Tendonitis, Tendinosis, and Tendinopathy...A Rose by Any Other Name?

Today, as a healthcare provider to honest Americans like yourself, I am coming clean- we have been lying to you. The situation is similar to a well-intentioned parent confirming that yes, Santa Clause will be coming this year and of course his sleigh is powered by 8 ridiculously-named reindeer. How else would Santa carry presents for the over 7 billion people on this earth, silly?

The analogy is fitting indeed. It's not that we mean to be overtly deceiving or manipulative. It's that the standard has been in place for so long that it is just easier to hop on board. Sometimes, it's too difficult to explain that the rest of the neighborhood children believe in Santa Clause because their parents are conformists and have duped them. Go ahead and leave some cookies out anyway though kid, Mom and Dad always enjoy them with wine. 

But enough about Santa Clause. We are talking about tendon injuries here. 

How many times has your health care professional told you that you had patellar tendonitis? Plantar fasciitis? Lateral epicondylitis? Any name-of-body-part-that-hurts followed by -itis?

You were lied to.  By the time most patients recognize that they are having pain, and seek advice for it, they are actually suffering from tendinosis.  Tendinosis may have started out as tendonitis at some point, but it certainly doesn't stay that way. 

GASP. Please contain your outrage. 

I'll admit to have committing this crime. I've told little old ladies that yes, they have tendonitis of their rotator cup muscle because I didn't want them to feel silly. Can you imagine correcting adorable Adeline by stating that a) it's called the rotator cuff and b) your tendon pain is about as new as you are young and it's been tendinosis for decades at this point? No, me neither. In other instances I just want to avoid that bored, glazed over look I get when I start delving into tendon structure and histology with a patient who clearly doesn't give a lick. 

So yes, I've confirmed a diagnosis of achilles tendonitis when I knew better. I'm sorry. Forgive me. I think I even debated on what word to use in a previous blog post out of concern that readers would think "tendinosis? what the heck?" and write me off as some wacko who didn't know how to spell. I don't, but I digress. 

So do we care what our doctors, physical therapists, massage therapists, athletic trainers, etc. call our injuries? Or is tendonitis, tendinosis, and tendinopathy all just a rose by any other name?

My opinion is that correct nomenclature matters. Proper treatment for tendonitis verses tendinosis is different, and those differences are important to your recovery. As providers of healthcare, we need to stop assuming that our patients don't understand and don't need to understand. As a patient, you need to educate yourself so that you don't ask for a cortisone shot believing that it will cure your 8-month-old stint with plantar "fasciitis" pain. Knowledge is power people, empower yourself to make proper healthcare decisions. 

To start, let's get a few things straight. By strict definition:

Tendonitis refers to microtrauma and acute (read: new) inflammation of the tendon. Think red, hot, swollen, painful, and sudden! The body actually increases blood flow to the area, sends out cells that fight infection, and makes blood vessels more permeable or "leaky". Anti-inflammatory medications, ice, rest, and immobilization can be helpful in this stage depending upon the severity of the trauma.

Tendons are made of a substance called collagen. Tendinosis refers to an actual change in the collagen structure of the tendon. If we took a teeny-tiny slice of a healthy tendon and put it under a microscope, the collagen fibers would be orderly and straight like dry spaghetti in a box. A microscopic view of an unhealthy tendon with tendinosis would look disorderly, like cooked spaghetti (see below). Ironically these disorganized tendons can be physically bigger and thicker, but because the collagen fibers are not pointing in the correct anatomical direction the tendon is actually weaker and more prone to injury. It's a vicious cycle. 

 A HEALTHY TENDON- see nice straight collagen lines with very little white space between them (the white on the right is adipose tissue, or fat)

A HEALTHY TENDON- see nice straight collagen lines with very little white space between them (the white on the right is adipose tissue, or fat)

 AN UNHEALHTY TENDON- note wavy, disorganized fibers with white spaces in between. This tendon may be thick, but it is not strong!

AN UNHEALHTY TENDON- note wavy, disorganized fibers with white spaces in between. This tendon may be thick, but it is not strong!

Tendinopathy, on the other hand, refers to a "diseased state" of the tendon. Tendinopathy describes a tendon that has failed to heal. Both tendonitis and tendinosis are considered to be stages of tendinopathy. 

Now that we are pros at the name game, how does diagnosing an injury as tendonitis verses tendinopathy change treatment? And it certainly should change treatment! The difference between an inflamed tendon and a degraded, disorganized tendon is vast. Do you think I should treat these two patients with achilles pain the exact same way?



Yeah, me neither. The difference, among other things:


1. Drugs, shots, and the good stuff. 

If you have tendonitis, your injured tendon is being bathed in an inflammatory soup. Anti-inflammatory medications like ibuprofen (for example, Advil) may help alleviate your pain and expedite normal movement. As discussed above, by the time we seek advice most of us have tendinosis!! This means that there is very little inflammation in the actual tendon, and medications may slightly alleviate our temporary pain but will do nothing for our long term recovery. Cortisone is the most notoriously misused drug in treating tendinosis. Cortisone is a very powerful short term anti-inflammatory. However, a substantial amount of research indicates that cortisone shots weaken a tendon and increase the likelihood of tendon rupture in the long run. Why inject a weakened, disorganized tendon that has little to no inflammation with a powerful anti-inflammation drug? Especially when that drug can further weaken the tendon and potentially lead to complete tendon rupture? No thank you.

2. Exercise. 

Speaking of evidence, current research shows that specific exercise can stimulate collagen growth and strengthen a tendon in a meaningful way. In fact, complete rest of a degraded tendon can actually prolong recovery and increase the likelihood of re-occurring injury. That being said, exercise for tendinopathy must be patient specific, progressive, and enough to cause a stimulus for tendon growth. It can be difficult to know what exercises to perform, how often, how many repetitions, etc. I recommend seeking professional help. I recommend seeking professional help even if you are a professional! Exercise progression for tendon rehabilitation is an art. If you like to dive into the nitty gritty, check out the latest Journal of Orthopaedic & Sports Physical Therapy issue HERE.

Note that I only referred to exercise in the context of tendinosis. In the case of tendonitis (again, think red! hot! swollen! painful!) exercise is typically best kept to a minimum. This is because we are not trying to strengthen or reorganize a tendon, we are trying to decrease inflammation by removing aggravating factors and letting the tendon rest. 

3. Prognosis (read: expectation for recovery)

The prognosis for tendonitis verses tendinosis is very different. If you recognize signs of tendonitis immediately, stop the offending activity (running for example), and treat your symptoms things may completely resolve in a matter of days or weeks.

If you continue to push through symptoms of tendinosis without treatment, you can expect your recovery to be much longer- a matter of weeks or months. On the positive side, there is often a "grey area" in tendinosis where one can gradually return to their normal activity as they continue to rehab and strengthen the tendon. This grey area works best if supervised by someone who knows what they are doing (ie. your physical therapist)

In conclusion:

Know the difference between a tendonitis and a tendinosis like you would know the difference between a stress fracture and a bone break. These things are more than simple semantics, they are determinants of your efficient and effective treatment. Question your health care professional if they tell you that your chronic injury is just tendonitis. Question your healthcare professional if they offer you a cortisone shot for your tendinosis. From here on out, I vow to never use a diagnosis incorrectly simply because it is easier. Knowledge is power, let's spread the wealth!

For more questions about tendinopathy, tendonitis, tendinosis, and proper treatment of your symptoms contact your friendly physical therapist.