Tendinopathy, Not Tendonitis

Tennis elbow. Hip “bursitis.” Jumper’s knee. Achilles’ pain. Golfer’s elbow. Shin splints.

What do all these have in common?

You could probably guess it by the title, but we’ll make it obvious, just in case. They are all forms of tendinopathy. Now, before you navigate away from this blog post because you have tendonitis – not tendinopathy – hear us out for just one second.

The overwhelming majority of cases “diagnosed” as tendonitis in the US are actually tendinopathy. We aren’t joking. This stuff gets misdiagnosed all the time. And, when it’s misdiagnosed, you don’t get the right treatment. Our aim with this blog post is to clear up what tendinopathy is, what helps it get better, and what is a waste of your time and/or money.

Tendinitis vs. Tendinopathy

Before we go any further, we are going to clear up the difference between these two. While tendonitis can progress to tendinopathy, the overwhelming majority of people who are seeking to be pain-free have tendinopathy as tendonitis is very short lived. Most individuals seek help primarily because they can’t do something they need or want to be able to do and not because they are in pain. It takes time for pain to progress to a loss in function. This means the pain has typically been around for quite some time when individuals choose to seek help, indicating that the tendonitis phase is almost always past.

To break it down a bit further –

Tendonitis

• Very short duration (similar to muscle soreness but feels like pain instead)
• Typically occurs after a short bout of increased activity or repetitive motions
• Pain occurs with motion but goes down very quickly afterwards
• Very rarely does a loss in function occur

Tendinopathy

• Persistent discomfort that lingers more than 2 weeks
• Typically unable to do a specific task(s) without pain
• Pain occurs with motion and may or may not go down afterwards
• Can be easily aggravated with activity
• A noticeable loss in strength can be present
  

What Doesn’t Help

There is a whole host of things that a doctor may suggest that aren’t supported by research. In fact, all the following options that we are going to discuss have research primarily against their use in treating tendinopathy. These include: PRP injections, stem cell injections, and corticosteroid injections. We will tackle each one individually.

PRP Injections

For those who are new to PRP, it stands for platelet-rich plasma. Essentially, they draw your blood out and spin it around in a device that separates the solid from the liquid. From here, they inject concentrated platelets in the painful area. The goal is to create a new inflammatory reaction to induce tendonitis and start the process all over again.

Unfortunately, these do not restore a degenerated tendon to a healthy tendon and it is advised against using these as front-line treatments. They are typically not covered by insurance and done as a last-resort (read: physical therapy has been exhausted). There is often a lengthy recovery protocol after these are performed as well.

Stem Cell Injections

All cells differentiate three times. A stem cell is a cell that has been harvested from the human body before the last differentiation can occur. One of the most dense source of these cells is a growing fetus. Because of this, the use of stem cells and how they are obtained can be controversial.

Similar to PRP injections, these do not allow an unhealthy tendon to become a healthy tendon. We have (anecdotally) seen them be helpful with arthritis, but only when the arthritis is mild or moderate. When arthritis is severe, a stem cell injection tends to offer a very brief period of very little relief.

These are also not covered by insurance and can be quite costly – up to $12,000 in some locations depending on the area(s) that are completed. We recommend not seeking to use this as an option for tendinopathy as they do not heal the injured tendon.

Corticosteroid Injections

This is the most common type of injection performed for tendinopathy. Here is why: it gives short term pain relief. What you aren’t told while you are getting this injection it is that the long-term consequences outweigh the short-term benefits.

Cortisol is a steroid and it breaks down tissue. Yes, it relieves pain, but that occurs at the cost of putting your tendon in a worse position than it currently is. When the pain relief wears off, you are left with tendon fibers that are more misaligned and this is problematic for future injuries (a healthy tendon has all fibers aligned in the same direction).

You are also left with a decrease in tenocyte volume. A tenocyte is a tendon cell. That means there are less cells in the tendon, increasing the chance that the tendon can get injured again because a smaller structure is left to bear the same loads as before. Less tendon cells also mean a decreased capacity for the tendon to grow and regenerate itself.

Looking at all of these three types of injections, corticosteroid injections are the worst in terms of long-term outcomes. Fortunately, there are options to improve pain associated with tendinopathy besides injections.

What Does Help Tendinopathy

There are two main things that have been shown in research to help with tendinopathy: dry needling and graded loading (exercise). Let’s break both of them down further.

Dry Needling

Dry needling is a “newer” treatment that addresses local trigger points in the muscle. Relieving these local trigger points can decrease the pain associated with tendinopathy. This allows you to load the tendon more, make it stronger, have less pain, and thus get better. If you haven’t heard what dry needling is, this is an overview that will help it make more sense.

The following tendinopathies have been shown in research to benefit from dry needling

• Biceps
• Lateral epicondylitis (tennis elbow)
• Proximal hamstring
• Rotator cuff

Clinically, we have also seen really good results with

• Achilles
• Hip “bursitis” (this is really tendinopathy of the gluteus medius and gluteus minimus, but we’ll save this soapbox for another day)
• Proximal hamstring
• Jumper’s knee (patellar tendinopathy)

But There’s No Placebo…

One caveat to studying dry needling is it impossible to have a true placebo. Thus, the positive results could come from psychosocial factors surrounding the patient-provider interaction(s), the patient believing the dry needling will help, or a whole host of other factors that contribute to placebo effects.

Our question to you is – does it really matter why we got the positive results if we obtained them? There are very little risks with dry needling. When in skilled hands, it is more common to have an adverse event while walking down the street than it is during dry needling (this is likely because you spend more time walking down the street than experiencing dry needling, but we digress).

So, if there’s little to no side effects and a positive result, why quibble about how we get that positive result? We’re not saying that scientists shouldn’t keep researching and figuring it out. But, if we have a safe and effective method of getting rid of pain on our hands, why wouldn’t we use it?

Graded Loading

There are some cases where you can rehab yourself, but this is one where we highly suggest against it. The reason for this is the recovery from tendinopathy is anything but black and white. The goal is actually to cause some discomfort – but not too much discomfort – so your tendon can adapt and heal. The problem is that it is incredibly difficult to know how much is too much. It is also incredibly helpful to have someone who has seen what you are going through many times over. Using objective data can tell you when to step on the gas or the break and it’s easier to know which to step on when someone else is making the decision for you.

Furthermore, you want the tendon to gradually progress in terms of static loads, energy storage, compressive loads, and friction. You need enough of each, in the right order, without overdoing it, to get results. Sounds complicated, right? We think so too.

Dr. Sarah’s 2 Year Injury

Even when you know all the information, you can still go wrong. Dr. Sarah struggled with hamstring tendinopathy for two years. For two whole years she attempted to progressively load her hamstring, but kept accidently overloading it and setting herself back after a brief period of progress. It took her being unable to move and having to have other people carry all her furniture and boxes for her after a flare-up where she couldn’t walk to get help.

It took her 9 months from the time she sought help to where she could run three miles without more than mild discomfort the next day. She had someone telling her what to do in terms of loading, she got some good hands-on therapy and dry needling, and she had success. However, she fully knows that the time it would have taken her to get better would have been much faster if she would have asked for help sooner. (Hindsight is 20/20, right?)

Even professionals make mistakes. Learn from our mistakes and don’t make the same ones we did. If you are struggling with tendinopathy, reach out. We know what it’s like. We’ve been there and we’d like to help you get back to what you are doing without pain. We’d also like your journey to take less than 2 years!

Articles referencing any of the facts included in this blog post are available upon request. Simply contact us and we will be happy to send them your way!