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tendonitis (tendon injury)

Etiology: 1) trauma a) strain 1] excessive tensile forces on musculo-tendinous junction resulting in stretching & tearing 2] risk factors: lack of flexibility, insufficient warm-up, local corticosteroid injection, fatigue, deconditioning, recent injury b) contusion 1] a result of high velocity compressive forces 2] the more contracted the muscle at the time of injury, the worse the injury 2) overuse (tendinosis) a) repetitive microtrauma exceeds the capacity of repair processes & accumulates over time b) tendon injuries are the most common overuse conditions encountered in sports injuries c) the tendon body & the site of bony insertion (insertional tendonitis) are the 2 most common sites of overuse injury d) activities that require repetitive overhead movement 3) inflammatory arthropathy unlikely if isolated tendon involvement a) rheumatoid arthritis (RA) b) systemic lupus erythematosus (SLE) 4) risk factors a) extrinsic risk factors 1] training 2] play or work surfaces 3] equipment or footwear 4] biomechanics of sport or activity generally determines the tendon(s) at risk b) intrinsic risk factors 1] anatomic malalignment 2] leg length discrepancy 3] muscle imbalance 4] muscle weakness 5] inflexibility 6] excessive joint laxity 7] associated diseases a] rheumatoid arthritis b] hypothyroidism c] diabetes mellitus 8] previous injury improperly or incompletely treated Clinical manifestations: 1) general a) pain on active range of motion - passive range of motion is NOT painful b) range of motion is preserved unless limited by contracture or calcification c) may be elicited by palpation of the involved tendon(s) [3] 2) traumatic tendonitis a) an audible pop or snap indicates significant muscle-tendon tearing b) initially there is frequently very little pain & disability c) swelling, pain & disability progress over several hours & are maximal the day following the injury d) weakness without reproduction of pain indicates nerve injury e) mild of 1st degree strain of muscle-tendon unit 1] 'pulled muscle' 2] overstretching of muscle-tendon unit 3] no palpable defect 4] mild inflammatory changes f) moderate or 2nd degree strain of muscle-tendon unit 1] 10-90% tearing of muscle-tendon unit 2] palpable defect 3] significant inflammatory changes g) severe or 3rd degree strain of muscle-tendon unit 1] complete rupture of muscle-tendon unit 2] large palpable defect 3] proximal contracted ball of torn tissue 3) overuse tendonitis a) grade 1 (symptoms present for < 2 weeks) 1] soreness after the aggravating activity 2] pain resolve quickly, generally within hours 3] no functional impairment b) grade 2 (symptoms persist for 2-3 weeks) 1] pain during the later phase of the aggravating activity 2] pain persists after the activity is complete 3] no functional impairment c) grade 3 (symptoms present for 3-4 weeks) 1] pain during most of the aggravating activity continuing after the activity is complete 2] performance is affected d) grade 4 (symptoms present for > 4 weeks) 1] pain is continuous, before, during & after the activity 2] activities of daily living frequently affected e) palpation of involved tendon frequently reproduces patient's pain f) resisted active contraction of the involved tendon generally reproduces the patient's pain Laboratory: 1) coagulation workup if indicated 2) rheumatologic work-up if indicated a) erythrocyte sedimentation rate (ESR) b) C-reactive protein (CRP) c) antinuclear antibody (ANA) d) rheumatoid factor (RF) Radiology: 1) radiographs generally not necessary when diagnosis is tendonitis [4] 2) radiographs should be obtained if a) myositis ossificans suspected b) stress fracture suspected Complications: 1) bursitis may result from the proximity of a bursa to the inflamed tendon 2) compartment syndrome may occur with any severe injury Differential diagnosis: 1) nerve injury with radicular pattern may mimic traumatic or overuse tendonitis 2) distal nerve compression may present with proximal pain 3) connective tissue disease may present as overuse tendonitis or may be complicated by acute tendon rupture 4) steroid abuse-induced tendon rupture, especially at uncommon site 5) myositis ossificans may occur post muscle-tendon injury 6) coagulation disorder: i.e. hemophilia 7) stress fracture Management: - R: rest - I: ice - C: compression - E: elevation - D: non-steroidal anti-inflammatory Drugs - Jones dressing: 2 alternating layers of cast padding & ACE wrap applied distal to proximal - painless range of motion - strengthening exercises after swelling has subsided & range of motion is pain free - glucocorticoid injection may improve outcome over the short term, but long-term benefits are doubtful [2] - follow-up a) re-evaluate grade 2 & 3 traumatic injuries in 7-10 days b) re-evaluate grades 2-4 overuse tendonitis every 2-4 weeks c) do not continue NSAIDs to permit return to activity

Related

tendon

Specific

Achilles tendonitis; posterior tibial tendonitis biceps tendonitis (bicipial tendonitis) calcific tendonitis coxa saltans; snapping hip; iliopsoas tendonitis; dancer's hip gluteal tendonitis insertional tendonitis intersection syndrome quadriceps tendonitis rotator cuff tendonitis; impingement syndrome; painful arc syndrome; subacromial pain syndrome supraspinatus tendonitis tendinosis

General

enthesopathy (enthesitis) inflammation

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 765-768
  2. Coombes BK et al Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials The Lancet, Early Online Publication, 22 October 2010 PMID: 20970844 doi:10.1016/S0140-6736(10)61160-9
  3. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
  4. Medical Knowledge Self Assessment Program (MKSAP) 16, 19 American College of Physicians, Philadelphia 2012, 2022
  5. National Institute of Arthritis and Muscluloskeletal and Skin Diseases (NIAMS) Tendinitis https://www.niams.nih.gov/health-topics/tendinitis