Your Tendinitis Is Really Tendin-OSIS!

In the last 2 months, I seem to have had a influx of patients with wrist, elbow and shoulder tendon injuries!  What’s going on????…

People often come in saying “I think I have elbow tendinitis” or have a referral slip from their family doctor that says “Rotator cuff tendinitis, treat accordingly”.

Tendin-ITIS is easy to understand for the general public.  Because ITIS refers to inflammation.  And everyone knows inflammation means injury which means pain.  It’s a term that our doctors and drug companies use so much that it is part of our vernacular.

But if I now say, “No you actually have a tendin-OSIS”, there’s a brief moment where crickets chirp and a look of confusion.

So what’s the difference between TENDINITIS and TENDINOSIS and does it matter?

Let me start first with a quote from Dr. Karim Khan who is a medical doctor and researcher at the University of British Columbia:

Most currently practicing general practitioners were taught, and many still believe, that patients who present with overuse tendinitis have a largely inflammatory condition and will benefit from anti-inflammatory medication. Unfortunately this dogma is deeply entrenched.  Ten of 11 readily available sports medicine texts specifically recommend non-steroidal anti-inflammatory drugs for treating painful conditions like Achilles and patellar tendinitis despite the lack of a biological rationale or clinical evidence for this approach.  Instead of adhering to the myths above, physicians should acknowledge that painful overuse tendon conditions have a non-inflammatory pathology.

So in reality, what most patients exhibit as an elbow, wrist, rotator cuff, Achilles or patellar tendinitis is in fact an elbow, wrist, rotator cuff, Achilles or patellar TENDINOSIS.

There is no true INFLAMMATION to support the tendinitis diagnosis a large majority of the time.  When inflammation is actually present, it is short-lived and mostly associated with tendon tears or ruptures following a very specific incident or injury.

Conversely, TENDINOSIS is considered a degenerative condition with NO INFLAMMATION that can be caused by repetitive overuse as well as underuse(!) and is often not even particularly symptomatic until it becomes a painfully debilitating problem.  The patient story is often very similar: “It wasn’t bothering me at all until last week for no apparent reason”, “I’ve had some minor pains there on/off but they always went away after a couple of weeks”.

When I say a degenerative condition, what do I mean?  Basically that there are microtears and progressive breakdown of the tendon.  As the body tries to heal tendon, a poor regeneration process typically happens that results in a mismashed array of collagen fibers (instead of linear, parallel fibers) as well as abnormally large number of new blood vessels that don’t actually improve the circulation to the tendon.

If a normal, healthy tendon were to look like a new rope, then what we would see are fibers running uniformly in one direction with little to no fraying.

With tendinosis, we’d see fraying, fragmentation, tangled and twisted fibers resulting in decreased structural strength, poor elasticity and for the patient affected…pain.

What does this mean practically to you as the patient in terms of treatment options?

First, it means that commonly prescribed anti-inflammatories are pretty much useless.  There’s no inflammation present remember?  In addition, research studies have actually shown that non-steroidal anti-inflammatory medications (NSAID’s) such as Aspirin, Tylenol, Nuprin, Ibuprofen, Naproxen, Celebrex and no-longer-on-the-market-because-of-serious-side-effects Vioxx 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.  Read some examples of cited research here:

And if you are being offered cortisone/corticosteroid injections, you should walk out the door too because they actually deteriorate or “eat” collagen-based connective tissue, including bone!!  This is the reason why doctors will limit the number of cortisone shots that you can receive even if the injections seem to be providing some pain relief.

So what is the best way to handle tendinosis?

A multi-faceted approach is in order that involves:

  1. Manual therapy such as deep tissue release, active release therapy, Graston technique, Rolfing…basically techniques that involve trying to break down and remodel the dysfunctional collagen tissue
  2. Laser therapy, ultrasound, shockwave therapy.  These modalities promote improved circulation and tissue repair.
  3. Appropriate stretches and eccentric strengthening exercises that promote better collagen fiber orientation and linkages
  4. Drinking plenty of water, supplementing with fish oil, Vitamin C, Glucosamine Sulfate, Chondroitin, MSM, proteolytic enzymes like Bromelain and a diet based on whole foods.
  5. Activity/work modifications, adequate sleep and time.


Graston Technique for Injuries and Pain

No significant blog writing for me this week…just a link to a news segment re: Graston Technique that I use here regularly at our Richmond Hill chiropractic clinic!

For more information regarding Graston technique, click here.  Also read more at the Graston website.

You have Tennis elbow…but you don’t play tennis!

You don’t have to play tennis like me to get tennis elbow!

Lateral epicondylitis is the ‘fancy’ medical term for what’s commonly known as Tennis elbow.  It was originally coined ‘tennis elbow’ because doctors were seeing the same type of elbow pain occurring with people who played alot of tennis.

But these days, just about ANYONE can get tennis elbow.  It’s more than just about playing tennis.  It’s about subjecting the forearm and elbow structures to REPETITIVE stresses over time.

So into my Richmond Hill clinic will walk in men and women, young and old, who have a shared symptom pattern:

  • sharp pain along the outside portion of the elbow (the bony part is called the lateral epicondyle…the inside portion is called the medial epicondyle)
  • pain with lifting objects, even light ones
  • pain turning door knobs or shaking hands
  • pain with grabbing things like grocery bags, plates from the cupboard, your dog’s leash, etc.
  • most don’t play tennis or any other racquet sport
  • many have sedentary lives and work in front of a computer all day
  • elbow stiffness in the morning

No single treatment has been shown to be totally effective and each individual’s situation is different.  However a combination of possible treatments are known to resolve tennis elbow over time.  Everyone will respond differently to different treatments.

So what can you do for yourself?

  • Apply ice to the elbow for 15 mins, 4-6 times a day.  This will help reduce pain and inflammation.
  • Rest you arm as much as possible which is an extremely important component in the healing of this injury.
  • Wear a specialized elbow braceto protect the tendon while it is healing and strengthening, particularly when returning to playing / equivalent. The brace is placed approximately 2″ down from the area of pain and relieves strain on the tendon when doing activities with your hand and arm.
  • Stretch out both sides of your forearm regularly.

What can a doctor or therapist do to help?

  • Determine if other issues are at work including a (radial) nerve entrapment at the elbow, nerve irritation/sensitivity in the neck, muscular imbalances or tension in the neck and shoulder region
  • Use manual therapies such as Active Release, Graston Technique or cross-friction massage over affected muscles and tendons
  • Apply electric stim, ultrasound or laser therapyto help reduce pain and inflammation as well as stimulate healing
  • Try acupuncture which has been shown to be extremely effective for tennis elbow.
  • Instruct you on appropriate exercises to assist with recovery and rehab
  • Provide advice on neural stretching exercises if nerve tissue involvement is suspected.
  • Examine ergonomic factors at home or work which need to be addressed in order to avoid recurrence.
  • Discuss other possible treatment options like steroid injections or extracorporeal shockwave therapy (ESWT).

A recent patient of mine is a 38 year old, male pipe fitter who was having pain in his elbow and shoulder because his work requires daily repetitive use of tools that involve gripping and turning.  After examining him, it was clear that he had dysfunctional muscles and soft tissue structures in the neck, shoulder and forearm that were resulting in the pain.

I ended up having to address his problems with a variety of tools.  Graston Technique is a soft tissue therapy that helps to break down scar tissue and adhesions in his neck, shoulder and forearms.  I also started initially with Bioflex laser therapy applied over both the shoulder and elbow/forearm.  Although he got some relief from a few sessions, I felt that the response wasn’t as much as I intended.  So I switched him over to electroacupuncture using a combination of classical Chinese acupuncture points as well as inserting needles into various trigger points in the affected areas.  Also, I used a “surround the dragon” technique where I encircled the lateral epicondyle with about 6 short needles to stimulate a greater immune system response where the tendon attaches to the bone.

This treatment combination worked very well and a few more sessions later, he was no longer feeling any pain with his work.  Unfortunately, there is little that can be done to change the nature of his work so he regularly returns every few weeks to have some acupuncture done to relieve the stress and strain on his shoulder and forearm muscles/tendons before any significant elbow or shoulder pain develops.

As I mentioned earlier, although each patient may present with a similar set of symptoms, not everyone will respond the same to therapy so it’s important to design a treatment plan that is custom made for the individual.

Dr. Keith