Tendinopathy refers to conditions affecting the tendons which cause pain, swelling, or decreased function. It may include tendonitis or tendinosis.
Chronic tendinopathy can lead to weakening of the tendon and subsequent rupture.
Middle-aged adults are most susceptible to the development of tendinopathy. Tendons transmit mechanical loads and it is thought to be a major causative factor but exact pathogenesis of tendinopathy is not clear.
Common Sites of Tendinopathy
- Shoulder – Supraspinatus [rotator cuff tendinopathy]) and bicipital tendons
- Elbow – Origin of the wrist extensors (ie, lateral epicondylitis, tennis elbow) and flexors (ie, medial epicondylitis – Golfer’s elbow)
- Knee – Patellar tendon, popliteal tendons, and iliotibial band
- Leg – Posterior tibial tendon in the leg (ie, shin splints)
- Ankle – Achilles tendon at the heel
Presentation of Tendinopathy
Lateral Epicondylitis or Tennis Elbow
It is common in tennis or other racquet game players. Pain is present at the lateral aspect of the elbow. The pain is reproduced on deep palpation over the lateral epicondyle and resisted dorsiflexion of the wrist.
Medial Epicondylitis or Golfer Elbow
It is common in pitchers, golfers, bowlers, and carpenters. Pain is located at the medial aspect of the elbow and occurs on deep palpation of the medial epicondyle and resisted flexion of the wrist.
Rotator Cuff Tendinopathy or Supraspinatus Tendinopathy
There is usually a history of overhead activities like painting, swimming, and throwing. There is a deep-seated pain in the shoulder and shoulder range of motion is painful.
There is a pain on palpation over the greater tuberosity [at the insertion of supraspinatus tendon]
Jobe Test [ Both arms abducted to 90° and forearms are fully pronated. Resistance is placed on both arms to compare strength and presence of pain. If the patient is not able to hold the arm up or there is a pain, it suggests rotator cuff disease.] and Hawkins test are positive
Bicipital Tendinopathy
The pain is in the anterior shoulder in the bicipital grove that worsens when flexing the shoulder or supinating the forearm. There is tenderness on humerus between the greater and lesser tuberosities.
There is a pain on shoulder flexion against resistance with the elbow extended and forearm supinated). [Biceps Resistance Test]
Pain with resisted supination of the wrist with the elbow flexed at 90° and the arm adducted against the body [to cause external rotation at the shoulder at the same time] is also present [Yergason test]
Another test for bicipital tendinopathy where the pain is produced on downward resistance with patient’s shoulder in slight flexion and elbow in full extension and forearm supinated. [Speed Test]
Yergason and Speed test are demonstrated below.
Patellar Tendinopathy or Jumper Knee
There is the insidious onset of anterior knee pain. The problem is common in basketball, volleyball, jumping and running. Pain worsens when a person changes position from sitting to standing or when walking or running uphill. There is tenderness at patellar tendon insertion into lower pole of the patella.
Popliteus Tendinopathy
This presents with lateral knee pain and there is tenderness in posterolateral joint line. With the patient supine, the knee flexed to 90°, and the leg rotated internally, resisted external rotation elicits pain (Webb maneuver). Running downhill is considered as a risk factor.
Iliotibial Band syndrome
It is the most common overuse syndrome of the knee and results in lateral knee pain. Cyclists, dancers, long-distance runners, football players, and military recruits are at risk.
Typically, pain begins after completion of a run or several minutes into a run. Pain is aggravated by running down hills, lengthening stride, or sitting for long periods of time with the knee flexed.
The pain is in lateral femoral condyle. Flexing knee while standing with weight on affected knee resulting in pain at approximately 30° of flexion [Renne test]
In Ober test, the patient lies down with the unaffected side down and unaffected hip and knee at a 90° angle. If iliotibial band is tight, the patient will have difficulty adducting the leg beyond midline and may experience pain at the lateral aspect of the knee.
Shin Splints
Pain is located at the anteromedial aspect of the lower leg. Shin splints have been associated with overpronation. Runners running on hard surfaces without proper footwear are predisposed to this condition.
Achilles Tendinopathy
Pain in the heel in the retrocalcaneal area is a hallmark of this.
Runners and other athletes have an increased incidence of Achilles tendinopathy. Increased mileage, change in running surface, and poor footwear are associated factors.
There is localized tenderness approximately 6 cm proximal to the Achilles insertion on the heel. Pain with resisted plantar flexion of the ankle and passive dorsiflexion of the ankle. Crepitus may be palpable with severe cases.
Lab Studies
Generally not required.
Imaging
Radiographs are usually negative for any finding. The bone at the site of tendinous insertion may be roughened or may show avulsion fracture in some cases. Calcium deposits along the tendon may be visualized with calcific tendinopathy. Ultrasonography and magnetic resonance imaging, are usually reserved for when the diagnosis is unclear or the patient’s condition fails to improve with conservative management.
Ultrasonography reveals alterations in tendon morphology like mucoid degeneration and tearing diminished echogenicity due to tear in tendons Calcification can also be appreciated. Ultrasonography has been shown to be accurate in evaluating the rotator cuff and Achilles tendon.
MRI is also accurate in accessing tendon pathology.
Treatment
The goal of treatment is to reduce pain and to return to activity. Rest, ice, splinting and/or immobilization for 24-48 hours followed by strengthening and stretching exercises.
Nonsteroidal anti-inflammatory drugs are effective in relieving the pain.
Corticosteroid injection may be considered for patients with tendonitis in whom conservative therapy with rest, immobilization, and anti-inflammatory agents have failed thought their long-term efficacy is debated. Corticosteroid injections directly into a tendon because of the risk of tendon rupture.
Patients with symptoms resistant to conservative therapy may benefit from arthroscopic or open tendon decompression and tenodesis.
There is insufficient evidence to support the clinical use of platelet-rich therapies.
Complications of Tendinopathy
Complications of tendonitis may include chronic disability, tendon rupture, and adhesive capsulitis. Generally, the prognosis is very good with rest and conservative treatment.
