TENDINITIS -vs- TENDINOSIS
ITS ALL ABOUT THE QUALITY OF THE WAVES —- THE COLLAGEN WAVES
Over the past decade, medical research has conclusively shown that the major cause of tendinopathies is not inflammation (aka “itis“), which even a decade ago was nothing new. For decades, the scientific community has been concluding that while the immune system mediators we collectively refer to as “INFLAMMATION” are probably present in tendinopathies; inflammation itself is rarely the cause (HERE). So, if inflammation is not the primary cause of most tendon problems, what is? Follow along as I show you from peer-review, that since the early 1980’s, research has shown the primary culprit in most tendinopathies is something called “osis“. Thus the name, “tendon – osis” (tendinosis). But what the heck is osis?
The suffix “osis” indicates that there is a derangement and subsequent deterioration of the collagen fibers that make up the tendon. The truth is, even though doctors still use the term “tendinitis” with their patients, their AMA-mandated Diagnosis Codes almost always indicates the problem is “tendinosis” or “tendinopathy” (HERE). Is this differentiation between tendinitis and tendinosis really that important, or am I splitting hairs and making a big deal out of nothing — making a mountain out of a molehill, semantically speaking? Instead of answering that question myself, I will let two of the world’s preeminent tendon researchers — renowned orthopedic surgeons — answer it for me.
“Tendinosis, sometimes called tendinitis, or tendinopathy, is damage to a tendon at a cellular level (the suffix “osis” implies a pathology of chronic degeneration without inflammation). It is thought to be caused by micro-tears in the connective tissue in and around the tendon, leading to an increased number of tendon repair cells. This may lead to reduced tensile strength, thus increasing the chance of repetitive injury or even tendon rupture. Tendinosis is often misdiagnosed as tendinitis due to the limited understanding of tendinopathies by the medical community.“ Tendon researcher and orthopedic surgeon, Dr. GA Murrell from a piece called, “Understanding Tendinopathies” in the December 2002 issue of The British Journal of Sports Medicine.
“Tendinitis such as that of the Achilles, lateral elbow, and rotator cuff tendons is a common presentation to family practitioners and various medical specialists.1 Most currently practicing general practitioners were taught, and many still believe, that patients who present with overuse tendinitis have a largely inflammatory condition and will benefit from anti-inflammatory medication. Unfortunately this dogma is deeply entrenched. Ten of 11 readily available sports medicine texts specifically recommend non-steroidal anti-inflammatory drugs for treating painful conditions like Achilles and patellar tendinitis despite the lack of a biological rationale or clinical evidence for this approach. Instead of adhering to the myths above, physicians should acknowledge that painful overuse tendon conditions have a non-inflammatory pathology.” Karim Khan, MD, PhD, FACSP, FACSM, and his group of researchers at the Department of Family Medicine & School of Human Kinetics at the University of British Columbia, from the March 2002 edition of the BMJ (British Medical Journal).
“The American Academy of Orthopedic Surgeons has provided a new classification of tendon injuries…. In the microtraumatic tendon injury the main histologic features represent a degenerative tendinopathy thought to be due to an hypoxic [diminished oxygen] degenerative process. The similarity to the histology [study of the cells] of an acute wound repair with inflammatory cell infiltration as in macrotrauma seems to be absent. A new classification of tendon injury called “tendinosis” is now accepted. “Tendinosis” is a term referring to tendinous degeneration due to atrophy (aging, microtrauma, vascular compromise). Histologically there is a non-inflammatory tendinous degeneration due to atrophy (aging, microtrauma, vascular compromise), as well as a non-inflammatory intratendinous collagen degeneration with fiber disorientation, hypocelluarity, scattered vascular ingrowth, and occasional local necrosis or calcification.”
“The relatively new term ‘Tendinopathy’ has been adopted as a general clinical descriptor of tendon injuries in sports. In overuse clinical conditions in and around tendons, frank inflammation is infrequent and if seen, is associated mostly with tendon ruptures. Tendinosis implies tendon degeneration without clinical or histological signs of intratendinous inflammation, and is not necessarily symptomatic. The term ‘Tendonitis’ is used in a clinical context and does not refer to a specific histological entity. [The term] Tendonitis is commonly used for conditions that are truly Tendinosis, however, and leads athletes and coaches to underestimate that proven chronicity of this condition……. Most articles describing the surgical management of partial tears of a given tendon in reality deal with degenerative tendinopathies [Tendinosis].” From an official document found on the website of the International Association of Athletics Federations (IAAF) — the official governing body of professional Track and Field
SKIP TO THE NEXT SECTION IF THE SCIENCE BORES YOU
“Tendinosis is a medical term used to describe the tearing and progressive degradation of a tendon. Tendons are structural components of the human body that ensure muscles remain bound to the correct bone during normal daily activities. Tendinosis differs from tendonitis in that the affected tendon is not inflamed.” Rachel Amhed from a July 2010 article for Lance Armstrong’s ‘Livestrong Website’ called Tendinosis Symptoms.
“Based on the information of various lines of investigation of tendinopathy, we can summarize some major points which must be considered in the formulation of a unified theory of pathogenesis in our model of tendinopathy….. The primary results of pathology are the progressive collagenolytic [Collagen-Destroying] injuries co-existing with a failed healing response, thus both degenerative changes and active healing are observed in the pathological tissues….. These pathological tissues may aggravate the nociceptive responses [PAIN] by various pathways which are no longer responsive to conventional treatment such as inhibition of prostaglandin synthesis [NSAIDS & Cortcosteroids]; otherwise the insidious mechanical deterioration without pain may render increased risk of tendon rupture.
For example, overuse is a major etiological factor but there are tendinopathy patients without obvious history of repetitive injuries. It is possible that non-overuse tendon injuries may also be exposed to risk factors for failed healing. Overuse induces collagenolytic [DEGENERATIVE] tendon injuries and it also imposes repetitive mechanical strain which may be unfavorable for normal healing. Stress-deprivation also induces MMP expression [Matrix Metallo Proteinase — an enzyme which breaks down Connective Tissues], and whether over- or under-stimulation is still an active debate. It is possible that tenocytes [tendon cells] are responsive to both over- and under-stimulation, both tensile and compressive loading….. By proposing a process of failed healing to translate tendon injuries into tendinopathy, other extrinsic and intrinsic factors would probably enter the play at this stage, such as genetic predisposition, age, xenobiotics (NSAIDs and corticosteroids) and mechanical loading on the tendons….. Classical characteristics of “tendinosis” include degenerative changes in the collagenous matrix, hypercellularity, hypervascularity and a lack of inflammatory cells which has challenged the original misnomer “tendinitis”.” Cherry-picked quotes from a comprehensive collaboration by teams from the Department of Orthopaedics & Traumatology at Prince of Wales Hospital, The Chinese University of Hong Kong, and the Department of Orthopaedic Surgery at Huddinge University Hospital in Stockholm. The study was published in a 2010 issue of Sports Medicine Arthroscopy & Rehabilitation Therapy Technology.
“Rotator Cuff Tendinosis is a degenerative (genetic, age or activity related) change that occurs in our rotator cuff tendons over time. Rotator cuff tendinosis is exceptionally common. Many, many people have tendinosis of the rotator cuff and do not even know it. Why rotator cuff tendinosis bothers some people and doesn’t bothers others is currently a question the orthopedic surgery community can not answer. Rotator cuff tendinosis is just as likely to be found in a professional body builder as it is likely to be found in a true couch potato.” From an August 2011 online article / newsletter by Dr. Howard Luks, an Orthopedic Surgeon and Associate Professor of Orthopedic Surgery at New York Medical College as well as being Chief of Sports Medicine and Arthroscopy at Westchester Medical Center.
“The gross pathology of Angiofibroblastic Tendinosis is [that] there are no inflammatory cells in this tissue. Therefore the term “Tendinosis” is much better [than Tendinitis]. The pathological tissue is instead characterized by very immature tissue and nonfunctional vascular elements.” Loosely quoted from a YouTube video of famed tendon researcher / surgeon Dr. Robert P. Nirschl’s (Nirchl Orthopedics) presentation to the American Academy of Orthopedic Surgeons annual meeting (2012).
“The more commonly used term of tendinitis has since been proven to be a misnomer for several reasons. The first of which is that there is a lack of inflammatory cells in conditions that were typically called a tendonitis…. The other two findings present in tendinosis, increased cellularity and neovascularization has been termed angiofribroblastic hyperplasia by Nirschl…… These are cells that represent a degenerative condition. Neovascularization [the creation of abnormally large numbers of new blood vessels] found in tendinosis has been described as a haphazard arrangement of new blood vessels, and Kraushaar et al. even mention that the vascular structures do not function as blood vessels. Vessels have even been found to form perpendicular to the orientation of the collagen fibers. They then concluded that the increased vascularity present in tendinosis is not associated with increased healing. Take Home Points: Chronic tendon injuries are degenerative in nature and NOT inflammatory. Anti-inflammatory medications (NSAIDs) and/or corticosteroid injections can actually accelerate the degenerative process and make the tendon more susceptible to further injury, longer recovery time and may increase likelihood of rupture.” Quotes cherry-picked from a recent online article called ‘Tendonosis vs. Tendonitis‘ by Dr. Murray Heber, DC, BSc(Kin), CSCS, CCSS(C), Head Chiropractor for Canada’s Bobsleigh / Skeleton Team.
“The data clearly indicates that painful, overuse tendon injury is due to tendinosis—the histologic entity of collagen disarray, increased ground substance, neovascularization, and increased prominence of myofibroblasts. [It is] the only clinically relevant chronic tendon lesion, although minor histopathologic variations may exist in different anatomical sites. The finding that the clinical tendon conditions in sportspeople are due to tendinosis is not new. Writing about the tendinopathies in 1986, Perugia et al noted the ‘remarkable discrepancy between the terminology generally adopted for these conditions (which are obviously inflammatory because the ending ‘‘-itis’’ is used) and their histopathologic substratum, which is largely degenerative“ Dr. Khan once more showing that tendon problems are not caused by inflammation.
“Overuse tendinopathies are common in primary care. Numerous investigators worldwide have shown that the pathology underlying these conditions is tendinosis or collagen degeneration. This applies equally in the Achilles, patellar, medial and lateral elbow, and rotator cuff tendons. If physicians acknowledge that overuse tendinopathies are due to tendinosis, as distinct from tendinitis, they must modify patient management in at least eight areas.” Dr. Karim Kahn M.D / Ph.D and his research team from University of British Columbia’s School of Kinesiology in an article published in the May 2000 issue of The Physician and Sportsmedicine called “Overuse Tendinosis, Not Tendinitis“.
“[There is a] remarkable discrepancy between the terminology generally adopted for these conditions (which are obviously inflammatory since the ending ‘itis’ is used) and their histopathologic substratum, which is largely degenerative.” From an Italian medical text called, “The Tendons: Biology, Pathology, Clinical Aspects” (1986).
WHAT HAVE PEOPLE MUCH SMARTER THAN ME
TAUGHT US ABOUT TENDINOSIS THUS FAR?
- Tendinosis is a Degenerative Condition without inflammation. Scratch that. Science has recently shown us that there is inflammation in tendinosis — there should be, at least in the initial phase of healing. However, it’s the SYSTEMIC INFLAMMATION that’s been shown to be the biggest problem. Bottom line, this doesn’t really affect anything I’m telling you in this post, other than to reinforce your need to address systemic inflammation (hint: it can’t be done with drugs).
- Tendinosis is the proper model for understanding the majority of Tendinopathies. As a model for understanding Tendinopathies, Tendinitis has been retired for at least two and a half decades.
- Tendinosis is both misunderstood and mismanaged by the majority of the Medical Community.
- Traditional Therapies / Interventions for Tendinopathies significantly increase one’s chance of Tendon Rupture.
- Most Coaches and Athletes do not understand the difference between Tendinitis and Tendinosis.
- If it does exist, Tendinitis (Inflammation of the Tendon) is rare, short lived, and mostly associated with Tendon Tears or Ruptures.
- Tendinosis is caused by both overuse and under-use.
- Tendinosis is often times Asymptomatic (no symptoms), until it becomes a painful and potentially debilitating problem.
BEST TREATMENT FOR TENDINOSIS & TENDINOPATHIES
“I knew then and there I was in the wrong place.” Thoughts running through the mind of a new patient who had recently visited an Orthopedic Specialist’s office for a tendon problem and asked him about the difference between Tendinitis and Tendinosis. The doctor answered, “There is no difference between Tendinitis and Tendinosis. They are one and the same —- two different names for the same problem.”
- Although there is undoubtedly a certain amount of SYSTEMIC INFLAMMATION present with tendinosis, research has conclusively shown that tendon problems are not primarily problems of inflammation, but of degeneration.
- Scientific studies have actually shown that non-steroidal anti-inflammatory medications (NSAID’s) such as Aspirin, Tylenol, Nuprin, Ibuprofen, Naproxen, Celebrex, Vioxx (oops — one of the #1 drugs in America for 10 years running was taken off the market because it was found to be a huge cause of chronic illness and death), & numerous others, actually cause injured collagen-based tissues like tendons, ligaments, muscles, fascia, etc, to heal up to 33% weaker, with as much as 40% less tissue elasticity.
Corticosteroid Injections are even worse. Medicine’s dirty little secret of treating connective tissue injuries with steroids is that they actually deteriorate or ‘eat’ the collagen foundation. This is why they deteriorate ever tissue in the joint, including bone. This is bad news considering collagen is the tissue that is deranged — the very tissue that needs to heal the most. This is why corticosteroids are a known cause of DEGENERATIVE ARTHRITIS and OSTEOPOROSIS, not to mention a whole host of easily-verified systemic side effects. The fact that steroid injections are ridiculously degenerative is why doctors ration or limit the number of steroid injections a person can receive — even if they seem to be working. And understand; it’s not that drugs don’t sometimes do what they claim to do. It’s that they never reverse the underlying pathophysiology (HERE). They simply cover symptoms.
Years ago, the Journal of Bone and Joint Surgery reported that corticosteroids are so degenerative that if you have more than one injection in the same joint over the course of your lifetime; your chance of premature degeneration in the injected joint is (gulp) 100%! Ultimately, the problem of corticosteroids (or NSAID’s for that matter) being used to treat tendons or other collagen-based tissues, is that short term relief is being traded for long term (and often permanent) damage. In other words, tomorrow is being traded for today. Kind of reminds you of our government’s short-sighted fiscal policies, doesn’t it? It is also another in a long line of evidences that the gap between medical research and medical practice is growing (HERE).
Collagen is the building block of all connective tissues, including tendons (you probably learned a great deal about collagen on our FASCIAL ADHESION PAGE as well as our COLLAGEN SUPER-PAGE). If one looks at normal collagen fibers from tendons or other connective tissues under a microscope, each individual cell lines up parallel to the surrounding cells. This allows for maximum tissue flexibility (sort of like well-combed hair).
With tendinopathies (whether TRAUMATIC OR REPETITIVE — yes, trauma can cause tendinosis), the tissue uniformity becomes disrupted and unorganized, causing restriction and a severe loss of function. This in turn causes a loss of flexibility, tissue weakness, tissue fraying, increased rigidity, and stiffness (sort of like KNOTTED HAIR OR A HAIRBALL — or gristle in a bite of steak). This leads to a loss of strength and function, which ultimately means that you end up with pain and dysfunction of the affected joint or body part. As I will soon show you, loss of normal function is one of just a few known causes of joint degeneration. This is why anyone who has suffered through Chronic Tendinosis knows how debilitating it can really be.
NORMAL TENDONS -vs- TENDINOSIS
Tendons are one of the Elastic, Collagen-Based Connective Tissues that are Made up of
Three Individual Collagen Fibers Braided Together into Wavy Sheets or Bands
FRAYED TENDON (TENDINOSIS)
AREAS MOST COMMONLY AFFECTED BY TENDINOSIS
IMPORTANT: Please note that some muscles only cross one joint. However, many muscles cross two joints. Muscles that act on more than one joint have a greater propensity for problems. It also means that one muscle has the potential to give you problems (including tendinosis) at two different joints. Also note that Tendinosis is usually a bit tougher to deal with than Fascial Adhesions.
- ROTATOR CUFF TENDINOSIS: The Rotator Cuff is made up of four muscles that surround the shoulder.
- SUPRASPINATUS TENDINOSIS: The Supraspinatus Tendon is not only the most commonly injured of the Rotator Cuff Muscles, it is the most common to find tendinopathy in as well.
- TRICEP TENDINOSIS: Tricep Tendinosis is rare. About the only people I ever find it in is carpenters (hammering) and weightlifters. However, here is the webpage.
- BICEPS TENDINOSIS: Because both heads of the bicep muscle have attachment points in the front of the shoulder, Biceps Tendinosis is frequently mistaken for Bursitis or a Rotator Cuff problem.
- LATERAL EPICONDYLITIS (Tennis Elbow): Although I have never seen anyone who got this problem playing tennis (hey, I live in the Ozarks), it is nonetheless extremely common.
- MEDIAL EPICONDYLITIS (Golfer’s Elbow): Not quite as common as Tennis Elbow above.
- WRIST / FOREARM FLEXOR TENDINOSIS: This is tendinopathy on the palm side of the forearm and wrist.
- WRIST / FOREARM EXTENSOR TENDINOSIS: This is tendinopathy on the backhand side of the forearm and wrist.
- THUMB TENDINOSIS / DeQUERVAIN’S SYNDROME: This extremely common problem can be debilitating. You will frequently hear Thumb Tendinosis referred to as DeQuervain’s Syndrome.
- GROIN (Hip Adductor) TENDINOSIS: I have included Tendinosis of the Groin under “Hip Flexor Tendinosis” below.
- HIP FLEXOR TENDINOSIS: Hip Flexor Tendinosis will manifest in the upper front thigh or groin area. This is incredibly common in athletes — particularly soccer players.
- PIRIFORMIS TENDINOSIS: This problem is related to PIRIFORMIS SYNDROME, and causes pain in the butt (sometimes with sciatica as well).
- SPINAL TENDINOSIS: Although most people never think of it, the potential for developing Spinal Tendinosis is greater than you ever imagined possible.
- KNEE TENDINOSIS: This is arguably the single most common reason that people visit a Sports Physician.
- QUADRICEPS / PATELLAR TENDINOSIS: A form of Knee Tendinosis
- HAMSTRING TENDINOSIS: Hamstring Tendinosis can cause knee, hip, and buttock problems.
- ACHILLES TENDINOSIS: Achilles Tendinosis is found in the large tendon in the very back of the lower leg / ankle.
- ANKLE TENDINOSIS: This common Tendinosis can typically be dealt with by following a few simple procedures.
- TIBIALIS ANTERIOR TENDINOSIS: This is related to the category above, and is typically found in the front of the ankle.
- POSTERIOR TIBIAL TENDINOSIS: This is related to the category above, and is typically found near the bony knob on the inside of the ankle.
- APONEUROSIS / APONEUROTICA TENDINOSIS: Although you have probably never heard the word before, “Aponeurosis” are flattened out tendons. They are almost always referred to as fascia, but technically this is incorrect. They are most often associated with SKULL PAIN.
EFFECTIVELY DEALING WITH TENDINOSIS
There is a significant portion of the tendinosis-suffering population who have tried all of these things. Every type of pill imaginable, including ANTIBIOTICS (believe it or not, I have seen this used numerous times — some of which, like CIPRO, actually cause tendon weakness and rupture), TENS Units, braces & supports of all kinds, PLATELET INJECTION THERAPY, high powered ultrasound (a form of litho-tripsy called arthro-tripsy), prolotherapy (sugar water injections), all sorts of surgeries, and heaven only knows what else. And this doesn’t even start touching on many of the common drugs, which I’ve already dealt with.
The bottom line is that if your pain is being caused by adhesions, restrictions, and microscopic scarring in the collagen fibers that make up the affected tendon (or the fascial membranes that attach to the tendon), you are going to have a hard time dealing with it using the standard fare found in your average medical clinic. Although their various treatments may cover the symptoms for awhile, you are already becoming painfully aware (no pun intended) that standard medical therapies such as those listed earlier, are not likely to help with Tendinosis over the long haul. And although stretching and specific exercise can be of tremendous benefit, most clinicians tend to put the cart in front of the horse. Those things will not be effective until after the tissue adhesion has been removed (broken), except in minor cases.
Be aware that because of its microscopic nature, the collagen derangement associated with Tendinopathies will rarely if ever show up with even advanced diagnostic imaging (this is true even for MRI, unless your doctor is using a brand new machine with an extra large magnet, or your problem is especially severe). And whether it shows on the MRI or not, will not really change the way that your doctor treats the problem.
EFFECTIVELY TREATING TENDINOSIS AT ITS SOURCE
A FINAL WORD ON SYSTEMIC TENDINOSIS
If it is not caused by Fluoroquinolone Antibiotics, very frequently, this underlying problem turns out to be some sort of poorly understood or difficult-to-detect AUTOIMMUNE DISEASE. If for whatever reason, your body is making antibodies to attack it’s own tendons or connective tissues, you have a serious problem on your hands — a problem that will not respond to the Scar Tissue Remodeling Treatments that I do, and a problem whose cause likely won’t show up on standard medical tests.