So, you’ve been diagnosed with tendonitis and you’ve gone through the usual types of treatment programs like physical therapy, anti-inflammatory drugs, and even cortisone shots.

What else is available?Before we discuss the exciting new ways of managing chronic tendonitis, let’s talk about tendonitis is… and isn’t.

Tendons are thick cords of fibrous tissue that connect muscles to bones. It is this connection that allows joint motion. When muscles contract, they pull on the tendons which cause the bones to move. In order for tendons to glide they move inside a lubricated sheath of tissue that is lined with synovial tissue. This synovial tissue is the same type of tissue that lines the inside of joints.

Tendonitis occurs when the sheath through which a tendon glides becomes inflamed. This leads to severe pain. The pain usually gets worse with use of the affected joint. However, when tendonitis becomes severe, there may be pain at rest, particularly at night.

Since muscles and tendons surround most joints, tendonitis is rather common. Tendons can also be inflamed where they insert into bone. Tendons are subject to irritation because they cross joints.  When joints are used, so are tendons. 

While repetitive motion is the usual culprit that leads to tendonitis, aging is also a factor.

The diagnosis of tendonitis is relatively simple for the experienced clinician. Generally, the diagnosis is made by history and physical examination. In difficult diagnostic cases, diagnostic ultrasound or magnetic resonance imaging is helpful in confirming the diagnosis.

Some of the more common types of tendonitis are:

Shoulder tendonitis. The tendons in the shoulder that are most often affected are the rotator cuff and biceps tendons. The rotator cuff consists of four tendons that sit on top of the upper arm bone. They are the supraspinatus, infraspinatus, subscapularis, and teres minor tendons. The location of these tendons and the muscles they attach to are what give the shoulder such a great range of motion.

Rotator cuff tendonitis may occur as a result of repetitive activity or tendon degeneration. Pain is felt with most movements and is usually located on the outside part of the shoulder. Certain movements such as reaching behind or to the side may be uncomfortable. The biceps tendon permits the arm to be flexed at the elbow.

Biceps tendonitis also occurs due to repetitive activity and pain is felt in the front of the shoulder.

Shoulder tendonitis can sometimes be treated successfully with anti-inflammatory medication, physical therapy, and occasionally glucocorticoid (cortisone) injection.  These methods are most useful for acute tendonitis.

Tendonitis in the elbow is usually located either on the outside and is called lateral epicondylitis or tennis elbow. It may also occur along the inside part of the elbow- medial epicondylitis. This is called golfer’s elbow.

Treatment for this condition consists of physical therapy, stretching and strengthening exercises, splints, and injections. While surgery is sometimes recommended for chronic case, I will discuss why that is inadvisable.

Tendonitis in the wrist arises because of repetitive motion.

A peculiar form of tendonitis, called Dequervain’s tendonitis, is felt on the outside of the thumb. Tendonitis in this area is managed with glucorticoid injections and immobilization with a splint. Physical therapy modalities may be helpful. Rarely, if ever, is surgery required.

Tendonitis in the fingers can lead to catching of the fingers. This is termed “trigger finger.” Trigger finger usually responds to injection.

Tendonitis in the knee may affect the patellar tendon. This is the tendon that connects the knee cap to the tibia (lower leg bone).

Patellar tendonitis usually occurs because of excessive jumping and is actually called “jumpers knee.” This is treated with rest, anti-inflammatory medications, and physical therapy.

Tendonitis in the ankle can occur along the outside of the ankle (peroneal tendonitis), the inside of the ankle (posterior tibial tendonitis), or at the back of the ankle (Achilles tendonitis). The tendonitis that occurs along the outside or inside of the ankle can occur because of trauma or because of mechanical instability. Another potential cause is an underlying arthritis condition.  

Achilles tendonitis often occurs as a result of excessive stress and loading of the tendon as well as repetitive motion.

The Achilles tendon is the thick cord at the back of the ankle that connects the heel bone to the calf muscle. Treatment involves rest, elevation of the heel to take the tension off the Achilles tendon, and physical therapy. Glucocorticoid injection should be avoided because of the danger of Achilles tendon rupture. Anti-inflammatory medication may be helpful.

Another problem I need to mention is that often arthritis and tendonitis coexist and make each other worse.  Arthritis can also be aggravated by overuse.So what can be done to treat chronic tendonitis as well as the arthritis that accompanies it? What can you do if you’ve tried all of the above treatments and still have a problem?

In severe case, open surgical procedures are performed

Fortunately, there is a relatively new option that appears to be having surprisingly good results.

Since tendonitis is due to inflammation, the old thinking has been that reducing inflammation is the best approach.  As a result, anti-inflammatory drugs, steroid injections, and so forth have been the mainstays of the “old school” of treatment.

Unfortunately, inflammation is also the body’s attempt to heal the damage to the tendon.  The problem is that inflammation is not always accompanied by the increased blood flow required to bring new nutrients to the area to help with the healing processes.

So, new techniques have been devised to actually try to temporarily increase blood flow through carefully and selectively injuring the tendon at the area of concern, and then stimulating the body’s normal healing mechanisms to spring into action.  While this seems paradoxical, it works.

The first part of this process involves the use of ultrasound guided percutaneous tenotomy (UGPT). Ultrasound is employed to diagnose the problem and then to guide the insertion of a needle to selectively injure the tendon at the site where tissue repair needs to occur.

The second part of the process is to inject a small amount of platelet rich plasma.  Platelets are small blood cells that are rich in various growth factors.  These growth factors stimulate the growth and proliferation of new tissue.  In essence, the platelet rich plasma helps regenerate new tendon fibers.

The procedure goes like this…

When the patient arrives at the clinic, the physician sits down and explains the procedure including risks and benefits.

The patients, if they agree to proceed, are taken to the laboratory and approximately 20 cc’s of blood is drawn and then spun in a special centrifuge.  After the specimen is spun, the layer containing platelets is drawn off using a special syringe.  

The patient is first positioned in a comfortable manner.

The area of tendon pathology is then identified using diagnostic ultrasound.  Often other problems that aggravate tendonitis such as bone spurs and arthritis will also be demonstrated.

After informed consent is obtained, the area is sterilely prepared and anesthetized with a local anesthetic.  A special needle of suitable gauge and length is inserted through the anesthetized skin and soft tissue and advanced to the tendon at the site of injury. Bone spurs, if present are gently chiseled away using the needle. Using carefully placed movements, multiple small holes are then placed in the tendon.

Since local anesthetic has been administered previously, a minimal amount of discomfort is experienced.

After the needling procedure, a small amount of platelet rich plasma (also called “autologous tissue grafting material”) is slowly injected into the area.

The needle is then removed and a simple bandage is placed over the needle hole.

Post-procedure care consists of absolute rest for three days followed by modified rest for another four days, then slow and careful resumption of activity.

Analgesics such as tramadol (Ultram) or Darvocet may be used.  However, anti-inflammatory drugs and immunosuppressive drugs should be held for approximately a week before and a week after the treatment.

Ultrasound guided percutaneous tenomy and autologous tissue grafting often prevents the need to perform an open surgical procedure. This outpatient procedure is done using only local anesthetic.

A course of physical therapy may be initiated after the period of rest with the goals of improving function, decreasing pain, and increasing strength.

In some cases, a second course may be required.  However, the long term results are extraordinary with very few patients requiring open surgery.

So who is a candidate for this procedure?  Any patient with a history of chronic tendonitis that hasn’t responded to other measures is a good candidate.  This includes people with arthritis who also have tendonitis (sometimes the distinction is not always easy to make and the arthritis pain may actually be tendon-related pain). Patients with tendon rupture are not good candidates.

More about platelet rich plasma…

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