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: http://www.rheumatologynetwork.com/articles/do-nsaids-impair-healing-musculoskeletal-injuries
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:
- 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
- Laser therapy, ultrasound, shockwave therapy. These modalities promote improved circulation and tissue repair.
- Appropriate stretches and eccentric strengthening exercises that promote better collagen fiber orientation and linkages
- 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.
- Activity/work modifications, adequate sleep and time.