Tendinitis is the inflammation of a tendon and of tendon-muscle attachments i.e. where the tendon attaches to the bone (insertional tendinitis). It is an overuse phenomenon, can be excrutiatingly painful and functionally debilitating. Treatment should focus on addressing the cause of the tendinitis, reducing the inflammation and the pain, and remodelling the tendon through a controlled exercise progression.
Most frequently seen diagnoses in our physical therapy clinic are rotator cuff tendinitis (supraspinatus tendinitis), posterior tibial and peroneal tendinitis (pain in the foot and ankle), tennis elbow (lateral epidondylitis), achilles tendinitis, patella tendinitis and iliotibial band syndrome. Interestingly, we have recently been seeing an increase in tendinitis of the guteus medius (hip abductor muscle). We see golfer’s elbow (medial epicondylitis) less frequently than tennis elbow.
Despite tendinitis occuring in tendons all over the body, the approach to treating the condition remains the same for each structure involved. You treat the tendonitis by following a specific intervention progression. The exercises are different for the different tendons but the principle remains the same:
Treat the cause of tendinitis.
It does not matter what tendon is involved, the cause is most frequently overuse. Overuse means the stress the tendon has had to endure, as a result of the force it is being asked to apply (both intensity and frequency), results in microtrauma to the tendon structure and hence inflammation. If the tendon is not given rest, it does not have the opportunity to recover. Examples of activities which can result in tendinitis include typing, repeated gripping on a production line, fly fishing, overhead lifting or repeated jumping. Ankle sprains may cause tendinitis in the posterior tibialis and peroneal tendons of the foot.
So, the first line of attack is to decipher what the causative activities are and modify them. For most rapid resolution, these should be stopped completely to avoid the continuous trauma to the tendon. Sometimes this is not possible and a program of relative rest must be designed by the physical therapist:patient team.
Treat the inflammation.
Part of controlling the inflammation is reducing the stress on the tendon. The physical therapist will address this with you in detail. As mentioned above, rest gives the tendon the opportunity to recover from the microtrauma (as noted above). Non-steroidal anti-inflammatories or even streroids may be prescribed by your physician at the same time. Physical therapy interventions to control inflammation include ice in the form of an ice pack or even ice massage and, iontophoresis – the administration of an anti-inflammatory, dexamethazone, to the tendon utilizing electrical currenct to faciltiate the passage of the medication through the skin (Yes! No needles!).
Treat the pain.
By following the above suggestions, pain should subside over time as the inflammation is controlled. If the pain is severe enough your physician may subscribe analgesics (pain killers).
Remodel the tendon.
Here is where the work is! Your physical therapist will teach you how to stretch the involved tendon as well as progress you through a specific exercise regimen which involves both concentric and eccentric exercises which will stress the tendon. A concentric exercise is one in which the muscle contracts and shortens at the same time e.g. the bicep contracts to bend the elbow bringing the coffee cup to your mouth. An eccentric contraction is one in which the contracting muscle is lengthening while it contracts e.g. the bicep contracts and lengthens as it controls the extending elbow to put the coffee cup back down on the table. An eccentric contraction places more tension on the tendon than a concentric contraction and can thus promote tendon remodelling. Eccentric exercises are more aggressive than the concentric type.
The goal of the stretching and strengthening progression is to stimulate tendon remodelling. This improves the flexibility and tensile strength of the tendon. This, in turn, improves the tendons ability to tolerate the original activity which caused the tendinitis.
Soft tissue mobilization? Deep transverse friction?
What about soft tissue mobilization and deep transverse friction? Soft tissue mobilization of the involved muscle belly and, indeed, of the surrounding musculature can be helpful in alleviating discomfort. It is less aggressive than deep transverse friction and is definitely more comfortable.
Deep transverse friction is used to stimulate blood flow in the involved tendon and break up any adhesions which may have developed as a consequence of the microtrauma of the tendinitis. It is done by applying significant pressure (up to 7/10 pain) over the tendon with the thumb or index finger and rubbing in a direction transverse to the direction of the tendon fibers. Sound like fun!? It is done in conjunction with the tendon remodelling exercises detailed above.
YOU CALL TO ACTION:
- Make sure you visit us early on in the process because it is much easier to treat than if you have had tendinits for more than a few weeks. EARLY INTERVENTION!
- Make sure you specifically ask to be sent to physical therapy the very first visit you have with your doctor so you can be shown the specific exercises and enjoy the hands-on treatment from the physical therapist.
- Pass this on to someone you know who has tendinitis.
- Call us with any questions you may have: 775-331-1199.