In our last 3 newsletters, we have discussed shoulder mobility and some common shoulder injuries like AC joint sprains and partial thickness tears. In our last series on the shoulder, we will look at the differences between tendonitis, tendonosis and tenosynovitis and how these present in the shoulder.
These are confusing terms are they not? When the ending -itis is added to the end of a word, it indicates inflammation” is present at the anatomical term or body part. For example, appendicitis, or “inflammation of the appendix”. Or meningitis, “inflammation of the meninges (which is the membrane surrounding the brain and spinal cord). Hence “tendonitis” would therefore indicate “inflammation of the tendon”. Now, I am going to make it a little more complicated.
As stated, tendonitis is used to refer to the inflammation of a tendon. Microscopically, there would need to be inflammatory cells, like white blood cells, present to use the ending “-itis”. However, we just don’t see this. More commonly, injured tendons tend to have repair cells (fibroblasts) and no white blood cells under the microscope. A better term to use then would be tendonosis. Tendonosis is a term used to describe chronic inflammation with degenerative changes within the structure of the tendon (-osis on the end of a word indicates a “process” or “pathological state”).
To be absolutely sure, a biopsy of the tendon is the only way to see the structures under microscope, and typically that is not done. Many choose to use the word tendonopathy to describe any injury, acute or chronic overuse, to a tendon because they don’t want to make a diagnosis of -itis or -osis, without knowing the cellular process present.
Further looking at the anatomy of a tendon, we see that there is another layer of tissue that plays a large role in tendon injury. Surrounding the tendon is a thin layer of tissue called the synovium. The synovium folds over the tendon and then wraps back around itself forming a cavity containing fluid. We now know that many injuries that result from friction, or rubbing of the tendon repeatedly over bone, actually starts with damage to the synovium. Damage to the synovium will likely occur first, as it is the outer layer, then the inner tendon damage would occur later, with friction type injuries. Tenosynovitis is then the term used to indicate there is inflammation in the synovial membrane that surrounds the tendon.
Ultrasound imaging of tendons are becoming more detailed and accurate at determining the layer of tissue that is actually injured. If we now consider severity, the presence of tenosynovitis would be the preferred diagnosis as there is no damage to the structure of the actual tendon.
Treatment considerations:
Reduce inflammation– Treat with PRICE (Protect Rest Ice Compress Elevate) if you can see visible swelling.
Address nutrition– Ensure adequate calories for growth and repair. Increase collagen and protein consumption for tendon repair. Bone broth or meat on the bone, are excellent sources. For vegetarians, increased protein from tofu and vegetables/fruit high in Vitamin A and C help with natural collagen formation.
Reduce the irritation– Correct joint mobility locally or elsewhere if the injury is the result of a compensation. Unless there was an acute trauma to a tendon or a deceleration injury, most likely the injured tendon resulted from an overuse, friction or degenerative change. And these generally occur as a result of a compensatory motion due to an immobility elsewhere.
Add eccentric load– We know that adding load to a tendon and muscle will stimulate growth and repair. Cellular response to strain increases as the degree of strain increases. And when you load a tendon you are increasing the strain on that tendon. Eccentrically loading a muscle (the lengthening phase of a contraction) produces the greatest amount of force on a tendon. Tendonopathies are treated with more eccentric contractions to help increase the cellular repair response.
Please keep in mind that these are general guidelines to aid you in your self treatment. A more thorough assessment will provide a more specific protocol for you to follow in your injury recovery. For any questions or concerns regarding your health and tendon injury, please email to info@mmdchiropractic.ca, or book your appointment with our online booking system by clicking the button below.