Dr. Brett Lawlor: Overuse can lead to painful tendonitis

By Dr. Brett Lawlor, Journal columnist | Tuesday, October 02, 2007

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In Dr. Steve Wisniewski's last article, he wrote about bursitis. Another infamous "itis" that can cause pain around the joints in our bodies is tendonitis.

Tendons are collagen structures in our bodies that attach muscles to the bone. Tendons, when viewed under a microscope, have a structure not unlike a wire cable. When a muscle contracts, the tendon is pulled and the desired joint moves. The tendon slides within a sheath that surrounds the tendon so that this motion can be achieved with minimal friction. When a tendon is functioning as it should, the muscle shortens, the tendon slides within its sheath and the joint moves, all without pain.

Tendon injuries and tendon pain occur as a result of either inflammation, degeneration or rupture of the tendon or inflammation of the tendon sheath. Those suffering from tendonitis will report pain usually in the area around a joint but not within the joint itself.

Common areas of the body that can develop tendonitis include tendonitis of the elbow (tennis elbow), patellar tendonitis (tendonitis at the knee cap) and tendonitis of the shoulder (rotator-cuff tendonitis). Tendonitis also commonly occurs at the hip, fingers, wrist and foot (at the insertion of the Achilles tendon), but can occur anywhere in the body where there are tendons.

By far the most common tendon injuries occur as a result of overuse. With overuse injuries, repetitive motion and stress on the tendon lead to micro-tears and breakdown of the cellular structure of the tendon. This cellular breakdown results in the release of chemicals that promote inflammation and pain. Anyone who does any activity that requires forceful repetition can develop tendonitis. Carpenters swinging a hammer, golfers swinging a golf club, or tennis players swinging a tennis racket are all at risk for developing tendonitis at the elbow if they do this activity too long, or too hard without sufficient training.

Tendonitis is graded on a I-V system. Grade I tendonitis has symptoms only after the activity, but does not interfere with the performance of that activity. With grade II tendonitis, there is tenderness and only minimal interference with performance of the activity. Those who have Grade III tendonitis have tenderness and pain that interferes with activity, but the pain disappears between activity sessions. With Grade IV, there is a significant tenderness that seriously interferes with activity. Finally with Grade V tendonitis, pain interferes with sporting activity and with normal day-to-day activities, symptoms are often chronic or recurrent, and there are signs of tissue change and altered muscle function.

When someone has Grade V tendonitis, he or she is at risk for tendon rupture as a result of cellular changes that occur in tendons that are chronically inflamed. These changes result in a condition known as tendonosis. These cellular changes weaken the tendon and if enough force is applied to this weakened tendon, the tendon can rupture or tear.

Tendon injuries can be assumed clinically based on a history of overuse or repetitive use and clinical exam finding of pain, swelling or crepitus (sandpaper feeling with motion) over the tendon. Radiologic imaging studies are necessary for definitive diagnosis. MRI has been the standard imaging study and can show evidence of inflammation or tearing of the tendon. A newer alternative is Ultrasound imaging of the tendon. Ultrasound also can show fluid or swelling around the tendon and allow the physician to determine if there is partial or complete tears of the tendon.

Treatment for tendonitis includes ice, non-steroidal anti-inflammatory medicine, rest and possibly splinting. Splinting should be done cautiously as this may promote stiffening of the affected joint. Physical therapy should include range of motion exercise and, as the pain decreases, strengthening of the affected muscle to improve overall strength and endurance. This type of injection can now be performed with ultrasound guidance to insure proper needle placement outside the tendon. Steroid injections should never be done into the tendon itself as this can weaken the tendon. The needle for tendon area injections should be placed into the tendon sheath and the steroid spread along the outer surface of the inflamed tendon.

Finally, if tearing or complete rupture of the tendon occurs, then surgical repair is a consideration. If a tendon is completely torn and the muscle contracts and pulls the ends of the tendons away from each other, then surgical repair of the tendon may no longer be an option.

To avoid developing tendonitis, you should progress slowly with the length and intensity of any sport or activity that requires forceful repetitive motions, warm up sufficiently before performing these activities and maximize your strength and flexibility in the appropriate muscle groups.

Dr. Brett Lawlor operates The Rehab Doctors in Rapid City. His column appears monthly in the Journal's Body&Mind section. If you have questions or suggestions for future columns please contact Dr. Lawlor at the Rehab Doctors, 1136 Jackson Blvd., Rapid City, phone 721-7246 or e-mail skyemad@starband.net