By Ashley O'Rourke PT, DPT, ATC, LAT
Have you ever gone to an urgent care or your PCP and been told that you have tendinitis? Did they then tell you to rest it, ice it and take anti-inflammatories for it? Typically that is the remedy that physicians prescribe their patients for this type of injury, but I am here to tell you why doing that may be hurting you, not not helping you.
What is tendonitis?
A tendon is the tissue that connects a muscle to the bone. "Itis" refers to the inflammation of that tendon. However, most people with tendonitis would actually be more accurately diagnosed as having a "tendinosis" due to it's chronic nature. In the first few weeks tendonitis may be accurate because there is new inflammation in the area causing pain and rest/gradual return to activity may be effective, however, after several weeks, this is unlikely to be the answer. After that, it is more of a matter of chronic tissue breakdown versus an inflammatory problem. Generally speaking, the older a patient is or the longer the issue has been going on, the longer it can take to resolve. While rest may allow the pain to resolve temporarily, the pain will often return once the patient resumes the aggravating activity. Therefore, we get in a chronic pattern where the tissue will not heal itself. Some areas- such as the achilles tendon- also have very poor blood supply, making it even less likely that it will heal on its' own with rest.
So what can we do?
We need to do something to disturb the tendon so that the body thinks it is a new, acute injury and ultimately increase inflammation to the area. That's right! We want inflammation. Inflammation is the way our body naturally heals itself. It is what brings the healing properties to the area. While rest and ice can be used early on in the beginning stages, eventually some sort of intervention is needed to stimulate the healing process and strengthen the tendon so that it can accept future loads that are, at the moment, currently aggravating activities. While rest from the aggravating activity itself may be needed, this does not mean to stop physical activity all together. Nor does it mean to not use the affected area. For example, if a patient has a tendonosis in their shoulder and the patient is a swimmer, they will, in fact, want to avoid swimming for the short term as it is provoking the pain, but this does not mean that they should not be doing other aerobic activity (such as biking or brisk walking) or exercises to strengthen the shoulder so that the tendon can eventually tolerate the repetitive movements and demands required by swimming.
Will anti-inflammatories (Advil, Motrin, Aleve...) help?
Anti-inflammatories are helpful for the pain (just as Tylenol or another analgesic like ice), but they're not helpful for tissue healing. Nor are they beneficial in a "tendinosis" where inflammation is likely not present nor the reason for the pain. Some studies show that they may even slow down the healing process since inflammation is our body's natural way of healing itself.
Cortisone is a steroid anti-inflammatory given as an injection that people frequently encounter as a treatment option from their doctor. When there is a legitimate "tendonITIS" this may be beneficial, however it would not be helpful in a "tendonOSIS" situation where inflammation is not the cause of the pain. Additionally, we know that the downsides of such injections include the possibility of slowing down healing process and weakening the tendon which could lead to a rupture later on.
What are effective treatment options?
IASTM (instrument assisted soft tissue mobilization aka Graston, scraping etc) or deep friction massage can be used to try and disturb the tendon in an attempt to stimulate the healing process, but strengthening is ultimately what we really want to focus on- particularly eccentric strengthening or the "gradual lengthening of a muscle while it is loaded and contracting" (the negative of an exercise). An example of this would be placing a dumbbell in your hand with your elbow bent as you slowly lower it down and extend your elbow. This would eccentrically load the bicep tendon. An eccentric strengthening regimen done 1–2 times daily for 12 weeks has been clinically proven to be a very successful treatment for tendinosis, especially when the exercises are performed slowly. Eccentric strengthening effectively stimulates collagen production, improves collagen alignment, and stimulates collagen cross-linkage formation, which in turn, improves tensile strength or the tendon's ability to resist load. It is important to progress loading slowly as tendinosis is not a traumatic injury- it is an overuse injury- so doing too much too quickly is likely what triggered the injury to occur in the first place. The body will adapt to the stresses put upon it. In weightlifting, gradually lifting more and more weight causes the muscles to adapt by getting stronger. This goes for every tissue in the body: bones, tendons and ligaments all get stronger as you put more stress on it in a controlled manner. A physical therapist can ensure that this is done properly. Lightly stretching and moving the affected area through its natural range of motion while minimizing pain will also be beneficial in preventing the shortening of the muscles and increase circulation, thereby assisting the healing process.
Overall, tendonitis is the inflammation of a tendon whereas tendiosis is the chronic degeneration of the collagen elements that make up the tendon tissue. Tendonosis is a less common diagnosis, but likely more prevalent. Tendinosis comes about when the surrounding areas are overloaded with excessive and/or repetitive tensile forces. Properly progressed eccentric loading (strengthening) has been shown to clinically relieve the symptoms of tendonosis. Provocation of the tissue such as deep-friction massage can also be beneficial as they serve to stimulate fibroblast activity and collagen production and bring healing properties to the area through the inflammatory process. Some commonly used treatments such as rest, ice and anti-inflammatories (Ibuprofen, Cortisone etc) used to reduce inflammation may actually be contraindicated with tendinosis as they inhibit collagen repair and may weaken the tissue leading to further damage. Tendinosis causes tissue changes that make the tendon more prone to injury, so it is important that the patient continue to take care of the compromised tendon once the initial phase of treatment is complete. Ongoing massage, stretching, strength training, and warming up before exercise can help to prevent re-injury and keep the tissue as healthy as possible.