Tendinitis, Tendinosis or Tendinopathy? | Physiotherapy for Tendon Pain in Fremantle
Tendon injuries are some of the most common injuries seen in physiotherapy. You often don’t have to go far to encounter someone who has experienced an injury such as:
- Achilles tendinopathy
- Gluteal tendinopathy
- Tennis Elbow or Lateral Epicondylalgia
- Golfer’s Elbow or Medial Epicondylalgia
- Patella Tendinopathy or Jumper’s Knee
… and the list goes on!
Tendinitis, Tendinosis or Tendinopathy
Our thinking behind tendon pathology has changed considerably in recent years. Although it is common to still hear these injuries referred to as tendinitis or tendinosis, the current term that is recommended to describe this type of injury is tendinopathy.
Historically, these injuries were almost always referred to as tendinitis, which suggested inflammation along the site of the injured tendon. However, imaging studies demonstrated that a lot of these injuries actually had NO inflammation present at all! As such, the term tendinosis became more popular, which suggested a degeneration of the structure of the tendon in the absence of inflammation.
Presently, we use the term tendinopathy as an umbrella term that describes any disorder involving the tendon.
The Tendon Pain Continuum
Tendon pathology moves along a continuum. Simply, the earlier along this continuum that pain can be detected and treated, the faster this issue will resolve itself.
As can be seen from the picture above, these stages are termed: reactive tendon pathology, tendon dysrepair and degenerative tendon pathology.
Reactive Tendinopathies are the 1st stage of tendon pathology. Clinically, these occur through an acute overload, or blunt trauma to the tendon. Think, going out and running 20km when your usual running distance is only 5km.
This results in a stiffening of the tendon, but there is no change in thickness. Also key, is that there is minimal damage to the tendon. At this stage of the pathology, often all that is required is a period of rest and de-loading, and treatment of compressive forces (e.g. tight muscles that compress the tendon).
This occurs when we do not allow our tendon sufficient time to recover from the initial incident. Typically, when people ‘push through the pain’ (especially when it is above a mild to moderate amount of discomfort) ongoingly for weeks and months.
However, a key change also happens within the structure of the tendon when it gets to this point along the tendon continuum. Specifically, the strong collagen fibers that comprise our tendon become separated and disorganised. This means that the tendon becomes significantly weaker!
This is the final stage on the continuum and is suggested that at this stage there is a poor prognosis for the tendon and changes are now irreversible. It has been documented that there areas of cell death, trauma and tenocyte exhaustion and general disorganisation of the cell matrix.
On imaging there are areas of this degeneration scattered throughout the tendon and interspersed with normal sections of tendon and parts of the tendon that are in the dysrepair phase. The tendon can be thickened and present with nodular sections on palpations.
Clinically this tendon is present in the older individual who has had ongoing problems with tendinopathy, or the younger individual who has continued to overload the tendon.
Tendon Pathology on Imaging
The first two pictures demonstrate the difference between the normal tendon and reactive tendon (in this case, taken from the unaffected side compared the affected side).
In the tendon dysrepair stage, we can see that the tendon has gained size as the collagen fibers become separated and disorganised.
As the tendon pathology progresses to the degenerative tendon stage, we can visualise the red areas of cell death, trauma and tenocyte exhaustion interspersed with the areas of the tendon still in the dysrepair stage.
Physiotherapy and Tendinopathy
Learning how to adequately de-load and then progressively strengthen and reload your tendon is paramount in the recovery from any tendinopathy, regardless of what stage of the pathology you are in.