Pain Management

An In-Depth Look at Tendonitis

WHAT IS TENDONITIS?

Tendons work with the muscle during movement. They are strong bands of connective tissue that attach muscles to your bones. If a tendon develops inflammation from overuse or injury, the result can be tendonitis. This inflammation often occurs when the tendon is strained and small tears begin to form in the tendon. If this occurs, it will become painful, especially when the tendon is being used. The pain is often described as a “dull” ache, but can vary depending on the severity of the tear. If the affected area also has tenderness and swelling that is severely painful, it can keep a person from moving the tendon at all. There may also be stiffness and restricted mobility, muscle weakness, and the area may even feel warm when touched. If the sheath around the tendon happens to become inflamed (instead of the tendon), this condition is called Tenosynovitis. Surprisingly, it is possible to have tendonitis and tenosynovitis at the same time. Tendonitis can affect several different areas of the body; those who suffer from it may experience the pain in their wrist, thumb, knees, elbows, hips, shoulders, or the Achilles tendon. The pain that comes with tendonitis can be so severe that it becomes debilitating. This means that some activities that a person normally performs in their daily life may be so painful to do that they are unable to live life normally. Many are forced to stop doing the things they love to do. In the end, sufferers of tendonitis may end up making major lifestyle adjustments just to keep from experiencing the pain associated with tendonitis.

WHO IS AT RISK FOR DEVELOPING TENDONITIS?

Tendonitis is typically caused by repetitive movements or high impact movement of the tendons and muscles that surround a specific joint. Anyone is at risk for developing tendonitis, however, the older you are, the more likely you are to develop tendonitis because as we age our tendons lose elasticity and cannot handle stress as well. Activities that are known to cause tendonitis include: weightlifting, tennis, golf, skiing, throwing or pitching, climbing, shoveling, painting, raking, carpentry, gardening, scrubbing or cleaning. The following information describes instances that are known to increase a person’s risk for developing tendonitis:

Those who are starting a new job that requires physically demanding labor (or returning back after being away for a while) have a high risk for developing tendonitis.
Tendonitis is also commonly found in athletes or in those who perform high impact exercise. In fact, any sport that requires a lot of running and jumping may lead to the development of tendonitis.
Other causes include bad posture, joint deformities, calcium deposits on the tendon, failure to warm-up properly before exercise, exercising in cold temperatures, obesity, and side-effects from specific medications.
People with gout, arthritis or diabetes are at a higher risk for developing tendonitis. Some experts believe that this high risk for diabetics developing tendonitis is due to the fact that the blood supply to the tendons is lower for diabetics than it is for those without it. Another possible explanation that researchers believe is that high blood sugar levels can cause abnormal thickening of the tendons. (1) However, possibly due to lack of research, very few doctors these days seem to be aware of the connection between tendonitis and diabetes. Also, improving the levels of sugar in your blood does not seem to have an immediate effect on refining problems in the tendons.

Since Tendonitis can affect so many different areas of the body, we will explain each form of Tendonitis in detail.

TENDONITIS IN THE ELBOW

The first type of Tendonitis to discuss is Tennis Elbow or Golfer’s Elbow. They received these names because of how many tennis players and golfers develop tendonitis in their elbow. Even though they both affect the elbow, the fact is each one affects different areas of the elbow. In cases of Tennis Elbow, also referred to as lateral epicondylitis, the outside part of the elbow is affected with pain and tenderness. Any activity that involves turning or hand gripping (like using tools, shaking hands, etc.) can result in pain. The pain typically occurs in the elbow but can also travel to the upper arm and the forearm. Tennis elbow generally affects 40%-50% of adult athletes who play racquet sports, but can also result from everyday tasks such as carrying a suitcase (constantly gripping a handle), pulling up weeds, or turning instrument knobs on and off all day.

Golfer’s Elbow, also referred to as medial epicondylitis, causes pain in the inner side of the elbow and is typically less common than tennis elbow. It occurs due to damage of the muscles and tendons that control movement in the fingers and wrists. Any activity that makes you bend and straighten your arms repeatedly can lead to this form of tendonitis. It is common to see golfer’s elbow in construction workers or other physically demanding jobs, more than in sports. However, as the name explains, people who play golf tend to develop tendonitis.

TENDONITIS IN THE SHOULDER

One of the most common forms of tendonitis is in the rotator cuff and is typically related to overuse, often from sports or an occupation where the arm is lifted above the head repeatedly. The rotator cuff is described as a group of muscles attached to the arm to the shoulder blade. The cuff allows the arm to lift and twist back and forth, but constant, repeated motion of the arms in this manner, can damage the tendon and result in tendonitis. People who might be at risk for rotator cuff or shoulder tendonitis include:

swimmers
painters
carpenters
any occupation that requires you to lift your arm over your head for long periods of time
The typical sufferer of shoulder tendonitis is a 40-45 year old male whose occupation involves physical labor, and the pain is located on the same side as their dominant hand.

TENDONITIS IN THE KNEE

Knee tendonitis, which is also referred to as patellar tendonitis, affects the tendon that connects the kneecap to the shinbone. This particular tendon works with the muscles in the front of the thigh in order to help you kick, jump, and run. The patellar tendon has to absorb the majority of the body’s weight, therefore it is prone to injury for runners and jumpers; one study found that patella tendonitis accounts for just under 5% of all running injuries. (4) Unlike other typical running ailments, patellar tendonitis is more common in men than in women. Patellar tendonitis typically starts with a “stiff” sensation in the patellar tendon, especially when running downhill or when running up and down stairs. Tendonitis in this area often results from overusing the tendon during physical activities such as dancing, bicycling, or running. These types of injuries often happen to older individuals because their tendons tend to be weaker and stiffer, and dealt with years of repetitive activities that have caused the tendons to degenerate.

Pain in the tendons around the knee is also called “Jumper’s Knee” because it often happens to athletes who play basketball, or other sports that include a lot of jumping. Jumping can cause damage to the tendon because of the forceful impact that occurs when a person lands on the ground. Also, if a person significantly increases their levels of activity, the tendon may become damaged due to overuse. Tendonitis of the knee may cause severe pain for an individual while they are running or jumping. Since the knees are a hard area to keep stabilized and rested, knee tendonitis can increase the risk for large tears to the tendon, so please be cautious if you are experiencing knee pain.

Just like most other tendon injuries, pain may disappear when your body is warmed up, but as tendonitis becomes worse, it may continue to be painful for the majority of your workout. It is also important to be able to tell the difference between patellar tendonitis and patellofemoral pain syndrome (Runner’s Knee). Patellar tendonitis is not painful at the top or the side of the kneecap, and is typically not that sensitive when being touched.

TENDONITIS IN THE ACHILLES TENDON

The Achilles tendon is the largest tendon in the body; it runs from the heel of the foot to the back of the calf muscle. Working as a flexor between the foot and the calf muscle, the Achilles tendon is what helps us stand on our toes, and is used in walking, running and jumping. Achilles tendonitis and other Achilles tendon injuries are mostly found in athletes who spend a lot of time running and jumping, specifically runners. In fact, Achilles tendon injuries account for 5-12% of all running injuries (2). Achilles tendonitis can happen to a series of athletes including: runners, gymnasts, dancers, and football/baseball/basketball players. Those who spend a lot of time in speed training are more susceptible to developing Achilles tendon injuries or tendonitis. Achilles tendon injuries can happen during ordinary activities, like when you are climbing stairs. However, these types of injuries are commonly found in “weekend warriors,” or those who do not exercise regularly or take the time to warm up before they start a high impact exercise.

TENDONITIS IN THE WRIST

In cases of wrist tendonitis, pain is often located in the back of the wrist and at the base of the thumb. This injury typically occurs when the tendon is torn from overuse of grasping or pinching objects with the thumb and fingers. However, it can also stem from constant turning of the wrist, which is a task that many jobs require from an employee. Wrist tendonitis can be quite debilitating since we use our wrists for almost every single thing we do on a daily basis.

HOW DO I FIND OUT IF I HAVE TENDONITIS?

Discovering if you have tendonitis, will most likely require a visit to your doctor. Your doctor will probably begin with a series of questions regarding the signs and symptoms of your tendonitis. You will be expected to answer questions such as:

When did the pain start?
How long have you been showing signs of tendonitis?
Have you ever experienced sudden increases or decreases in pain?
Are you currently taking any medications? If so, what are they?
What type of job do you have?
Have you played a lot of sports?
How does the pain feel: sharp or dull?
Where is it specifically located?
Does the pain spread around, or is it localized to a specific area?
What makes the pain come and go?
Are you getting enough rest?

Throughout the physical exam, your doctor will try to identify tenderness in the area, as well as swelling, redness, muscle weakness and limited motion in the damaged tendon. Your doctor may also request that you move in specific ways (like raising your arm above your head or bending your wrist). These requests may seem painful to perform, but they are significant in revealing to your doctor which tendon is damaged. Other things that may occur during your doctor’s visit can include:

A test called “selective tissue tension test” which is used to determine if the tendon is damaged and causing your pain.
Your doctor can also inject anesthesia into the affected area to determine if the pain decreases or not. If the pain goes away after the injection, it is likely that tendonitis is the root of the pain.
A blood test may also be conducted to determine if you have tendonitis.
Since the swelling that is observed with tendonitis may be caused by an infection, your doctor may take a fluid sample from the affected area in order to test it.
An x-ray machine can also be used when diagnosing tendonitis to ensure that the tendonitis is not caused by arthritis or an injury to the bone.
It is possible that your doctor may even suggest an MRI (Magnetic Resonance Imaging) to determine if the tendon is actually torn or if there is something more serious going on inside the affected area. While X-rays are far less expensive than an MRI, X-rays are not able to show what condition your tendon is in or if there is a tear in the tendon.

HOW IS TENDONITIS TREATED?

Typically, treating tendonitis and managing the pain is performed using more than one treatment option at a time. Many doctors will recommend that you take NSAIDs or prescription painkillers to control pain from Tendonitis. If you are diagnosed with tendonitis and visit an orthopedic surgeon, they might suggest a cortisone shot. While this may reduce the pain temporarily, evidence tells us that it doesn’t actually improve healing in the tendon. There are also numerous side effects that you may suffer from if you receive a cortisone injection. While they range in severity, none of them sound comfortable to deal with.

It is also worth noting for readers: if you are a diabetic that is suffering from Tendonitis, receiving a cortisone injection for the pain may not be the best thing for you. Cortisone shots may involve more risk to people with diabetes because cortisone significantly worsens blood sugar control, and because some diabetics who suffer from tendonitis report that after a typical cortisone shot, their blood sugar control became worse and did not return to normal.

Most doctors will prescribe these types of treatment options for your Tendonitis, but do not rule out natural remedies that are affordable and easy to perform on your own, in your own house. If you discuss natural treatment options with your doctor, you may learn about some of the following options for treating your pain naturally.

NATURAL TREATMENT OPTIONS FOR TENDONITIS

SPLINTS

Some sufferers of tendonitis have found aid and comfort with the use of splints or braces. Since tendonitis may arise from excessive weight placed on the tendon during motion, braces and supports that decrease weight through the tendon may help the area heal faster. Certain braces, like heel lifts, support the Achilles tendon, while orthosis help control pronation in the Achilles and patellar tendons. These splints/braces are designed to keep the affected tendon from moving too far which makes the tears in the tendon larger. Preventing this from occuring gives your tendon a chance to heal properly. They can be worn during the night or day. There are splints/braces designed to help with tendonitis in the wrists, fingers, elbows, knees, and the heel/foot area. Splinting allows us to do what we normally do each day, without experiencing severe levels of pain or causing further damage to the tendon. This is very convenient for those who work physically demanding jobs; it can give them relief from their tendonitis pain without having to miss much work. Splints are great for athletes as well because they prevent further damage from high impact activities but allows them to still perform some of their training, even with a case of tendonitis. Splints are relatively inexpensive, but range from cheap to pricey. You can find them online, in a pharmacy, and in medical supply stores. It is advisable to speak with your doctor before wearing a splint for long periods of time during the day.

ICE THERAPY

Another approach for treating tendonitis is ice or cold application. Cold applications have been practiced for centuries, since they relieve the sensation of pain in the afflicted area. Ice can reduce the swelling in the area affected by tendonitis, and help reduce inflammation and pain. Ice can help blood flow properly in the damaged tendon and actually allow the inflammation process to move quicker. You can place a sizeable portion of ice into any sealable bag mixed with water. You may also purchase an inexpensive ice pack at most types of stores. However, it is very easy to make your own ice pack at home. Take a sealable bag and combine 3 cups of water with 1 cup of rubbing alcohol and mix well. It should start to solidify a little after mixing well. Place the bag in the freezer until it hardens into ice. Use your new ice pack as much as you need and when it becomes slushy again, place it back in the freezer. You should never apply ice or ice packs directly onto your skin as it can damage the surface of your skin; always place an article of clothing or a small towel between the ice pack and your skin.

REST

Proper rest of the affected area is probably the most crucial treatment option in successfully healing tendonitis. As one of the primary causes of tendonitis is overuse, taking a week off can help the area heal faster and return to normal. During periods of rest, you can reduce the pain caused by inflammation by not placing added tension on the area. Since inflammation is often present in cases of tendonitis, it is important for the inflammation process to run its course, allowing blood flow to reach the afflicted area and begin to heal. For some individuals, taking time off from work or athletics is not an option, however, a good night’s rest and keeping the affected area as still as possible is the easiest way to treat tendonitis.

MASSAGE

Transverse Friction Massage is another option for treating tendonitis and providing relief from pain. By enhancing blood circulation, it can prevent the formation of scar tissue. A friction massage will basically “scrub” the fibers in the tendon and doesn’t necessarily have to be a “deep tissue” massage. You can learn to perform this massage by yourself; however, it would be most beneficial to have this massage performed by a trained massage therapist. Since friction massage is safe and provides beneficial results in those with tendonitis, it can’t hurt to experiment with this treatment option. To perform this massage, gently rub the affected area back and forth perpendicular to the tendon (almost like strumming a guitar back and forth, where the “strings” would be your tendons). Using low to moderate pressure with your fingers, perform this massage for 5-10 minutes and repeat as you feel necessary. You may experience some discomfort during transverse friction massaging; this is completely normal. The discomfort, however, should decrease after 1-2 minutes. If the pain continues throughout the massage or if it is more severe than normal, immediately stop massaging the area. If you experience no pain whatsoever, you may be massaging the wrong area or it is possible that you do not even have tendonitis. If friction massage is not working at all for you, try a different approach in treatment; there’s no reason to cause further, unnecessary damage to the area.

TOPICAL ANALGESICS

Topical solutions for pain relief are gaining in popularity. This is most likely due to the fact that these products are a safe, reliable, and inexpensive way to treat tendonitis. Topical ointments deliver pain relief that does not need to be increased in dosage. You’ll never have to increase your dosage when using topical pain relief, as they do the same job (with the same amount or dosage) every time and most often provide positive results. Not only do topical analgesics provide risk-free treatment but they are also easy to come by and do not require a prescription from your doctor. Some topical analgesic products range higher in price (for good reason) and not all of these products are created equal. What you’ll be looking for is solutions that can provide anti-inflammatory ingredients. There are plenty of anti-inflammatory ingredients being used in topical analgesics, that are completely natural and help reduce pain and swelling. Ingredients like Arnica, Aloe Vera, Glucosamine, Emu Oil, Capsicum, and Chondroitin can be found in the best types of topical analgesics. Do not just settle for something that only contains Menthol; while Menthol provides positive benefits for pain, there are other ingredients that can provide relief and rejuvenation. Do not be afraid to try as many options as you can until you find a topical solution that’s right for you. If strong smells bother you, there are solutions that offer no-smell or even a less pungent odor.

STRETCHING AND STRENGTHENING

When the pain of tendonitis has decreased, strengthening and stretching exercises might be the right approach in preventing and healing your tendonitis. Eccentric strength training has been known to be effective in treating this condition and even helps the formation of new collagen in the affected area (5). Eccentric contraction includes the expansion of muscle fibers as the muscles contract. Eccentric exercise has shown to be beneficial in Achilles tendonitis and possibly other forms of tendonitis as well (6). Stretching exercises help to improve flexibility and is a common practice among athletes and those who have physically demanding jobs: “Numerous stretching studies have documented increases in the joint range of motion after stretching exercises” (7). Since pronation is a culprit in causing tendonitis (especially Achilles tendonitis), stretching can help increase flexibility in a way that strengthens the tendons and keeps them in their proper range of motion. An example of a wrist stretching exercise is as follows:

Holding your elbow/arm straight and have your palm facing down toward the floor, use your other hand to stretch the wrist downward.
Perform the exercise in reverse to flex the wrist the other direction.

You can also perform stretching exercises on tendonitis areas such as the elbow, knee and fingers. The idea is to build flexibility, but not to cause further damage to the area. Some tips that would be beneficial to remember during stretching is:

Focus on what is happening when you stretch these muscles.
Use direct, flowing movements.
Never jerk or pull on the muscle itself.
Take your time when flexing areas with tendonitis.
If you feel immediate and severe pain when stretching any part of the body, stop immediately!
It is also not a bad idea to speak with your doctor before doing a regular stretching exercise routine. They may be able to inform you about what exercises are specifically right for you, as well as safe ways to perform them without causing further damage to the affected area.

FOAM ROLLER

Foam rollers are another way to treat tendonitis, especially in cases of Achilles tendonitis. Foam rollers are inexpensive (especially the “cheap blue rollers”) and easy to find in most athletic stores and online. The idea in using a foam roller is to apply pressure that massages the afflicted area and helps with the healing process for damaged areas in the Achilles tendon. Some people may not be physically able to do some exercises with the foam roller, but if you have tendonitis in an isolated spot (and don’t have much trouble standing up and sitting down), they may be beneficial to you. You can use a foam roller at home anytime you want, and for some people, they have the convenience of using the roller at the gym, at work, or in other public places. If you are using a foam roller to treat your Achilles tendonitis, the calf is typically the area that is massaged. This is because direct application or pressure on the Achilles tendon may create further pain or injury if massaged incorrectly. The calves also work in unison with the Achilles tendon in everyday movement, so sometimes working out this area can help alleviate pain. You can sit on the floor and move the foam roller back and forth underneath your calf. Do not move the roller anywhere near the tendon or the affected area as this can cause further damage to the tendon. The roller works to counter massage the muscles and improve blood flow, which helps the affected area heal faster. It is important to be careful when using the foam roller. There are plenty of ways to exacerbate your tendonitis or cause other problems if you use the foam roller incorrectly. This often happens when people place the roller directly on the affected area, or roll too fast during treatment. The idea is slow and steady and make sure to concentrate on the task at hand. Other issues come from using bad posture during a foam rolling exercise or spending too much time working out the “knots,” which can cause nerve or tissue damage.

IN CONCLUSION:

Tendonitis treatment is not only achievable, but can be done in safe, natural ways that are convenient to your lifestyle. Perform your own research that is custom to you and your tendonitis, and educate yourself on what you can do to be more proactive in your tendonitis treatment. Tendonitis is not really anyone’s fault. It happens to millions of people every year, but some sufferers never fully understand how to relieve their pain and manage their condition. If your doctor has diagnosed you with tendonitis, work out a treatment plan with her/him or a specialist. Tendonitis can be a debilitating condition, and those who have it understand how it can rob you of certain pleasures in life. When you are not able to pick up certain objects, perform daily tasks, or even go to work, you’re going to want to handle your condition in a way that gets you back to normal, faster. This is why it is important to not only work with your doctor on a treatment plan, but also actively research your specific condition, to fully understand what treatment options will rid you of tendonitis.

References:

Thickness of the Supraspinatus and Biceps Tendons in Diabetic Patients Mujde Akturk et al. Diabetes Care 25:408, 2002
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Taunton, J.; Ryan, M.; Clement, D.; McKenzie, D.; Lloyd-Smith, D.; Zumbo, B., A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine 2002, 36, 95-101.2.
Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998; 26:360–6.
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