tendinopathy
TENDINOPATHY

Tendinopathy is a clinical syndrome characterized by tendon thickening and localized tendon pain, swelling or impaired performance.
It usually is a temporary condition if treated early but may also be recurrent or chronic.
Principles of therapy include: ddentification & elimination of the cause of tendinopathy, behavior modification to minimize or eliminate sources of continuing irritation, specialist referral for appropriate follow up care and to reduce pain & to return function

 

Diagnosis

Common Types of Tendinitis
Achilles Tendinopathy
  • Common in runners, football, tennis & basketball players; incidence increases w/ age
  • Caused by tight or weak calf muscles, anatomic misalignment, improper technique, uneven training surfaces & improperly fitted shoes
  • Pain is experienced at the posterior heel proximal to the tendon insertion
  • Physical exam may show thickened, tender & palpable nodules
    • Observe for anatomic deformities (eg heel varus, forefoot, excessive pes planus or foot pronation)
  • Magnetic resonace imaging (MRI) is useful for showing partial tendon tears, tendon thickening & chronic degenerative changes
  • Ultrasonography shows tendon thickening & heterogeneous echogenicity
  • Plain film radiography may show calcific tendinopathy, calcaneal avulsion fracture & soft-tissue swelling
Bicipital Tendinopathy
  • Causes pain in the anterior shoulder & radiates to the elbow & forearm
  • There is worsening of pain when flexing the shoulder or supinating the forearm
  • Yergason’s test
    • Done w/ patient’s arm fully pronated & elbow flexed to 90°. Patient is asked to supinate his arm against resistance applied by the examiner
    • Considered positive test if pain localized to the long biceps tendon is elicited
  • Speed’s test
    • Patient forward flexes the shoulder about 30° against resistance applied by the examiner, while keeping the elbow fully extended & the arm fully supinated
    • Considered positive if pain is elicited in the anterior shoulder
Calcific Tendinopathy 
  • Deposition of Ca hydroxyapatite crystals in or around the tendons of the rotator cuff
  • Affects any of the rotator cuff tendons but has a predilection for the supraspinatus
  • Has been postulated to be related to continuous microtrauma
  • Symptoms are similar to those of an impingement syndrome
  • Physical exam reveals point tenderness over the greater tuberosity
  • Plain film radiography confirms evidence of calcification in or around the rotator cuff tendons
Elbow Tendinopathy
  • Equally affects men & women; most common in patients >40 years of age
  • Lateral epicondylitis or tennis elbow
    • More common than medial epicondylitis
    • Common in persons who play racquet sports or manual laborers whose activities involve repetitive wrist extension
    • Patient experiences insidious lateral or outer elbow pain aggravated by wrist supination or extension activities (eg grasping & twisting)
    • Physical exam reveals tenderness over or just distal to the lateral epicondyle where the extensor tendons insert
    • Cozen test
      • Patient is asked to keep his fist clenched while extending the wrist. The examiner grasps the forearm w/ the left hand while the right hand pulls the patients hand toward flexion against the patient’s resistance
      • Positive test if pain is elicited at the lateral epicondyle
  • Medial epicondylitis or golfer’s elbow
    • Common in golfers, bowlers, carpenters & other manual laborers whose activities involve repetitive wrist flexion
    • Can result from microtrauma at the site of the insertion of the flexor carpi radialis on the medial epicondyle
    • There is medial or inner elbow pain exacerbated w/ wrist flexion & pronation
    • Physical exam reveals tenderness over the medial epicondyle near the insertion of the wrist flexor tendons
  • Imaging modalities:
    • MRI shows degenerative thickening of the tendons, fibrovascular proliferation & mucoid degeneration
    • Ultrasonography shows tendon thickening & heterogeneous echogenicity, which are common findings in elbow tendinopathy
Iliotibial Band Syndrome
  • Common in cyclists, dancers, long-distance runners, football players, military recruits
  • Pain is observed after completion of a run or several minutes into a run
  • Pain is exacerbated by running down hills, lengthening stride or sitting for long periods w/ knee flexed
  • Positive Renne test
    • Knee is flexed while standing w/ weight on affected knee resulting in pain at approx 30° of flexion
  • Ober test
    • Patient lies down w/ unaffected side down & unaffected hip & knee at a 90° angle
    • If iliotibial band is tight, patient will experience difficulty in adducting the leg beyond midline & may experience pain at the lateral aspect of the knee
Patellar Tendinopathy or Jumper’s Knees
  • Common in those who engage in jumping sports (eg basketball, high jumping, volleyball) & running
  • Characterized by insidious onset of localized anterior knee pain
  • Pain is exacerbated when changing position (eg going up & down the stairs, sitting to standing)
  • Physical exam reveals pain at the inferior pole of the patella w/ the leg fully extended using resisted leg extension
  • Decline squat test
    • Pain is reproduced when placing greater load on the patellar tendon than a squat performed on level ground
  • MRI is useful for showing changes consistent w/ chronic degenerative changes of the tendon as well as other detailed anatomic information of the knee joint
    • Has a 78% sensitivity & 86% specificity
  • Ultrasonography shows tendon thickening, decreased echogenicity & tendon calcification
    • More specific (94%) than sensitive (58%)
Rotator Cuff Tendinopathy (Supraspinatus Tendinopathy)
  • Common in athletes who throw repetitively & in persons w/ history of participating in overhead activities (eg painting, swimming)
  • Pain on top of the shoulder & upper arm; usually worsened when reaching, pushing, pulling or lifting the arm above the shoulder & when lying on the affected side
  • May elicit point tenderness over the greater tuberosity
  • Jobe’s test
    • A resistance test to assess the supraspinatus function
    • W/ both arms abducted to 90°, held slightly in front of the body & arms fully pronated, comparative resistance is placed on both arms to compare strength & presence of pain
    • Weakness or presence of pain is suggestive of supraspinatus tendinopathy
  • Hawkin’s Test
    • Test for rotator cuff tendinopathy or subacromial impingement
    • Elicits pain w/ forcible internal rotation w/ the patient’s arm passively flexed forward at 90°
  • Neer’s Test
    • Test for impingement of the rotator cuff tendons under the coracoacromial arch
    • Elicits pain w/ full forward flexion between 70° & 120°
  • MRI is 95% sensitive & specific for the detection of chronic tendinopathy, cuff tears & degeneration
  • Ultrasonography is useful for detecting moderate to full thickness tears
    • Has limited ability to detect small tears but may show tendon changes of chronic tendinopathy

History

  • Diagnosis is based on medical history & careful physical exam
  • Elicit the following in the history:
    • History of repetitive stress (eg changes in sports or other recreational activities, work activities, changes in workplace) either recent or over several weeks/months; determine the type of activity or training
    • History of infectious disease, fluoroquinolone therapy or other systemic illness
  • Pain is the most common symptom
    • May be described as sharp, stabbing, insidious, localized pain aggravated by activity, or as a dull ache after activity & during rest period
    • Initially, pain is present during activity but subsides after a period of warm-up. Later, there is gradual increase in pain intensity & duration, & may be present at rest

Physical Examination

  • Inspection of muscle for atrophy, asymmetry, erythema, swelling, & joint effusions
    • Atrophy is usually observed in chronic conditions & gives information on the duration of the tendinopathy
    • Asymmetry, erythema & swelling are common in abnormal tendons
    • Joint effusions are infrequent w/ tendinopathy & more suggestive of intra-articular problems
  • Search for signs of deformity, trauma
  • Palpation
    • Localized tenderness along the involved tendon or its sheath
  • Motor evaluation such as active & passive range of motion, strength
  • Physical maneuvers
    • Support the diagnosis by simulating tendon loading & reproducing patient’s pain
  • Important to determine the source of pain, whether articular (w/in the joint capsule) or periarticular (around the joint capsule), to narrow down the diagnosis

Imaging

  • Plain film radiography
    • Indicated if a history of trauma is present
    • Not useful in showing tendons & other soft tissue changes but helpful in excluding other joint or bone abnormalities (eg osteoarthritis)
  • Magnetic resonance imaging (MRI) & Ultrasound
    • Can show damage to bones & soft tissues (eg tendon tears, tendon thickening, degenerative changes)
    • Reserved for when the diagnosis is uncertain, in cases of recalcitrant pain despite adequate conservative management, & for preoperative evaluation
    • Changes seen do not necessarily correlate w/ clinical symptoms
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