Tendinopathy, tendinitis or tendinosis are all interchangable terms. They refer to damage or degeneration of a tendon that can be thought of as repetitive microtearing that has failed to heal. For many people it starts as mild pain torwards the end of exercise, and when they cool down. As it progresses the pain comes on earlier in exercise, and lasts from cool down into the next day. Some people find they get significant pain getting out of bed in the morning, and pain continues until they warm up. In many cases the pain gets to a point where people are unable to do the exercise or work they want to.
When dealing with tendons, our sports physicians commonly look at the tendon using an ultrasound and then grade the tendon based on the way it looks. A normal tendon has straight fibers that are well packed together. In the acute phase of a tendinopathy there is swelling about the tendon. The fibers remain quite straight and there is no thickening in the tendon. During this phase, cortisone injections and anti-inflammatories can be effective treatment modalities. This phase generally lasts 6-8 weeks.
As the tendon tries to heal itself, the nice straight fibers you see in a normal tendon are lost, the tendon starts to thicken and small dark regions begin to form. These regions correspond to mircotearing in the tendon. This phase is known as a proliferative phase and is quite responsive to shock wave therapy, the use of GTN patches (also known as nitrate patches) and an eccentric exercise program.
As the tendon disease progresses, the microtears coalesce into larger tears. New blood vessels grow into the tendon and bring nerves with them. Finally, as the tendon continues to try to heal itself you get the laying down of calcium. At this point in time the tendon is commonly described as a calcific tendinopathy. During this degenerative phase of a tendinopathy injection therapies such as autologous blood, platelet rich plasma injections, and more recently hyaluronic acid can be successful. GTN patches, and eccentric exercise programs also form an essential base of treatment during this phase. It is possible to block off the new blood vessels, and certainly this is done by some groups, with the use of polidocanol. In circumstances where there is persistent swelling about the Achilles and the tendon has failed to respond to treatment, a procedure called a hydrodilatation can be performed. For those tendons that have moved to become calcific tendinopathies, the use of shock wave therapy again has been shown in some circumstances to be an effective way of addressing these issues.
For the treatment of tendon problems there is currently no magic bullet. We have found tailoring treatment strategies to the patient and the specific phase of tendinopathy, to be most successful. This in some cases can result in people with bilateral problems being treated differently for each tendon.
