Tendinitis Flashcards
Tendinitis
Inflammation of a tendon
Inflammation of a tendon:
Tendons are made of regularly arranged, dense collagen fibrils
They attach muscle to bone and are part of the musculotendinous unit
Tendons appear in two shapes: cord-like structures and broad, sheet-like called aponeuroses
A tendon that moves in a straight line is surrounded by a paratendon-blood vessels are coiled in the loose alveolar tissue which stretches along with the tendon
A tendon that runs across a bony prominence is surrounded by a tendon sheath-this double-layered tubular structure is filled with synovial fluid
Tendons
The dense CT of tendons has a limited blood supply originating from muscles and bones
Tendons are subject to great tensile stress
When a load is placed on a tendon, the waves of its collagen fibres straighten out
The collagen fibres then temporarily deform
Over time, a tendon can experience micro-tearing, partial tearing or complete rupture, usually at the point of most reduced blood supply
Causes of Tendinitis
Chronic overload of the tendon, leading to microtearing and an inflammatory response in the tendon
- Contributing Factors:
Muscle imbalances, lack of flexibility, improper equipment and training errors
Types of Tendon Overuse Injuries
Tendon overuse injuries have all been termed “tendinitis”
- Tendinitis
- Paratendinitis:
- Inflammation of the paratendon or the tendon sheath where these structures are associated with a tendon, either of which may be irritated by the tendon as it rubs over a bony prominence
- Associated with tendon injuries
- Also called tenosynovitis or tenovaginitis
- Tenosynovitis is irritation of the inner surface of the tendon sheath by the roughened surface of the tendon
- Tendovaginitis is irritation and thickening of the sheath itself
- Tendinosis:
- Degenerative changes occurring with chronic overuse tendon injuries, such as “tennis elbow”
- Aging and avascularity may be contributing factors to tissue degeneration
- There are no signs of inflammation in the tendon itself, but biopsies have shown
angiofibroblastic degenerative changes occurring (invasion of organized vascular tissue and a disorganization of collagen tissue in the tendon)
Grades of Tendinitis
Grade 1-pain after activity only
Grade 2-pain at the beginning of activity which disappears during activity then returns after activity
Grade 3-pain at the beginning of activity, during activity and after activity. Pain may restrict activity
Grade 4-pain with ADL’s and pain continues to get worse
Common Tendinitis Locations and Causes
- Supraspinatus tendon
- Infraspinatus tendon
- Subscapularis tendon
- Biceps long head tendon
- Common extensor tendon
- Common flexor tendon
- Abductor pollicis longus and Extensor pollicis brevis tendons
- Patellar tendon
- Popliteus tendon
- Tibialis posterior tendon
- Achilles tendon
- Supraspinatus Tendon
To palpate:
The client is seated with their arm held behind the back and the elbow in flexion
The humerus is maximally internally rotated and maximally extended, bringing the humeral attachment of supraspinatus out from under the acromion
The tendon is palpated immediately inferior to the AC joint
The therapist palpates through deltoid in the indentation between the anterior and middle fibres
- Infraspinatus Tendon
To palpate: (infraspinatus and teres minor)
The client is seated or prone with the humerus flexed to 90 degrees, adducted 10 degrees and externally rotated 20 degrees
This position brings the tendon out from under the acromion
The tendon is palpated immediately inferior to the AC joint and the lateral portion of the spine of the scapula
The therapist palpates the tendon through the posterior fibres of the deltoid muscle
- Subscapularis Tendon
To palpate:
The client is seated with the humerus at their side and the elbow flexed to 90 degrees
The tendon is palpated inferior to the clavicle, lateral to the coracoid process (medial to anterior deltoid)
The tendon is palpated deep in the deltopectoral triangle, between the tendons of the long and short heads of biceps
- Rotator Cuff Tendons
Supraspinatus, infraspinatus, teres minor and subscapularis are prone to tendonitis with sports such as swimming, tennis, golf or any throwing sport
Occupations or activities that stress the shoulder muscles with the arms in an overhead position, such as drywall installation or assembly line work
Pain is usually experienced when the arm is in more than 90 degrees of abduction
- Biceps Long Head Tendon
To palpate:
The client is seated with the humerus internally rotated 20 degrees or to a “hands on lap” position
The tendon is palpated inferior to the clavicle, lateral to the coracoid process in the same areas as the subscapularis tendon
Swimming and throwing sports where the arm is adducted, compressing the tendon can cause bicep tendinitis
- Common Extensor Tendon
To palpate:
The client is seated with the elbow in slight flexion
The tendon is located distal to the lateral epicondyle
It may extend over top of the radial head which can be located by the client pronating and supinating the hand while the therapist palpates for the moving head
Repetitive forceful extension, supination and radial deviation are the movements lost likely to provoke extensor tendinosis
Wheelchair athletes and meat cutters are also susceptible
- Common Flexor Tendon
To palpate:
The client is seated with the elbow in flexion and the wrist supinated
The tendon is located distal to the medial epicondyle
Repetitive activity such as hammering or using a screwdriver may cause injury to the CFT
Sports involving wrist flexion and pronation such as golfing and overhead serving in tennis are other causes
- Abductor Pollicis Longus & Extensor Pollicis Brevis Tendons
To palpate:
The sheaths of these two muscles is palpated at the radial side of the wrist
Activities requiring repetitive thumb use, repetitive radial and ulnar deviation and forceful gripping cause De Quervain’s tenosynovitis
- Patellar Tendon
To palpate:
Palpated immediately inferior to the patella
Pain is localized to the tendon
Activities include running or jumping such as track and field are causes
- Popliteus Tendon
To palpate:
Palpated just inferior to the lateral femoral condyle, directly posterior to the lateral collateral ligament and biceps femoris tendon
It is palpated through the lateral gastrocnemius muscle
Activities such as downhill running or downhill walking combined with foot pronation cause this tendinitis
Can be confused with ITB friction syndrome
- Tibialis Posterior Tendon
To palpate:
The foot is placed in plantarflexion
The tendon in its sheath is palpated just posterior and inferior to the medial malleolus
Pain runs along the medial border of the tibia and along the course of the tendon
Activities such as running, using step machines or doing step aerobics combined with excessive pronation can cause this tendinitis
- Achilles Tendon
To palpate:
The tendon lies between the gastrocnemius-soleus complex and the calcaneus
Pain is felt along the tendon
Activities such as running combined with pronation, poor footwear or tight gastrocnemius-soleus muscles cause this condition
Medical Treatment of Tendinitis & Tendon Tears
For acute tendinitis, inflammation is controlled through rest, ice and NSAIDs
Stretching, strengthening and a gradual return to activity are recommended
Surgical repair is necessary with a total tendon rupture
Other Tendon Pathologies
Rotator cuff tendons may suffer:
- Impingement syndrome
- Partial or complete tears
- Calcific tendinitis
- Trigger Finger
- Impingement Syndrome
Inflammation, pain and edema in the tissues within the coracoacromial arch and between the acromioclavicular and glenohumeral joints
Painful compression of the tendons, especially supraspinatus, may occur when the humerus is abducted against the acromion
The biceps tendon and the subacromial bursa may be affected as well
Stage 1-edema and hemorrhage of the subacromial bursa
Stage 2-tendinitis and fibrosis are present. Both stages are reversible with conservative care such as rest, stretching and progressive strengthening
Stage 3-incomplete tears or complete tendinous rupture occurs. There may be associated bony changes in the acromion and the AC joint. Surgery is usually indicated
- Rotator Cuff Tears
Overuse, impingement and normal aging can lead to painful tearing of the rotator cuff tendons
Tears may be partial or full thickness with supraspinatus the most frequently injured
Medically, tears are treated by open rotator cuff repair surgery in which the rotator cuff is exposed
- Calcific Tendinitis
A late-occurring stage of rotator cuff tendinitis, usually developing in the supraspinatus tendon
Supraspinatus functions to hold the head of the humerus in place and this constant pressure of the head of the humerus seems to “wring out” the blood supply to the poorly supplied tendon
The tendon’s fibrocytes change to chondrocytes, collagen disintegrates and calcific deposits accumulate in the cells
Over time, these deposits are set free into the intercellular spaces
The deposits can be soft, toothpaste-like material or hard and chalky
- Trigger Finger
Through overuse, flexor tendons of any finger may develop a thickened, nodular swelling
This swelling is unable to move through the tendon sheath and gets caught
The finger is stuck in flexion until it is passively extended by an external force
Rest, NSAIDs and stretching are the usual treatments
Symptom Picture
By nature, tendinitis is a chronic condition with an initial acute inflammatory stage
- Acute:
- Gradual onset with tenderness local to the tendon, one or two days after activity
- Initially, pain diminishes with renewed activity which progresses to pain during activity as the severity increases
- Microtearing occurs with adhesion formation as the tendon attempts to heal
- Repetitive use tears these new adhesions, causing more inflammation and a cycle of reinjury
- Inflammation, heat and swelling develop along the tendon or tendon sheath
- Crepitus may develop with tenosynovitis and paratendinitis
- Decreased ROM of the affected muscle
- Chronic:
- Pain occurs during and after activity
- Chronic inflammation, fibrosis and adhesions are present
- Chronic swelling or thickening may be observed if the tendon is superficial enough, as with the Achilles tendon
- Crepitus may be present
- Decreased ROM and decreased strength
- Flare-ups to the acute stage may occur with repeated overuse
- Tendon may degenerate to such a degree that tendon rupture occurs
Health History Questions
What activities or movements cause pain?
Where is the pain located?
What are your current symptoms? How long have these symptoms been present?
What is the client’s recreational or occupational posture?
Have you begun a new activity or increased duration or speed of a previous activity?
Was there a previous injury to the affected limb?
Has the condition been diagnosed by a physician?
What parallel therapies are you taking?
Are supports or braces being used during activities?
Are you taking any meds?
Observations
- Acute:
- Antalgic posture or antalgic gait may be present
- Swelling and redness may be noticeable if the tendon is superficial
- Chronic;
- A postural assessment may be performed to determine sources of muscle imbalance
- Thickening of the tendon may be observed
- Muscle wasting and disuse atrophy occur with complete tendon tears
Palpation
- Acute:
- Point tenderness occurs over the tendon
- Heat and swelling may be palpated at the tendon
- HT and TPs are present in the affected muscle and its antagonists
- Chronic:
- Pain occurs over or near the tendon
- Swelling adhesions are present. The tendon may feel granular or hard at the adhesion site
- HT and TPs occur as in the acute stage
- Crepitus may be palpated on movement of the tendon in its sheath
- A snapping sensation may be felt due to tight tendons that snap over bony prominences or bursae
Testing
Acute & Chronic:
AF ROM of the affected limb is usually painless
PR ROM may reveal pain on actions that fully stretch the affected tendon
AR isometric testing is painful on contraction of the muscle of the affected tendon, especially if the muscle is contracted in a stretched position. Pain is local to the tendon and increases with the force of the contraction. The therapist may have to move the muscle through its range, testing isometrically in different positions to provoke a positive test. If this fails, the client puts the limb in the position that causes pain and isometric resistance is applied in this position
Treatment
Acute
Positioning depends on the location of the tendinitis and the client’s comfort
Hydrotherapy is cold
Reduce edema on the affected limb
Reduce HT and TPs in the proximal and antagonists muscles
Reduce HT in the affected muscle with GTO on the unaffected tendon
Distally, muscle squeezing and stroking are used
Maintain ROM with passive relaxed ROM on the proximal and affected joints
Mobilize hypomobile joints
Treatment
Chronic
Positioning is chosen for comfort and for accessibility of the structures that are treated
Hydrotherapy proximal to the tendinitis and on the lesion site itself include deep moist heat to soften adhesions and to increase local circulation
Contrast hydrotherapy is useful to flush out edema
Reduce fascial restrictions and any chronic edema
Reduce HT and TPs in the proximal limb and antagonists and the affected muscle is treated working towards the lesion
Reduce adhesions that may have formed in the tendon and between. Fascial techniques and muscle stripping are used over the lesion site to break down as many adhesions as possible before frictions are used. After frictions are applied, stretch and ice
Mobilize hypomobile joints in the affected limb
Restore ROM with PR ROM
Stretch shortened muscles with passive stretches
Self-care: Acute
- Acute:
Educate the client regarding relative rest with activities that cause the tendinitis
Hydrotherapy of ice immediately after activity
Stretch shortened muscles with slow, pain-free stretches
Strengthen weakened muscles with progressive strengthening that is pain-free, submaximal isometric exercises
- Chronic:
Educate the client regarding relative rest with activities that cause the tendinitis
Hydrotherapy of contrast bath is used
Self massage may be used on the antagonists and affected muscles
Stretch shortened muscles, progressing from isometric to isotonic exercise
Eccentric exercises can be effective for a strengthening effect on the tenon