Tendinosis

What is tendinosis?

Tendinosis is a degenerative process that affects a tendon, causing it to gradually break down. Tendons are cord-like connective tissues that attach muscles to bones. They’re mostly made of bundled collagen fibers. With tendinosis, these bundles start to break apart, weakening the tissue. Eventually, different types of cells fill in the gaps. This changes the composition of the tendon, making it heavier and stiffer.

What are the symptoms of tendinosis?

Tendinosis symptoms may include:

• Pain with activity, often described as burning.
• Stiffness and lost range of motion in the tendon.
• Weakness when trying to do activities you’re used to doing.
• Chronic pain (lasting more than three months).

Tendinosis doesn’t cause swelling, redness or heat (inflammation). In the early stages, it may not cause noticeable pain. Some people only notice it when the weakened tendon puts strain on other tissues. But in the later stages, when the tendon starts to rebuild itself as a different kind of tissue, it typically becomes more sensitive. This is because the tendon creates new blood vessels and nerves.

Where does tendinosis occur?

Tendinosis can occur in any tendon. It’s most common in your:

• Knee (patellar tendinosis).
• Heel (Achilles tendinosis).
• Foot (posterior tibial tendinosis).
• Shoulder (supraspinatus tendinosis or infraspinatus tendinosis).
• Elbow (lateral or medial elbow tendinosis).
• Thumb/wrist (De Quervain’s tendinosis).

What causes tendinosis?

Tendinosis happens when something injures your tendon and it’s unable to heal properly. Repetitive strain injuries are likely the most common cause. If you frequently overuse your tendon by repeating certain activities too vigorously or too often, it creates tiny tears in your tendon. If you don’t stop the activity and rest your tendon long enough for those tears to heal, after a while, tendinosis can start.

Other factors that may contribute to injuring your tendon or preventing it from healing include:

• Prior injury. Trauma, such as a sports injury that never completely healed, or a previous surgery, may have weakened the tendon.
• Chemical injury. Certain medications have been known to cause tendon damage, including fluoroquinolones (a type of antibiotic), corticosteroids and statins.
• Age-related degeneration. Age can contribute to weakening your tendon, especially if you’ve used it a lot in your lifetime.
• Chronic inflammation. If tendinitis or synovitis (inflammation of the sheath around the tendon) lasts for a long time, it can weaken the tendon and start the process of degeneration.

Who gets tendinosis?

You’re more likely to develop tendinosis if you practice a sport or occupation that involves repeating the same movements frequently every day. Athletes, laborers and enthusiastic hobbyists are more prone to repetitive strain injuries in general. When injuries happen, it can be harder for people to stop the activity and rest the tendon long enough for it to heal properly. They want — or need — to get back to work.

Certain individuals also have variations of their anatomy that can predispose them to tendinosis. For example, the top of their shoulder blade may slope down, causing the tendons to rub when the shoulder lifts away from the body. This can trigger chronic inflammation (tendinitis) and progress to tendinosis. As the tendon erodes, small holes develop, which may progress to significant tears even without injury.

What are the potential complications of tendinosis?

Untreated tendinosis will continue to progress, weakening your tendon until it fails. One way it might fail is by suddenly tearing (tendon rupture). Another way is by simply failing to do its job in your body and shifting its weight-bearing load to another body part. This can have a domino effect. For example, if your posterior tibial tendon fails, the arch of your foot can collapse, changing the way you walk.

How is tendinosis diagnosed?

Diagnosing tendinosis begins with a physical exam and health history. A healthcare provider will ask about your symptoms, when they started and any recent changes in your routine, including medications. They’ll ask about your regular activities and prior injuries. Then, they’ll take images of your tendon to look for evidence of tendinosis. Imaging tests can clearly distinguish between tendinitis and tendinosis.

How do you treat tendinosis?

For any type of tendinopathy, healing begins with rest. Tendinosis won’t stop progressing until you stop the activities that are stressing your tendon. Depending on how advanced it is, you might need to stop using your tendon for three to six months. Tendons heal very slowly. With rest, the cycle of injury and degeneration can stop. The goal of treatment is to encourage your tendon to start building new collagen.

Your healthcare provider might suggest:

• Pain relief. While anti-inflammatory drugs like corticosteroids and NSAIDs are mainstays for treating tendinitis, these medications may actually contribute to tendinosis. Instead, your provider might suggest acetaminophen (Tylenol®), arnica or topical pain relievers, like patches, creams and gels.
• Ice. Icing is a standard home therapy for musculoskeletal pain with benefits for tendinosis. It constricts the blood vessels in the tendon, which discourages new ones from forming to help prevent tissue remodeling. Healthcare providers suggest icing for 20-minute intervals several times a day.
• Massage. Later in your recovery process, massage can help by stimulating circulation and healing. Your healthcare provider can guide you on when and which types to try. A new method called deep friction massage may have particular benefits for tendinosis. It has a temporary pain-numbing effect and may also stimulate new collagen production in the tendon.
• Physical therapy. While activity modification is critical to allow for healing, it’s also critical to avoid muscle loss (atrophy) through physical therapy and a home exercise program. Your physical therapist will guide you in passive exercises to help rehabilitate your tendon and the surrounding tissues. They’ll also prescribe exercises to practice at home during your recovery.

These treatments work for most people. If your condition doesn't improve with standard care, your provider might suggest additional treatments, such as therapeutic injections, laser therapy or surgery.

Does tendinosis require surgery?

Surgery is a last resort treatment for tendinosis when other treatments aren’t successful. You might need surgery for tendinosis if there’s too much damage for the tendon to recover on its own. If a large portion of the tissue has changed, it might not have the resources left to regenerate collagen. In this case, surgery can help by removing abnormal tissue and making small cuts in the healthy tissue to stimulate healing.

What can I do to prevent tendinosis?

Not everything that can cause or contribute to tendinosis is preventable. But you can prevent repetitive strain injuries with some self-care. For example, if your job involves repetitive movements, you can often reduce stress and strain by creating a more ergonomic workstation. If you’re an athlete, make sure you’re warming up properly and using the right technique. If pain develops, know when to ease up.

Is tendinosis permanent?

Some of the damage tendinosis causes is likely to be permanent. But that doesn’t mean it will continue to affect you too much. With appropriate care, most people can stop the cycle of damage, relieve the symptoms of tendinosis, and even restore some of the tendon’s former strength and flexibility. However, your tendon may be more prone to injury from now on, so you’ll need to continue to look after it.

Does tendinosis cause disability?

Tendinosis can be temporarily disabling. It can diminish your strength and range of motion and may cause pain with movement. This may make day-to-day tasks of living difficult. You’ll also need to discontinue using your tendon for several months while you recover. If this prevents you from doing your job, you may qualify for disability benefits, depending on the policies where you live or work.

What’s the difference between tendinosis, tendinitis and tendinopathy?

Tendinosis and tendinitis are different types of tendinopathy — conditions that affect tendons. Both can cause pain when you use your tendon but for different reasons. Tendinitis is inflammation in your tendon. It’s the pain you get immediately after you injure your tendon. Tendinosis is a more gradual process of degeneration in your tendon. Repetitive strain injuries that never heal can lead to tendinosis.