Tendonitis Risky Complications

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Tendinitis has risky complications.
Causes.

In some situations, a sudden injury can trigger tendinitis but is more commonly started from a movement with a “consistent repetition” which over time might cause tendon stress, for us runners this is not good news because our sport requires repetition for running. It’s not all bad news, the majority of runners are not destined to pick up this painful ailment. Prevention is better than cure, just keep an eye open for the early symptoms.

Symptoms.

Symptoms will stem from the area where a bone has a tendon attached to it, if you are noticing the following symptoms, this article will help you:

While moving a joint or limb you start to notice a persistent deep pain which aches.

The afflicted area feels tender and uncomfortable.

You notice the appearance of a mild swelling which is persistent.

Countless millions of runners run daily on roads, trails, in the mountains, in triathlon events, marathons, it is inevitable that some will be unlucky and start to develop symptoms of tendinitis, this is the time to start a preventative action.

This commitment to physical stress is necessary to progress in any sport. Miles of strikes to the ground later, an ache is felt in the knee, or maybe in the ankle; you have pushed yourself too hard. This is not the normal sore muscle caused by lactic acid build-up that can be worked out with a foam roller; this is a throbbing, red, inflamed spot that is getting worse. This is tendonitis.

What is tendonitis?

Tendons are fibrous cords of soft tissue that connect muscle to bone. They transmit the force from muscular contractions to the bone to produce movement.

 

From Wikimedia Commons

Pictured above is a tendon connecting muscle to bone. The tendon is white due to limited nerve and blood supply; for this reason, tendons are slow to heal.

The suffix –itis refers to “inflammation.” This is a natural physiological response to harmful stimuli such as excessive stress, irritation, injury, infection, or surgery. The body protects itself by increasing blood flow to the area, flooding the affected area with immune cells to bring the body back to normal functioning (eliminating possible invaders, clearing out dead cells and tissues, and initiating tissue repair). This process can cause some uncomfortable sensations:

  • Pain
  • Redness (heat)
  • Swelling (excess fluid)
  • Loss of function

Tendonitis is the inflammation of the tendon due to irritation from abnormal or prolonged repetitive use, traumatic injury or, less commonly, infection. Pain is felt just outside the joint, in the case for runners, usually the knee or ankle joint, and can be accompanied by all the classical symptoms of inflammation: redness, swelling, and even decreased or completely disabled functioning of the affected joint. The resulting lack of mobility is due to swelling (excess fluid), as it diminishes the available space for tendons to glide comfortably; it can also cause severe pain or a “grating sensation” upon movement.

Tendons and tendon subunits are encased in a protective sheath of connective tissue. Tenosynovitis, the inflammation of the synovium, a lining of these protective sheaths, commonly occurs with tendonitis.

A closer look at the anatomy of a tendon:

The smallest unit of a tendon is a collagen fibril; it is bundled sequentially into the following: collagen fiber, primary collagen fiber bundle (subfascicle), secondary fiber bundle (fascicle) and tertiary fiber bundle (the largest subunit of a tendon). Endotenon is a sheath of connective tissue that surrounds the primary, secondary and tertiary bundles. Epitenon, another sheath of connective tissue, surrounds the tendon, composed of tertiary bundles. The sheaths facilitate gliding of either the bundles or the tendon with their surrounding structures.

From Flickr

Pictured above is a representation of the hierarchical organization of tendon structure.

Tendons commonly overused by runners:

The health of these two tendons is especially important to runners:

  1. Patellar tendon:
  • This connects the patella (kneecap) to the tibia (shinbone). It extends your knee for kicking, running, jumping motions.
  • It is a bit of a misnomer because it technically connects two bones. However, it functions with the quadriceps tendon, which connects the patella (kneecap) to the quadriceps femoris (upper thigh muscle), to straighten the knee.

 

By Blausen.com staff via Wikimedia Commons

Pictured above is the Patellar tendon, which connects from the shinbone to the patella. It works in conjunction with the quadriceps tendon, which connects from the patella to the quadriceps femoris muscle.

  1. Achilles tendon:
    • This connects the calcaneus (heel bone) to the gastrocnemius and soleus (calf muscles). It plantarflexes the foot to stand on the toes in common activities such as running, jumping and walking.

From Vimeo

Pictured above is the Achilles tendon that connects from the calf muscle to the heel bone.

Both the Patellar and Achilles tendons are prone to injury due to excessive tension from repetitive motions and are difficult to heal because of limited nerve and blood supply. Tendonitis occurs more frequently with age as tendon flexibility decreases; this reduces its resilience to repetitive motion and increases the likelihood of trauma.

If tendonitis is not properly addressed, it may lead to complications that even further restrict proper movement and function due to weakening, thickening, degeneration, partial tearing, or complete rupturing of a tendon.

Symptoms

 In early stages, pain may be present only at the onset of physical activity or just after a vigorous workout. It can then keep progressing until it interferes with your training and eventually even daily activities, such as walking, going up the stairs, or rising from a chair. The following symptoms are also common:

  • A dull ache, especially when moving or resisting natural motion in the affected joint or limb
  • Severe pain the day after training
  • Varying degrees of tenderness to touch, along the length of the tendon
  • Stiffness, especially in the mornings
  • Redness in the affected area
  • Mild swelling that may be persistent and worsens with activity
  • Progressive tendon weakness as tiny tears accumulate in the affected area
Causes

The most common cause is overuse due to repetitive motion, causing prolonged stress on the tendon. Another common cause is extreme overload due to sudden, intense, or unexpected movement. Examples and causes include:

  • Traumatic injury
    • Example: Twisting an ankle on a pothole or slipping on ice and falling on the knee
  • Performing new or abnormal movements
    • Example: Learning to jump hurdles as a long-distance runner
  • Performing repetitive movements for an extended amount of time
    • Example: Training for the marathon
  • Training with improper form or technique
    • Example: Locking out the knee and heel-striking on strides
  • Diminished flexibility of tendon structure
    • Example: A 50-year-old man or woman starting a new workout regimen on weekends to improve cardiovascular health
  • Sudden increase in training intensity
    • Example: Attempting to run a marathon without any training in long-distance running

Inflammation is the body’s attempt to repair the tiny tears in the tendon caused by excessive or prolonged stress.

By stevepb from Pixabay

Pictured above is a common threat to all pedestrians, especially runners, especially in cartoons.

Risk Factors

The following increase your risk for developing tendonitis:

  • Sports with repetitive motions
    • Baseball
    • Basketball
    • Bowling
    • Golf
    • Running
    • Swimming
    • Tennis
  • Occupations with the following characteristics
    • Awkward positions
    • Forceful exertion
    • Frequent overhead reaching
    • Repetitive motions
    • Vibration
  • Age
    • Tendons lose flexibility as we get older
  • Improper recovery
    • Tight muscles can place undue strain on tendons
  • Improper training
    • Muscular imbalances (some muscles are disproportionately stronger than others) can cause an uneven pull on tendons

By Ducky2315 from Wikimedia Commons

Excessive pronation or supination of the foot (from improper from and faulty movement patterns) can cause abnormal wear on shoes and abnormal stresses on the ankle and knee joints.

Using old or damaged training equipment

The thin sole of a worn-out training shoe is less effective at absorbing impact and can transmit undue strain on tendons.

Excessive pronation or supination of the foot can improperly wear the soles of your shoes and increase strain on tendons.

Location and time of training

Unpredictable, hilly terrain can increase the risk of overloading tendons.

Training in cold weather, during winter months or just particularly chilly mornings, can cause muscles to stiffen and place extra strain on tendons.

Excess weight

Obese individuals are at a higher risk for injury, especially in the Patellar and Achilles tendons because of the weight-bearing demands placed on knee and ankle joints.

Complications

Untreated tendonitis can progress into serious conditions that decrease the function and mobility of the joint associated with the injured tendon:

By BruceBlaus via Wikimedia Commons

Pictured above is an Achilles tendon rupture, a complication of untreated tendonitis.

Diagnosis

If caught early, your primary care physician or physical therapist can treat tendonitis. If the condition does not respond to treatment, you may be referred to a specialist, such as an orthopaedist (a doctor who specializes in correcting abnormalities of the skeletal system) or a rheumatologist (a doctor who specializes in correcting abnormalities of the musculoskeletal system, and the immune system, specifically systemic autoimmune conditions, otherwise known as rheumatic diseases).

The doctor will obtain a medical history, perform a physical examination, and run the necessary tests.

Medical History
  • Onset:
    • What happened when you started feeling the pain? Was it gradual, sudden, or part of a chronic problem you already experience?
      • Example: you slipped and fell on your knee 3 days ago and started feeling swelling, redness, and tenderness the next morning
  • Provocation:
    • What makes the pain better or worse?
      • Example: it hurts to extend and flex your knee, running is uncomfortable but walking is ok, and applying pressure to the area causes pain
  • Quality:
    • What type of pain do you feel?
      • Example: You feel a dull ache around the knee joint.
  • Region and radiation:
    • Where do you feel the pain? Does it “travel” anywhere?
      • Example: It hurts around the knee joint. When the doctor touches the area, the pain is worse closer to the shin bone.
  • Severity:
    • How much does it hurt on a scale of 1-10?
      • Example: You have previously dislocated a shoulder, which had you screaming with pain when popped back in- this is the worst possible on a scale of 0-10, 10 being the highest and 0 being no pain at all. You rate the pain around your knee at around a 6.
  • Time:
    • How long has it been since the pain started and has it gotten worse, improved, or stayed about the same?
      • Example: At first, it was just uncomfortable to run. Now, it hurts to put any weight on the foot and, you struggle to walk normally.

The doctor will also ask about any allergies you have, medications you take (normally or any you have taken to lessen the pain of the current injury), and any past illnesses or injuries.

It is crucial to determine the cause of your symptoms, in order to help the damaged area heal and prevent future reoccurring injuries.

Physical Examination
  • The doctor will perform selective tissue tension tests. These are manual tests that help identify the tendon involved in the injury. The doctor will also palpate (touch) the tendon to identify the exact location of the inflammation.
  • The doctor will evaluate the alignment, range of motion, and flexibility of the affected joint (such as the knee) and the voluntary and involuntary reflexes of the limb attached to it (such as extending and flexing the knee).

Tests

  • X-rays:
    • An x-ray creates an image of the affected area but does not show tendons. However, it can be used to identify possible complications, such as a partial or complete tendon tear, by showing if any bones are in abnormal positions.
      • Example: In a patellar tendon tear, the patella (kneecap) will sit higher than normal. However, if the quadriceps tendon is torn, which is also connected to the patella (kneecap), it will sit lower than normal.

By Hellerhoff – Own work, CC BY-SA 3.0 via Wikimedia Commons

The x-ray on the left shows a patellar tendon tear, causing the knee disk to sit higher than normal. The image on the right is a quadriceps tendon tear that shows an indentation from abnormal knee positioning.

  • Ultrasound:
    • An ultrasound creates an image of the tendon and reveals any existing tears. It can also produce real-time images of a tendon in motion. A color-Doppler ultrasound can visualize blood flow surrounding the tendon.
  • Magnetic resonance imaging (MRI):
    • An MRI creates detailed images of bone and soft tissues (muscles, tendons, tendon sheaths, and bursae) and can be used to confirm a partial or complete tear of a tendon.
  • Centesis:
    • The doctor may puncture the area of inflammation with a hollow needle to draw a sample of fluid to test for a possible infection.
Treatment

If tendonitis is treated early, it may be as simple as taking a few days off with some at home care and pain relievers. If left untreated, it can progress to a severe or chronic condition requiring options such as physical therapy, injections, and surgery.

Self-Care

 The most noninvasive treatment for tendonitis is the self-care treatment for inflammation, represented by the acronym R.I.C.E.

  • REST:
    • Give the body time to repair the affected tendon, by staying off of the affected joint.
      • Take a break from your running routine to allow a knee injury (Patellar tendon) or ankle injury (Achilles tendon) to heal. Pushing through this type of pain can cause further injury and complications. This is the time to listen to your body.
      • Prolonged rest may cause stiffness in the joints. Gently move the joint through its full range of motion to maintain mobility, as you recover (do this only if it is mildly uncomfortable but not extremely painful; do not do this if it is contraindicated by your doctor).
  • ICE:
    • Apply ice packs. Place a thin towel around the ice to protect the skin. Apply for 20 minutes.
  • COMPRESSION:
    • Apply an elastic wrap to the affected joint to reduce swelling. This will help restore some mobility but full functionality will likely only return when the area is completely healed.
  • ELEVATION:
    • Slightly raise the affect area above the heart. This will help reduce swelling.
    • For knee and ankle injuries: Lie down on the bed and place enough pillows under the calves to elevate the lower part of the leg above the heart. Bend the knees slightly, with the shins parallel to the ground, to avoid locking out the knees. Your legs should not look like an entrance ramp, but rather a plateau.
Medications
  • Pain relievers:
    • Pills taken orally (by mouth)
      • Aspirin
      • Naproxen Sodium (Aleve)
      • Ibuprofen (Advil, Motrin IB, and etc)
    • Topical Creams containing anti-inflammatory medication: relieve pain without the side-effects of taking anti-inflammatory medications orally (by mouth)
Physical Therapy
  • Stretching Exercises
    • This helps alleviate tightness in the muscle-tendon unit, which may be causing muscle spasms. Static stretching exercises are assigned to be performed slowly and consistently to release tension and lengthen the affected structures.
      • Dynamic stretching exercises (more momentum) are contraindicated due to the possibility of overloading the unstable and weak muscle-tendon unit.
  • Strengthening Exercises
    • Tendon strain caused by weak muscles is commonly a problem for those who suddenly begin a new training regimen or are training with improper form, which may result in a muscle imbalance. This means that the tendons may be forced to compensate for the weak muscles. Strengthening these muscles will help relieve strain from the affected tendons. If the muscle is not properly strengthened, it will continue to cause damage to the affected tendon.
  • Rehabilitation Devices:
    • These provide support during the recovery process, depending on the area of injury.
      • Immobilization devices (e.g. brace)
      • Orthotics (e.g. orthopedic inserts)
      • Kinesiology tape

By C3Pio from Pixabay

Pictured above is kinesiology tape (physio-tape), applied in specific patterns to the affected area for stability.

Other Treatments

  • Corticosteroids:
    • Cortisone, a type of steroid, can be injected into the site of injury to reduce inflammation.
      • Not recommended for chronic tendonitis (<3 months). The injections can weaken the tendon and increase the risk of partial tears and complete rupturing.
  • Platelet-rich plasma (PRP):
    • A sample of blood is removed and centrifuged (spun) to isolate platelets and healing factors. The concentrated solution is then injected into the surrounding area of the injured tendon.
      • This treatment has been shown to be most useful for chronic tendonitis.
  • Focused Aspiration of Scar Tissue (FAST):
    • A less invasive option to open surgery. This treatment uses very small instruments guided by ultrasound to remove tendon scar tissue while preserving the healthy tendon tissue. It is performed under local anesthesia in a non-surgical setting. It has a fairly quick recovery period with most people returning to normal activities within 1-2 months.
      • This is a treatment for chronic tendon inflammation.
Surgery

If the tendon injury is severe, the tendon has detached from the bone, or the injury has not responded to the previous treatments, surgery will be the next option.

By Wikimedia Images from Pixabay

 

Pictured right is a fully ruptured Achilles tendon (the severed white band of tissue).

Prevention

“No pain, no gain,” is a common phrase used in the training world. But, there is a less common phrase, “wrong pain, no gain,” that is also very useful. If you are feeling unusual pain, or if you are a beginner and are not certain about what this pain indicates, it is better to be more conservative with your training. Seek medical assistance to help understand the various pains and sensations you are experiencing.

These are some training suggestions to help avoid developing tendonitis:

  • It’s ok to be a beginner
    • Becoming a great athlete takes time and a lot of energy. It is not fair to compare yourself to someone who has already put in years of effort. And, it is not realistic to try to “catch up” by training as much as possible at one time; this will only expose you to potential injuries. Embrace your new journey with patience, let your body adjust to this new activity, and gradually increase intensity after several weeks of consistent training.
  • Listen to your body
    • Pushing yourself to reach your goals is what makes athletes rise above the competition. Know the difference between pushing through fatigue and pushing through pain. An injury can have permanent consequences. A good rule of thumb to follow is a 10% increase in intensity. For example, if you’re running 50 miles a week (5 days with 10 miles a day), you can increase to 55 miles a week (5 days with 11 miles a day). A momentary rush of adrenaline will let you run 60 miles a week, but once it fades, it might be difficult mentally and physically to keep up with an increase that high. No one set formula works for everyone. It is important that you take the time to test out what works for you.
  • Don’t forget to warm-up
    • Tight muscles are inevitable. A good 10-15 minute warm-up focused on functional mobility exercises (taking joints through a smooth, controlled full range of motion) to loosen up any kinks prepares your body for training. Take this time to also do some drills and other bodyweight exercises to warm-up the muscles.
      • Example: high knee-ups, body squats, and hip strengtheners and openers

By Fit Approach from Flickrh

Planks are an excellent way to fire up the core and warm-up cold muscles.

    • Specific muscles can be targeted with dynamic stretching. This type of stretch incorporates a slow movement of a limb from a neutral position to complete extension, followed by a slow, eccentric contraction to bring the limb back to neutral. The eccentric contraction relaxes the lengthening muscle by reciprocal inhibition (e.g. the hamstring is lengthened by contracting the quadriceps). This is a great way to strengthen neuromuscular activation (mind-to-muscle connection). By taking time to focus on the contraction and relaxation of specific muscles and feel these sensations in your body, both the speed of muscle contraction will increase and muscle coordination (the simultaneous contraction of a group of muscles).
      • Example: from standing position, raise one leg to 90° at the hip with a bent knee, extend the knee to a straight leg, and then slowly lower the leg back to the ground. This is a common runner’s stretch that engages the quadriceps muscles to lengthen the hamstrings.
      • Moving slowly prevents activation of the stretch reflex at the end of the movement, which causes a sharp contraction of the muscle.
  • Recovery is just as important as the workout
    • Torn-up, over-used, and aching muscles need to be restored to keep your body functioning at its highest potential. Recovery helps to rebuild your body, forging it into a version with more strength, power, stamina, mobility, and agility.
      • One way to recover is myofascial release. Use a foam roller or muscle roller stick to massage big muscles (e.g. the quadriceps, hamstrings, and calves). Be sure to avoid rolling any joints (e.g. when rolling the hamstring or calf, avoid the back of the knee, which has many sensitive structures that don’t need rolling). Smaller muscles can be accessed with a lacrosse ball or your hands. This can be done by yourself or with the help of a friend after your workout.
      • Another way to recover is static stretching. It is an excellent way to maintain and increase the range of motion in your joints. Do this after your workout. Hold the stretch for at least 30 seconds; this will give you time to relax any tense muscles with smooth, full, even breaths. Don’t force the stretch (80% effort). If you are really tight and sore, it is a good idea to do some stretches after the warm-up as well. Static stretching can be done at any time, just make sure you get the blood flowing with some activity before diving down to touch your toes.

By BenKerckx from Pixabay

The picture above shows a quadriceps stretch (front thigh muscle), commonly performed by runners to relieve soreness.

      • And lastly, rest! If you find yourself so sore that you are unable to move properly, perform some recovery before your workout and take it easy. It may even be a good idea to just do some recovery instead of your workout and take the day off.
  • Proper form will protect you
    • Not only is proper form crucial to prevent injuries, it is also important for progress, which occurs when the right muscles are being trained with the correct motions. You can cheat by having the wrong muscles compensate, but this improperly overloads the kinetic chain and consolidates faulty movement patterns. It is a good idea to re-evaluate your running form, especially if you are experiencing a chronic dull pain in the knee or ankle joints. If you are not sure how to evaluate your running form, it may be a good idea to find a coach, at least for an assessment on your current technique and some tips. Reading articles online or looking at videos is also a great place to start. Many sports rehabilitation therapists post videos on common running problems and some even answer questions in the comments. You can also meet training partners and get running advice by joining a running community, either through social media, or your local fitness facilities.
  • Take a mental breather
    • The mind is a powerful tool; it can speedily thrust you through a tough training session or drag you down the entire time. Take some time to sort through any negative emotions you are feeling to understand what needs to be changed, removed, or improved in your training routine. Without focus, training can drain you mentally, especially if you reach a plateau and are not making progress. Negative thoughts and unrealistic expectations are a breeding ground for risky decisions. Don’t let mental clutter numb you or enrage you to push through unhealthy physical pains. Reset and re-energize your mind by giving yourself the permission to let go for a day. This break will give you the fresh perspective you need to tackle your next session without potential injuries.

By Mel from Flickrh

Meditation is one way to slow down the mind and focus. This mental clarity helps tackle challenges more productively.

  • Challenge yourself to expand your repertoire
    • Doing the same exercises for months is consistent, but boring and physically stressful for overused joints (i.e. knees and ankles, for runners). Once you have harnessed your steadfastness and have a disciplined routine, it’s time to incorporate variety to give your joints a break from the usual repetitive motions.
      • There is a wide array of training equipment to keep your training challenging and exciting:
        • resistance bands, resistance tubing, stability balls, balance boards, balance domes, balance pads, medicine balls, slam balls, sand bags, weighted vests, suspension training straps, speed ladders, jump rope, plyoboxes, steps, sleds, training (battle) rope, resistance parachutes, gliders, and roll out wheels, to name a few.
          • Use resistance bands with monster walks to increase hip mobility (this helps relieve tight hips).
          • Run against a resistance parachute or weighted bag to increase power and agility.
          • Stair-climb with a weighted vest for an endurance workout.
          • Challenge your running partner to some speed ladder drills; incorporate high knees, jump squats, and long jumps.
          • Improve your balance and coordination with balance boards and balance domes; excellent for core activation and overall muscular involvement. Incorporate planks, stationary lunges, and squats (use a buddy to help you balance).
          • Suspension training straps and gliders will take lunges to the next level as you fire up the core to keep your balance.
          • There is an unlimited amount of exercises you can do with these with an even greater amount of modifications; grab a buddy and get to it!

By rob9040 from Pixabay

Pictured above from left to right: balance dome, medicine ball, stability ball, dumbbells, and, resistance tube.

      • With strength training, specific muscles can be targeted to enhance athletic performance.
        • For example: Incorporating sumo squats, side lunges, and targeted hip adduction and abduction exercises will help increase hip mobility. This is especially important if you only run in one direction and do not train movement multi-directionally (e.g. speed-skaters, side-shuffles). Abdominal and lower back exercises help develop a stronger core, which will give your strides more power and protect your spine.
      • Yoga is known for slow, mindful, deliberate movements that will help you understand how your muscles work together and teach you to use your breath effectively.
        • Increase your mobility and flexibility with asanas (poses held for a number of breaths). A few interesting postures are listed below:
          • Forward Fold
          • Downward Facing Dog
          • Warrior 1 and Warrior 2
          • Hanuman
          • Chair
          • Monkey Pose
          • Plank Position
          • Low Cobra
        • Master your breath and increase endurance with vinyasa (transitioning poses with each movement as one breath).
          • Sun Salutations A, B, and Classical Sun Salute. There are also many variations led by yoga teachers like Vinyasa Flow and Yoga Flow.

By jeviniya from Pixabay

Pictured above is a yoga arm balance. This pose requires a lot of core strength.

Conclusion

Tendonitis is a common but preventable injury that responds very well to treatment, in the early stages. The complications of untreated tendonitis, such as tearing or rupturing of a tendon, can severely impact or disable a runner. It is better to consult a doctor and dispel any mysterious knee or ankle pains before they progress into serious conditions. If not currently experiencing any pains and aches, being proactive in preventing this common condition will keep your tendons healthy and keep you running.

Disclaimer

This article is solely for informational purposes and is not a substitute for medical advice from an accredited doctor. It is critical to seek medical attention for proper diagnosis of illness to reduce the risk of serious complications.

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