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Overview |
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Definition |
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Tendinitis is the painful inflammation of a tendon and its attachments to
bone. It is most often the result of the stress from a particular occupation
(e.g., drywall hangers, musicians, painters) or sport (e.g., baseball,
basketball, tennis, swimming). Acute tendinitis may heal within a few days or
weeks, but it may also become chronic if it is not treated acutely. Pain may
initially be only a dull ache with movement of the affected limb; however, with
time, if untreated, it may become severe, allowing only limited movement and
causing disability. The areas most commonly affected by tendinitis are the
shoulder (e.g., bicipital tendinitis, supraspinatus tendinitis, rotator cuff
tendinitis, or impingement syndrome), elbow (e.g., lateral epicondylitis [tennis
elbow] or medial epicondylitis [golfer's elbow]), wrist and thumb (e.g.,
stenosing tenosynovitis [de Quervain's disease]), knee (e.g., patellar
tendinitis [jumper's knee]), and ankle (e.g., Achilles and peroneal tendinitis).
Calcific tendinitis, which occurs when calcium deposits in a joint, is not
usually preceded by an identified trauma. There is much disagreement over the
cause of this type of tendinitis. Although some investigators hypothesize that
it results from chronic tendinitis, it appears to be associated with chronic
diseases, such as diabetes mellitus. Calcific tendinitis presents as an acute
inflammatory reaction, often resembling gout, that is often bilateral (e.g., in
both shoulders), progressing to a pattern of exacerbations and remissions.
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Etiology |
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- Sports, with over- or undertraining or poor technique
- Trauma
- Infections (e.g., gonococcal disease)
- Inflammatory conditions (e.g., Reiter's syndrome, ankylosing
spondylitis)
- Ill-fitting shoes (Achilles tendinitis)
- Falling
- Carrying or lifting heavy
objects
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Risk Factors |
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- Participation in sports activities
- Occupations involving repetitive activities
- Poor ergonomic positioning with office activities
- Alcoholism, because of an inadequate neurologic function
- Diabetes, because of an inadequate vascular
supply
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Signs and Symptoms |
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- Edema (usually minimal)
- Localized tenderness
- Pain, which may or may not be present at rest but is always triggered
or exacerbated by movement of the affected limb
- Warmth and redness
- Crepitus
(crackling)
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Differential
Diagnosis |
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It is often difficult to distinguish between tendinitis and bursitis.
Bursitis is the inflammation of the small fluid-filled sacs (bursa) located
between tendons and bones, which cushion tissues from friction. Bursitis is
usually characterized by a dull, persistent ache, while tendinitis typically
causes sharp pain on movement. The two conditions often coexist.
- Bursitis—inflammation of the bursa
(fluid-filled sacs)
- Polyarthritis—arthritis in many
joints
- Vasculitis—inflammation of the blood
vessels
- Periosteitis—inflammation of the periosteum
(connective tissue that covers bone)
- Fibrositis—inflammation of muscle sheaths
and fascial layers
- Polymyalgia rheumatica—severe pain and
stiffness in proximal muscle groups
- Diseases of the muscles, bones, or spine (e.g., Reiter's syndrome,
gout, rheumatoid arthritis)
- Malingering
- Fibromyalgia
- Carpal tunnel syndrome
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Diagnosis |
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Physical Examination |
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Pain at the point of inflammation is usually worsened by movement, but there
may also be pain at rest. The patient may exhibit crepitus when moving the
affected joint and complain of numbness and tingling. Range of motion may be
normal or limited because of the pain. Severe swelling is uncommon and may
indicate arthritis. |
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Pathology/Pathophysiology |
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- Shoulder: impingement of supraspinatus tendon between acromion and
greater tuberosity of the humerus, fibrosis and thickening, tear of the rotator
cuff, degenerative bony changes (e.g., bony spurs, sclerosis, cyst
formation)
- Knee: calcifications, fibrosis of the tendon, degenerative changes,
necrotic areas
- Elbow: small tears (microtears) of the tendon of the extensor carpi
radialis brevis, inflammation of tendinous sheath over extensor carpi radialis
and extensor communis, granulation tissue, degenerative changes
- Wrist and thumb: inflammation of abductor pollicis longus and
extensor pollicis brevis tendons, proliferation of fibrous tissue
- Foot: thickening of the Achilles tendon, adhesions between the tendon
and tendon sheath
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Imaging |
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- Computed tomography, to evaluate intra-articular
abnormalities
- Magnetic resonance imaging, to diagnose tendinitis, tears, or
tumors
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Other Diagnostic
Procedures |
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- Individual tests, chosen for their specificity, sensitivity, and
cost-benefit profile
- X rays, which are often normal in the early stages
- Arthroscopy, to diagnose arthritis, calcific tendinitis,
osteonecrosis, and cancer and to treat any abnormalities found
- Arthrography, to establish the correct diagnosis
- Ultrasonography, to diagnose intra-articular abnormalities
- Electromyography, to rule out neurologic problems
- Nerve conduction velocity
studies
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Treatment Options |
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Treatment Strategy |
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In all cases of tendinitis, treatment depends on the severity of the
symptoms. Conservative treatment is attempted initially, progressing to surgery
if needed. Health care providers will prescribe ice, analgesia, rest, temporary
immobilization, massage, steroid injections, light exercise, physical therapy,
and finally surgery for refractory cases. |
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Drug Therapies |
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- Nonsteroidal anti-inflammatory drugs (NSAIDs): indocin (25 to 50 mg
tid) and ibuprofen (200 to 600 mg bid to tid)
- Injection of lidocaine and corticosteroids (1 to 3 ml 1% lidocaine, 1
to 3 ml 0.5% bupivacaine, and 10 to 30 mg triamcinolone). Only three or four
injections spaced three weeks apart should be given. Steroid injections directly
into weight-bearing tendons are contraindicated because there is a risk of
tendon rupture. Injections should be into the tendon sheath or bursa.
- Colchicine (for calcific tendinitis only)
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Complementary and Alternative
Therapies |
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A combination of essential fatty acids (EFAs), castor oil packs, and
homeopathic treatment is often sufficient for simple tendinitis. Other therapies
may be added as needed.
- Ice, especially after the initial injury, to decrease circulation to
inflamed tissues and decrease pain caused by congestion
- Rest
- Massage or chiropractic for improved circulation
- Temporary immobilization (e.g., slings, splints, crutches) of the
affected limb. The shoulder should not be immobilized for a long period of time
because further loss of range of motion (frozen shoulder) may occur from
adhesions, capsular tightening, and muscle shortening.
- Flexibility and strengthening exercises after acute phase has
passed
- Physical therapy (e.g., range of motion exercises)
- Ultrasonography (phonophoresis with 10% lidocaine cream or arnica
gel)—high-frequency sound to heat an area and increase
the blood supply
- Transcutaneous electrical nerve stimulation
(TENS)—electricity used to control pain
- Proper occupational ergonomics (i.e., stop repetitive or offending
activity)
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Nutrition |
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- Vitamin C (500 to 1,000 mg tid) to aid in healing, increase immune
function, and reduce inflammation
- Calcium (1,500 mg/day) and magnesium (750 mg/day) to aid healing of
connective tissues and muscles
- Vitamin A (15,000 IU/day) to increase immune function and tissue
healing
- Vitamin E (400 to 800 mg/day) to reduce inflammation
- Bromelain (250 to 750 mg tid between meals) to reduce inflammation
and prevent swelling after trauma or surgery
- Essential fatty acids (EFAs) (1,000 to 1,500 IU one to three
times/day) as an anti-inflammatory
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
- Flavonoids (500 to 1,000 mg tid) to reduce inflammation and maintain
healthy collagen
- Curcumin, yellow pigment of turmeric (Curcuma
longa)—(200 to 400 mg tid) between meals to reduce
inflammation; serves as an antioxidant
- Willow (Salix alba) bark tea (2 to 3 tsp. per 1 cup of boiling
water tid) for analgesic effect (Caution: If allergic to aspirin, do not take
aspirin-like herbs.)
- Licorice (Glycyrrhiza glabra)—3 cups
tea/day to reduce inflammation (Caution: Long-term use is associated with
headaches, water retention, potassium loss, high blood pressure, and
lethargy.)
- Comfrey (Symphytum officinale)—1 tsp.
per 1 cup boiling water qid to aid healing and for pain relief. Use as the water
in contrast hydrotherapy.
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing, use 3 to 5 pellets of a 12X to 30C remedy every 1 to 4 hours until
acute symptoms resolve.
Externally:
Homeopathic treatments for tendinitis include creams or gels. Arnica
cream by itself or in combination with Calendula officinalis, Hamamelis
virginiana, Aconitum napellus, and Belladonna, applied three to six
times/day, speeds healing and decreases discomfort. For acute injuries, start
with Arnica.
Internally:
- Bryonia for pains that are worse with the slightest motion or
when jarred. The pain feels worse with cold and better with heat.
- Phytolacca for tendinitis where the pain is focused at the
insertion of the tendons and that feels worse with heat
- Rhus toxicodendron for tendinitis with restlessness that is
worse in the morning
- Rhododendron for tendinitis that gets worse with barometric
pressure changes
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Physical Medicine |
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- Orthotics or heel lifts and shoe correction (Achilles tendinitis)
- Elbow strap and small (2 lb.) weights (tennis elbow)
- Contrast hydrotherapy. Alternating hot and cold applications brings
nutrients to the site and diffuses metabolic waste from inflammation. The
overall effect is decreased inflammation, pain relief, and enhanced healing.
After first 24 to 48 hours, soak affected part for three minutes in hot water,
then 30 seconds in cold water.
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Massage |
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May be helpful for pain relief and improving range of
motion. |
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Patient Monitoring |
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Tendinitis often presents in three stages: Stage 1, a dull ache precipitated
by strenuous activity and resolving with rest; stage 2, pain precipitated by
minor movements (e.g., dressing); and stage 3, constant pain. Patients should be
seen every three to four weeks until the tendinitis resolves.
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Other
Considerations |
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Prevention |
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Proper stretching and warm-up exercises can be preventive measures for
athletes at risk for tendinitis. Braces are used for forearms, knees, and ankles
to give added stability and support to reduce recurrences. For occupational
injuries, job ergonomics must be reviewed and modified to prevent recurrences.
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Complications/Sequelae |
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- Tendon rupture
- After surgery, some patients do not attain their preinjury functional
level.
- Degenerative changes are often seen in patients over 40 with chronic
tendinitis.
- After steroid injection, there may be atrophy of the soft tissues
surrounding a joint or iatrogenic infections. In addition, steroids may weaken
the collagen structure of tendons, potentiating the risk for tendon
rupture.
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Prognosis |
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Although most case of tendinitis resolve within a few days to weeks of
treatment, recurrences are common, particularly with athletes and individuals in
occupations that require overhead or repetitive motions. |
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Pregnancy |
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- Stenosing tenosynovitis (de Quervain's disease) is common in
pregnancy, but usually resolves spontaneously without treatment.
- A health care provider should be consulted for the proper dosage of
vitamin A.
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References |
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Balch JF, Balch PA. Prescription for Nutritional Healing. 2nd ed.
Garden City Park, NY: Avery Publishing; 1997:174-175.
Duke JA. The Green Pharmacy. Emmaus, Pa: Rodale Press;
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Kelly WN, Harris ED Jr, Ruddy S, Sledge CB. Textbook of Rheumatology.
5th ed. Philadelphia, Pa: WB Saunders Co; 1997:372-373, 386, 422-429,
462-463, 486, 558-559, 598-599, 603-606, 642.
Koopman WJ. Arthritis and Allied Conditions: A Textbook of Rheumatology.
13th ed. Baltimore, Md:Williams & Wilkins; 1997:44, 1769-1771, 1795,
1894-1896.
Millar AP. Sports Injuries and Their Management. Sydney, Australia:
Maclennan & Petty; 1994:10-14, 84-85, 101-103, 111-112, 118-119,
8830-8831.
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993:72-74, 298.
Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed.
Rocklin, Calif: Prima Publishing; 1998:805-809.
Noble J. Textbook of General Medicine and Primary Care. Boston, Mass:
Little, Brown; 1987:228-229, 288-290, 293-296.
Vinger PF, Hoener EF, eds. Sports Injuries: The Unthwarted Epidemic.
Boston, Mass: John Wright; 1982:227,
255. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |