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.

• 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

• 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

• 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)

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

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.

• 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

• Computed tomography, to evaluate intra-articular abnormalities
• Magnetic resonance imaging, to diagnose tendinitis, tears, or tumors

• 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

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.

• 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)

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)

• 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

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.

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

• 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.

May be helpful for pain relief and improving range of motion.

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.

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.

• 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.

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.

• 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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