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Tendinitis is an acute, painful inflammation of a tendon, the tough, fibrous tissue that connects muscle to bone. The irritative condition usually occurs as the result of overuse and is one of several tendinopathies. Related conditions that also may occur include tendinosis, which is a chronic degeneration of the tendon, and tenosynovitis, inflammation of the sheath that surrounds the tendon.
Tendinitis is a very common condition especially among individuals engaged in heavy labor or sports. Tendinitis can be caused by acute trauma, poor technique during activity or exercise, lack of strength and flexibility, age-related deterioration, or overload and overuse of the affected tendon. Common sites for tendinitis include the shoulder (rotator cuff tendinitis), elbow (lateral and medial epicondylitis), knee, (patellar tendinitis, iliotibial band tendinitis), Achilles tendon at the heel, and the posterior tibial tendon in the leg.
Calcific tendinitis occurs when calcium deposits form in the tendons of the rotator cuff. The cause of calcific tendinitis is unknown, but it does not appear to be due to trauma and may instead be caused by systemic disease. Calcific tendinitis often resolves spontaneously in 1 to 4 weeks (Cluett).
Chronic degeneration of the tendon (tendinosis) results from microtrauma or overuse of the tendon, with symptoms developing gradually over time. The overuse can be caused by excessive pressure or workload. While up to 4% elongation of a tendon is tolerated well, greater elongation (4% to 8%) may cause microtrauma, and elongation greater than 8% may cause macrotrauma with rupture of the tendon fibers (Rettig). Repetitive tasks and excessive exercise also may cause tendinosis. Shearing stress on the tendon may occur where tendons pass in close proximity to the bone.
Risk: Tendinitis is more common in males, and Achilles tendon tears occur 4 to 7 times more frequently in males than females (Maffulli). Middle-aged individuals are more likely to develop tendinitis (Steele) since tendons deteriorate with age. Work-related factors that increase the risk for tendinitis and tendinosis include vibration, cold temperatures, intense and sustained exertion, and maintaining awkward postures.
The use of certain broad-spectrum antibiotics, known as fluoroquinolones, is associated with increased risk of tendinitis. Individuals who use steroids or have decreased kidney function (renal insufficiency) are at higher risk of developing fluoroquinolone-associated tendinitis. Fluoroquinolone-associated tendinitis often occurs bilaterally in the Achilles tendons and also has been reported in the shoulders and hands, whereas overuse tendinitis usually occurs on one side only.
Calcific tendinitis usually occurs in individuals between the ages of 30 to 40, and is more common in diabetics (Cluett). Incidence and Prevalence: Incidence of tendinitis as an occupational injury is 1.1 per 100,000 individuals who work full-time ("Incidence Rates").
Overuse tendinitis is most common in the wrist and hand, and comprises between 25% and 50% of all sports injuries (Rettig). |
Source: Medical Disability Advisor
| History: Obtaining a thorough history is important and should include the exact location of the pain; onset; associated activities at the time of onset; aggravating and alleviating factors; other medical conditions; current medications; and occupational and recreational history. The individual may complain of pain at a specific point in the area of a muscle origin or insertion. Pain may have begun gradually or be sudden in onset and reproduced with activity of the muscle or muscle group. The individual may also report repetitive use of that particular muscle group; it is very important to identify what activity (or activities) is causing the tendinitis. An athlete may report use of different footwear or equipment, or a change in training or training surfaces. Physical exam: A detailed physical examination is the key to diagnosis. Usually there is pain with palpation (gentle touch) of the muscle unit; the pain may be localized to the insertion or origin of the muscle. Swelling, warmth, stiffness, and redness may also be present. Creaking or popping (crepitus) may be palpated. Pain may limit the normal range of motion of the affected muscle or muscle group. A neurovascular exam will help to rule out compartment syndrome and nerve injury. If the tendinopathy is chronic, thickening of the tendon on the affected side may be noted when compared with the normal side. Extreme pain in a lower extremity may indicate acute compartment syndrome. Excessive swelling may be a sign of tendon rupture. Tests: Testing is seldom needed to make the diagnosis of tendinitis. If arthritis is suspected, specialized blood tests such as a rheumatoid factor assay may be helpful in determining the type of arthritis. If there is a history of trauma, an x-ray may reveal skeletal abnormalities at the site of tendon origin/insertion or calcium deposits in the tendons of the rotator cuff. Ultrasound can measure tendon width and integrity of the collagen as well as calcifications. Ultrasound is quick, non-invasive, and less expensive than MRI. |
Source: Medical Disability Advisor
| The goal of treatment is to reduce discomfort and restore function. Tendinitis caused by trauma, especially if it occurs suddenly (acute), is generally treated with rest, ice (cold therapy), compressive dressing, and elevation to control swelling (RICE). Heat rather than cold therapy may be used for acute forms of the condition, depending on patient response. Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed for pain and swelling. When the acute episode has passed, rehabilitation for strengthening and evaluation of individual factors that led to tendinitis may be needed to prevent recurrence.
Ongoing (chronic) tendinitis is treated by stopping the aggravating activity, initiating RICE therapy, and using NSAID medications. With chronic tendinitis, heat may be more effective than cold in therapy. Muscle strengthening may be recommended to restore normal function.
In the past, corticosteroids were injected into the tendon sheath to relieve pain and swelling in cases where conservative treatment failed or proved insufficient. However, this is associated with tendon rupture and should only be used in special circumstances. In extreme cases, surgery (excision, tenosynovectomy) may be needed to remove inflamed tissue or calcium deposits. |
Source: Medical Disability Advisor
| Full recovery is anticipated in acute cases. The prognosis is also very good in chronic cases in which the inciting circumstances can be identified and changed. Cases requiring surgery are rare, but individuals with significant tendon damage may experience at least partial loss of function. |
Source: Medical Disability Advisor
| Note on research and authorship The initial goals of rehabilitation for tendinitis are controlling pain and swelling, followed by regaining motion, flexibility, strength, and endurance of the tendon, muscle, and involved joint structures. An effort should be made to identify the underlying cause of the current symptoms, after which, when possible, modifications should be made to reduce the risk factors associated with the condition.
Modalities such as heat and cold may be used throughout rehabilitation to control pain and swelling (Braddom). If pain significantly limits motion, then splinting the involved part may be necessary. When indicated, therapy should begin with range of motion exercises, progress to strengthening exercises as indicated, and continue by instructing individuals in a home exercise program to complement supervised rehabilitation (Biundo; Mafi).
The final goal is returning the individual to full function for work and recreational activities with minimal risk of re-injury. If work tasks expose the individual to risk factors for tendinitis, an ergonomic assessment may be indicated. If leisure activities are suspect, the individual should be educated in ways to modify the activity and decrease the likelihood of developing symptoms.
Additional information may provide insight into the rehabilitation needs of these individuals (Huang). |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical | |
| Physical, Occupational or Hand Therapist | | Up to 16 visits within 8 weeks | |
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| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Compartment syndrome and nerve injury may be caused by tissue swelling from trauma associated with tendinitis. Inflammation of the lining of the tendon sheath (tenosynovitis) often accompanies tendinitis. Chronic tendinitis can weaken the tendon and lead to subsequent tendon rupture. Inflammation in tendons of the hand may cause the thumb to extend (de Quervain's disease). Fingers and/or the thumb may be hampered in movement by swelling of the tendons, which creates crepitus or catching (trigger finger). |
Source: Medical Disability Advisor
| Restrictions include stopping activities associated with causing the tendinitis. Depending on the tendon involved, this may include avoidance of lifting, carrying, or twisting movements of the wrist or forearm and any repetitive motions or overhead work. Use of protective or assistive devices such as splints, crutches, or slings may affect dexterity. Safety issues may need to be evaluated. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.
Return to work requiring physical activity may need monitoring, as many individuals attempt to resume "normal" activity too soon. This often leads to a cycle of recurring injury. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Which tendon is involved?
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Does individual have a history of injury, overload, or overuse of the tendon?
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Does individual have a history of fluoroquinolone use?
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Does individual's work or recreation involve repetitive tasks or excessive exercise?
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Does individual report a gradual onset of pain during or after activity, swelling, stiffness, and crepitus with motion?
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On exam, was swelling, warmth, tenderness, or crepitus evident?
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Is there pain with movement or decreased range of motion?
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Has individual undergone any imaging or other tests to rule out conditions with similar symptoms?
Regarding treatment:
- Is individual with an acute injury being treated with rest, ice, compression, and elevation (RICE)?
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Is heat being used rather than ice?
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Is individual being treated with NSAIDs?
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Has physical therapy been prescribed? Has individual stopped aggravating activity?
Regarding prognosis:
- Is individual active in physical therapy?
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Does individual have a home exercise program? Is individual complying with program?
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Does individual have any conditions that may affect ability to recover?
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Has individual developed any complications such as compartment syndrome, nerve injury tenosynovitis, tendon rupture, De Quervain’s disease, or a trigger finger?
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Source: Medical Disability Advisor
| Biundo, J. J., R. W. Irwin, and E. Umpierre. "Sports and Other Soft Tissue Injuries Tendinitis, Bursitis, and Occupation-related Syndromes." Current Opinion in Rheumatology 13 2 (2001): 146-149. National Center for Biotechnology Information. National Library of Medicine. 18 Nov. 2008 <PMID: 11224739>.Braddom, Randolph L. Physical Medicine and Rehabilitation. 2nd ed. Philadelphia: W.B. Saunders, 2000. Cluett, Jonathan. "Calcific Tendonitis." About.com. 20 Jun. 2006. 18 Feb. 2008 <http://orthopedics.about.com/od/rotatorcuff/a/calcific.htm>. Huang, H. H., A. A. Qureshi, and J. J. Biundo. "Sports and Other Soft Tissue Injuries, Tendinitis, Bursitis, and Occupation-Related Syndromes." Current Opinion in Rheumatology 12 2 (2000): 150-154. National Center for Biotechnology Information. National Library of Medicine. 18 Nov. 2008 <PMID: 10751018>. "Incidence Rates for Nonfatal Occupational Injuries and Illnesses Involving Days Away from Work per 10,000 Full-time Workers for Selected Characteristics and Industry Division, United States, 2002." U.S. Department of Labor. 28 Apr. 2004. U.S. Department of Labor. 27 Oct. 2004 <http://www.bls.gov/opub/cwc/sh20040414tb06.htm>. Maffulli, N., J. Wong, and L. C. Almekinders. "Types and Epidemiology of Tendinopathy." Clinics in Sports Medicine 22 4 (2003): 675-692. MD Consult. Elsevier, Inc. 27 Oct. 2004 <http://home.mdconsult.com/das/journal/view/40179602-4/N/14064018?sid=293465610&source=MI>. Mafi, N., R. Lorentzon, and H. Alfredson. "Superior Short-term Results with Eccentric Calf Muscle Training Compared to Concentric Training in a Randomized Prospective Multicenter Study on Patients with Chronic Achilles Tendinosis." Knee Surgery, Sports Traumatology, Arthroscopy 9 1 (2001): 42-47. National Center for Biotechnology Information. National Library of Medicine. 18 Nov. 2008 <PMID: 11269583>. Rettig, A. C. "Wrist and Hand Overuse Syndromes." Clinics in Sports Medicine 20 3 (2001): 591-611. MD Consult. Elsevier, Inc. 27 Oct. 2004 <http://home.mdconsult.com/das/journal/view/40179602-4/N/11908443?sid=293465610&source=MI>. Steele, Mark. "Tendonitis." eMedicine. Eds. Richard S. Krause, et al. 31 Mar. 2008. Medscape. 18 Feb. 2009 <http://emedicine.com/emerg/topic570.htm>. |
Source: Medical Disability Advisor
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