Tendinopathy injections and treatments

Donna Alderman, DODonna Alderman, DO

Tendonitis, a common diagnosis, is the Inflammation (“itis”) of a tendon. It is defined in Mosby’s Medical Dictionary, 14th Edition, as “an inflammatory condition of a tendon, usually resulting from strain.” A tendon is the end portion of a muscle where it attaches to the bone in the joint, allowing movement. A person can get tendonitis in any joint in the body. Some common areas for tendonitis are elbows (tennis elbow, golfer’s elbow), the shoulder (rotator cuff, biceps), and ankle, (Achilles tendon). However, any tendon has the potential to become inflamed and irritated, especially in sports where overuse can occur.

In most cases, in a healthy, non-stressed, non-smoking person, that area will usually heal in 4 to 6 weeks, depending on severity. However, in some cases the tendons do not heal, causing long lasting and chronic pain. This condition is usually referred to as chronic tendonitis.

In recent years, the word “tendonosis” (“osis” meaning diseased or abnormal condition) is being used in the medical literature to describe chronic tendonitis, and some authors believe that it is more common than chronic tendonitis, and may be a more accurate diagnosis. In this type of tendon irritation, inflammation is no longer occurring and collagen breakdown is the primary problem. Therefore, treatment should target the stimulation of collagen production rather than the elimination of inflammation, which may not even be present (Khan, etal., “Overuse Tendonosis, Not Tendonitis”, The Physician and Sportsmedicine, 2000; 28(5)). What causes tendonitis or tendonosis? You may recall that the muscle has a reddish color, while the tendon part which attaches to the bone is a whitish color and made of a more fibrous material. This is because muscles have a good blood supply, however tendons do not. When a tendon gets pulled or strained beyond its normal range of motion, either intentionally through exercise, or unintentionally through accident or trauma, that tendon stretches. However, it will stretch only so far, and if overstretched doesn’t spring back, much like taffy would be if you pulled on it too hard. In many cases there are “micro-tears” that occur as a result of this overstrain or pulling. The tendon needs to heal and in order to do that the blood has to get in to rebuild the injured tissue. How does the body get blood into the injured tendon? Inflammation is how the blood gets into the area. Inflammation consists of several phases, which start with swelling and ends with the development of new cells in the injured area. First, the injured area swells, much like you may have seen when someone sprains their ankle; the ankle swells in order to bring blood in to start the healing process. This healing process can take several weeks, but after the healing cycle of 4, 6 or even 12 weeks, if the body has not healed that area, the stimulation to heal is drastically diminished or gone.

This is because the body responds in a stimulus-response basis. For example, if you cut yourself today, your body starts the healing process to heal immediately. However, after a period of time, the stimulus to heal is gone and the body does not respond in the same way. This is what happens with tendonitis which has gone on too long without healing. The body’s natural stimulus to heal is gone and there is just low-grade inflammation, but not enough to effectively heal that area. Or, in the case of tendonosis, there is no inflammation and collagen breakdown is occurring faster than it is being rebuilt. So what now? Sometimes physical therapy can help to strengthen the muscle around the joint, which can indirectly help to give stability to the joint. However since the blood supply is so poor in the tendon, exercise, as a therapeutic remedy does not do much for the actual tendon. Anti-inflammatory medication work by decreasing inflammation, thus decreasing blood flow to the injured area. But inflammation is how your body heals. So these kind of medications slow the natural process of healing. And in the case of tendonosis, where there is no inflammation, studies provide little evidence that NSAIDS (non-steroidal anti-inflammatory medication) and corticosteroids are helpful (Almekinders and Temple, “Etiology, diagnosis and treatment of tendonosis: an analysis of the literature.” Medicine & Science in Sports and Exercise 1998;30(8)). So what can you do? Prolotherapy (short for “proliferation therapy”) is a treatment which stimulates the proliferation (growth, repair) of injured tendons which have not yet healed. It is a natural treatment that irritates the tendon, stimulating a repair cycle to occur, even if the injury is years old. It does this by stimulating the body to send blood and repair-building cells to the injured areas. Prolotherapy has a high success rate and is a safe, in-office procedure. On the average, a person needs between four to six prolotherapy treatments, spaced out anywhere from two to six weeks. Some people need less treatments, some people more. It can be done at any age as long as the person is generally healthy. My youngest patient was 13; my oldest patient was 100.

I treated my own mother, who was in her early 70’s at the time, for an injured knee ligament. Ligaments are much like tendons in composition, and respond to Prolotherapy as well. Ligaments hold one bone to another bone in joints. My mother was an avid walker, walking an average of 5 miles per day, until one day she overdid it and had knee pain that did not go away. She had to stop walking, and was miserable because she had planned a trip to Europe that involved a lot of walking and was worried she might have to cancel it. My mother is a conservative, retired RN, and originally was not very open to alternative treatments. She saw her orthopedist, her internist, and even spoke to my brother, a kidney doctor, before she talked to me. She was indeed skeptical of this “voodoo” I do. However, she wanted to get better and wanted to keep her vacation plans. Her other doctors told her she would just have to live with the pain and restrict her activity, which she was reluctant to do. So I did Prolotherapy on her knee, and two weeks later she called me up, exclaiming: “It’s a miracle!” and that the pain she had been suffering with for many months was gone. She headed for Europe as planned, had a great trip and did a lot of walking there without problem. The bottom line is, Prolotherapy is not for every injury, but it can be a tremendously successful treatment for the right problem. In my experience, chronic tendonitis, and/or tendonitis, as well as chronically sprained ligaments, in general, respond very well to this treatment because it stimulates the repair and rebuilding of collagen fibers, making the area stronger, strengthening the joint and reducing or eliminating pain.

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