THE MISTREATMENT OF TENDINITIS

Tendinitis is frequently diagnosed among otherwise healthy people who play golf, tennis and other sports, or who participate in activities that require repetitive motion. Most people let the problem go for a time, even a period of many weeks, until pain becomes severe. Doctors typically then tell them they have tendinitis, an inflammation of a tendon, and to take NSAIDs (nonsteroidal anti-inflammatory drugs including ibuprofen, naproxen and others) to calm the inflammation. So it was a surprise to read an editorial from the Clinical Journal of Sport Medicine that reported there is seldom a reason to take NSAIDs for tendon issues. The reason -- most so-called tendinitis is actually an entirely different condition. Some experts are calling this situation the tendinitis myth.

TENDON MYTHOLOGY

For more information, I called Sabrina M. Strickland, MD, assistant attending orthopedic surgeon at the Hospital for Special Surgery in New York City. Dr. Strickland explains that nearly all cases labeled tendinitis are in fact tendinosis, a condition that has nothing to do with inflammation. According to an article in the British Medical Journal (BMJ), animal studies show that within two to three weeks of an initial tendon injury, tendinosis is already present and inflammatory cells are absent. The problem is that many tendon injuries start out as tendinitis... however, the inflammation is not treated immediately. By waiting, the injury degrades into the damaged tissue of tendinosis. The ending "itis" refers to inflammation, but the "osis" ending means degeneration and that is what tendinosis is -- degeneration of a tendon, most commonly in the elbow, knee, shoulder and/or ankle. Although some people associate age with degenerating tendons, in fact age affects only tendons in the shoulders.

In tendinitis there is redness and swelling -- seen best in the hand or wrist where there is little soft tissue to mask the telltale evidence. In tendinosis, which is visible only through MRI, the affected area of the tendon is whitish and gray because it is dead tissue. Dr. Strickland agrees that there is no biological basis for taking NSAIDs to treat tendinosis since there is no inflammation present to reduce -- although the drugs may help ease pain of tendinosis caused by the surrounding vital tissue becoming tender due to the proximal dead tissue. A better approach is to follow a plan to resolve tendinosis and its pain.

THE RIGHT WAY TO TREAT

So, if NSAIDs are the wrong way to treat tendinosis, what is the right way to treat?

According to Dr. Strickland, the first order of business when tendon pain develops is to quiet the affected area. Stop the particular activity, ice the joint (she recommends warmth only for muscle spasms and those are nearly always in the back) and wear a special cuff or band, found in sporting-goods stores or drug stores, just below the area. The band decreases stress on the tendon and is good for pain management as well.

Physical therapy: Interestingly, most tendon injuries are not from overusing a tendon, but from incorrect form, such as flexing the wrist incorrectly when gardening or playing tennis. Consequently, working with a coach or other expert or physical therapist on the proper physical motions to use for a given activity is crucial.

Therapists design individualized exercise programs to improve range of motion and strength. The exercise technique used in the last few years to treat tendinosis is called eccentric loading, which involves stressing the muscles in the extended phase rather than the more usual contracted phase. For example, therapists may have a patient squat on the stronger leg and lift the weaker (eccentric) leg -- the one being rehabilitated. Therapists also, and importantly, help refine proper techniques for patients to use in the sport or activity that caused the tendon injury in the first place.

Dr. Strickland also urges flexibility training. Interestingly, she says that if you stretch regularly, for example, with yoga, Pilates, stretch classes or others, there is no need to stretch before or after an activity. The key is to have and maintain ongoing flexibility.

Finally, strengthening exercises are good as well because building muscles around the joint will help protect it from additional stress. Again, work with a physical therapist on appropriate exercises to build the muscles around the tendons.

Dr. Strickland suggests that people follow this action plan for several weeks, but if the tendinosis hasn't resolved itself by then, check back with the doctor regarding additional steps. Note: Doctors used to give corticosteroid shots for tendinosis, but, like with NSAIDs, these shots treat inflammation, so while they may relieve pain temporarily, they do not have any lasting affect on healing. One exception for using corticosteroid shots is in treating shoulder cuff tendinosis because bursa, fluid-filled sacs between tendons and bones that provide a slippery surface, sit atop the rotator cuff, and these often are inflamed and respond to anti-inflammation treatment -- at least temporarily.

THE EUROPEAN WAY

A European technique for treating tendinosis and one that is making a few inroads in the US is extracorporeal shock wave therapy (ESWT), similar to what is used to break up kidney stones. In ESWT, scar tissue is broken down while creating inflammation in surrounding tissues, which in turn helps regenerate healthy tissue. Dr. Strickland says studies have shown ESWT to be effective in the elbows but not in the knees or shoulders. In any case, it is still unproven in the US and insurance companies do not pay for the procedure.

Surgery is an eventual last-resort option for tendinosis... the doctor removes the dead part of the tissue and the body regenerates the tendon or other tendons compensate.

Once the injury goes beyond the inflammation stage to tendinosis, anti-inflammatory medications will be of no help.