenestration procedure, just with a smaller acupuncture needle. I often put it on physical therapy prescription for patients to consider as it can help with the pain in the short term to help make physical therapy less painful.
What steps can you take to help prevent tendinopathy?
Staying active but not too active and not increasing exercise too quickly can help. I tell people to increase exercise intensity and volume by about 10% per week. Additionally, making sure that you’re eating enough protein and carbs to support your muscle growth, staying mobile, and making sure that you’re doing balanced exercises.
How long does it take tendinopathy to heal?
It can take many weeks for tendinopathy to heal. You may be doing physical therapy for six to twelve weeks. In some cases, such as for Achilles tendinopathy where it is difficult to avoid using the tendon, you may need 16 weeks of physical therapy. For tennis elbow (lateral epicondylitis), it may take a year for the pain to go away.
Can tendinopathy be mistaken for arthritis or other conditions? How do you tell them apart?
Yes, there are similarities, and many people have both. We often get x-rays to evaluate the joint, which can effectively tell us if there is also arthritis present. Since the presentation is similar in both, it is hard for patients to know what they’re dealing with without some help from our end.