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Goodbye Tendonitis, Hello Tendinosis
By Warren Hammer, MS, DC, DABCOTendonitis is now considered a relatively rare condition.1 The good news is that with the diagnosis of tendonitis, patients were expected to get well in a short time, but with the realization that it is really tendinosis, more time is required (six weeks to six months, depending on the chronicity) for treatment and healing.
In many cases such as Achilles tendonitis, patellar tendonitis, lateral epicondylitis and rotator cuff tendonitis, a good percentage of cases do not get well as soon as we might desire. We do not have to blame ourselves. What we have to do is explain to the patient the underlying tissue damage that exists. Corticosteroid injections and NSAIDs cannot really heal a noninflammatory condition.
In my article "Is It Really Tendonitis?" which appeared in the January 12, 2000 issue of Dynamic Chiropractic, I quoted Boyer et al.,2 who stated: "Signs of either acute or chronic inflammation have not been found in any surgical pathologic specimens in patients with clinically diagnosed lateral tennis elbow syndrome." Maffulli3 states that "tendonitis" or "tendinosis" should only be used when the microscopic diagnosis of the condition has been confirmed.
Evidence is currently on the side of tendinosis over tendonitis. According to Bonar,4 tendonitis is symptomatic degeneration of the tendon with vascular disruption due to a partial rupture of the fibers. Most of the chronic conditions we see are not traumatic enough to cause a vascular disruption necessary for the creation of an inflammatory response. What we really are seeing is an intratendinous degeneration due to aging, and microtrauma where there is collagen disorientation, disorganization and fiber separation by increased mucoid ground substance. Tendinosis results from collagen degeneration and mechanical overload.1
Our treatment should emphasize the prevention of collagen breakdown, which requires rest and strengthening (especially the eccentric type). Elbow and ankle supports, for example, take on a new meaning. Warming up before activity and paying attention to correct biomechanics required for particular sports takes on a new emphasis. We must prevent collagen damage and, most importantly, stimulate collagen synthesis. Again, the knowledge that friction massage stimulates fibroblastic proliferation, which synthesizes new collagen, proves again why this method has proven so effective over the years.
Khan KM, Cook JL, Taunton JE, Bonar F. Overuse tendinosis, not tendonitis. The Physician & Sports Medicine 2000;28(5):38-48.
Boyer MI, Hastings H. Lateral tennis elbow: "Is there any science out there?" J Shoulder Elbow Surg 1999;8:481-91.
Maffulli N, et al. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy 1998;14(8):840-43.
Khan KM, Cok JL, Bonar F, et al. Histopathology of common tendinopathies: update and implication for clinical management. Sports Med 1999;27(6):393-408.