OVERUSE TENDINOSIS, NOT TENDINITIS 
Patients frequently complain of unexplained pain in the wrist, elbow or shoulder. They may even have progressed to the point where the pain/numbness and tingling make simple activities of daily living painful and difficult. Often I’ve heard people say “it hurts even to pick up a cup of coffee” These problems are usually caused by overuse of tendons in the wrist, elbow and shoulder. Clinically these are called: Wrist Flexor or extensor tendinitis Tennis Elbow (illustration #1) Golfers Elbow (illustration #2) Rotator Cuff Tendinitis of the shoulder (illustration #3, letter d) Biceps Tendinitis (illustration #3, letter a) The interesting thing is we call them tendinitis even though technically this is not usually the case. Rather they usually are tendinosis. Tendinosis is the degeneration of the proteins that make up the tendons. Tendinitis is the acute inflammation of the cells that make up the tendons. It is present early in the process of injury to the tendon. How do we know this? Research has shown in biopsies (tissue samples) of these tendons that the tissue is brown or grey, dull appearing and very soft in texture. Normal tendon tissue is white, glistening and firm. Microscopic evaluation shows no inflammatory cells, rather scar tissue producing cells are present. Necrosis (dead tissue) may also be present. What causes these problems in the tendons of the wrist, elbow and shoulder? What makes them so painful? These problems are caused by either highly repetitive activities or very intense use of the arms with no warm up or insufficient rest between activities. Secondly, these tendons are innervated by nerves and some run very near large nerves. The tendinosis can cause irritation and pain within these nerves. In fact, it’s not usually until these nerves are irritated that patients seek help. Delaying treatment only makes matters worse. It is very important to listen to the patient to try to determine which activities are causing this problem. The overloading of these tendons over and over can cause permanent tendon damage. I have seen patients disabled by these disorders due to continued use of badly damaged tendons. It can even lead to rupture of the tendon as it frays and breaks down, much like an overused rope on a pulley. Basically the tendon slowly dies and breaks down. If we imagine the tendon cut in half in cross section the outer layers die first. Imagine a telephone cable. First the outside protective layer is exposed and begins to fray and wear away. There comes critical time where if 50% of the tendon is still healthy, then there is likely to be enough healthy tendon tissue to regrow a healthy tendon. However, several things need to happen for the tendon to regrow and heal itself. Stop the abusive activity. Light duty at work, lay off the tennis racquet, stop moving the furniture to clean, etc. If it hurts back off Get into a good therapy program. Medicine alone will not heal the tendon. It takes careful stretching and special strengthening techniques to regrow healthy tendon. Special modalities can speed up healing. Avoid cortisone shots unless it is so painful it hurts to do simple ADL’s such as brushing your teeth or lift a coffee cup. Avoid multiple cortisone shots. Studies show cortisone shots can lead to tissue damage which may be irreversible. Surgery is a last resort. Successful outcomes of tendon surgeries, particularly for the elbow are limited at best. Realize this did not happen overnight and it will take months to heal and regrow healthy tendons. Time for full recovery may take two to six months. Studies show even if you do all the right things the likelihood of a full recovery is only 80%. When you continue the abusive (pain producing) activities you are only making the odds of recovery worse. Also consider the use of counterforce device for elbow problems. These “elbow straps” do not have a lot of research to support them but the concept of dispersing the force of the tendon over a wider area is sound. Do not put them on too tight, however. Ice can be helpful too, after activities. Use a moist towel and apply for 20 minutes. Remember, delaying getting help may only make treatment longer and increase your pain. It can also lead to permanent tendon damage and pain in the hand, wrist, elbow and shoulder. Give us a call today. |
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