Tendon Injury Nuthouse

Direct link-to 2002 paper
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1122566/

UPDATE 9/23/2013 - This 2012 paper found by andreh discusses the issue and says that tendinitis and tendinosis should be viewed a little differently -
http://bjsm.bmj.com/content/early/2013/03/08/bjsports-2012-091957.full

Interesting article. If nothing else it summarizes all research on tendon disorders done to date. It revisits inflammation and seems to suggest that the tendinosis diagnosis has now gone too far, although it does not claim that the old tendinitis diagnosis was correct either. Good read.
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There was a 2002 British article discussing the nature of tendon injuries such as Achilles 'Tendinitis', Tennis Elbow, Golfer's Elbow, etc. , the accuracy of information about these injuries, treatment effectiveness, tendinitis vs tendinosis, etc.

This article discusses the short paper-

http://www.bmj.com/content/324/7338/626?tab=responses

The link to the 2002 paper itself is on the top of the article.

http://www.bmj.com/content/324/7338/626 - but you must be subscribed to view it.

To view the article the British Medical Journal offers a free 1 month subscription. See link on the page.

I signed up and got the article. Is this how things are, mostly...........?
 
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janm

Rookie
I''ve become interested in tendons since I suffered an injury of my rotator cuff. As mine was a acute type injury I cannot answer your question re my treatment plan.

I'm more curious in the role of NSAIDS or ICE for treatment of tendons. Wether that be tendonitis, strain/tear...

I don't really understand why its necessary to reduce swelling after injury?

Is it to help with pain? to further this keep the joint mobile otherwise one may keep the area protected and stiff.

To prevent impingement of certain tendons?

Some other function...?

I've read somewhere NSAIDS my help with collagen allignment and keep the healed area from thickening too much. Don't know if this is good or bad. For tendons what can get impinged i'd imagine its good but what about others that don't suffer this problem. Wouldn't a thicker area where an injury has occured before be good.

So far i've read so much contradictory stuff i'm unclear on the above.

Sorry if i have gone off topic a bit...
 

LeeD

Bionic Poster
I always thought ice to decrease swelling was to allow more good blood to enter the injured area, so recovery time can be faster. If you leave clotted blood around too long, no new goodies come into the injured area, how can it heal?
 

janm

Rookie
The blood that leaks into surrounding tissue increases the bodys reponse by actiing as an irritant.

Not sure about vasoconstriction following application of ice will increase blood flow or mop up clotted blood quicker. It will stop blood leakage to surrounding tissue to an extent through damaged capillaries I think.
 

LeeD

Bionic Poster
Either way, it's now believed that after a catastrophic injury, and after it stablilizes, some amount of increased heartbeat and exercise does promote quicker healing and recovery.
My first broken leg, in the mid '60's, it was still a belief by some members of the medical society to just rest to recuperate, with no excercise or movement of the parts surrounding the actual injury.
 
I''ve become interested in tendons since I suffered an injury of my rotator cuff. As mine was a acute type injury I cannot answer your question re my treatment plan.

I'm more curious in the role of NSAIDS or ICE for treatment of tendons. Wether that be tendonitis, strain/tear...

I don't really understand why its necessary to reduce swelling after injury?

Is it to help with pain? to further this keep the joint mobile otherwise one may keep the area protected and stiff.

To prevent impingement of certain tendons?

Some other function...?

I've read somewhere NSAIDS my help with collagen allignment and keep the healed area from thickening too much. Don't know if this is good or bad. For tendons what can get impinged i'd imagine its good but what about others that don't suffer this problem. Wouldn't a thicker area where an injury has occured before be good.

So far i've read so much contradictory stuff i'm unclear on the above.

Sorry if i have gone off topic a bit...
I believe the report very briefly mentions some of those topics. What did you think?
 

LeeD

Bionic Poster
I think he needs to make some sort of decision by himself, for himself, and spend less time reading about studies conducted by people who never had an injury or ever will because they stay safe and locked up 24/7.
 

LeeD

Bionic Poster
Posts 1 and 2.
You can read till the sky turns green.
You can cite every report ever made on the subject.
Still, you gotta make your own decision based on your experience, for you yourself.
What you decide might not be applicable for another guy, just for yourself. That don't mean you should withhold it, just that the other guy doesn't need to heed it.
 

janm

Rookie
Just read its pretty short.

I guess its pretty much to the mark. I'm still not sure of the extent of my injury but its pretty clear the doctor gave me NSAIDs because I was complaining about pain and not because of any specific treatment plan.

Having read an article before showing how british GPs treat tendon complaints its pretty standard here.

rest for a few weeks -> NSAIDs -> phsio
surgery if its serious

I guess this article is saying avoid SAIDs, rest then phsio without pain upto collagen turnover naturally is the best bet for recovery for small injuries.

I've read somewhere turnover can be as long as 300-500 days.
 

LeeD

Bionic Poster
you need only to have suffered such injuries to know recovery can take much longer than any doctor's guess..
 
No one knows exactly what is going on at the tendon level in any one patient suffering from tendonitis/tendonosis.

There just is not a good test that will tell us how much inflammation really is present.




The bottom line is that it takes a long, long time for tendon to heal.

It has a lousy blood supply, and has to support very high forces.



Most people are familiar with the way a skin injury heals so very quickly in a couple of weeks.

They can't wrap their heads around the concept that different tissues heal at different rates.

Skin is growing at a very rapid rate and has a great blood supply. The pulling force on skin at any one point is quite small.

Tendon isn't growing at all under normal conditions, and has a lousy blood supply. The force of muscle pulling on tendon is great.



People think 2 weeks is a long time - long enough to injured tendon to heal.

They are wrong.



 
No one knows exactly what is going on at the tendon level in any one patient suffering from tendonitis/tendonosis.

There just is not a good test that will tell us how much inflammation really is present.

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The level of knowledge is not that great yet but the 2002 Kahn report says:

"Animal studies show that within two to three weeks of tendon insult tendinosis is present and inflammatory cells are absent."
 

janm

Rookie
charliefedererer that table is it for tendonosis, tendon tear or full tendon tear and subsequent recovery?

thanks
 

r2473

G.O.A.T.
I fully tore my distal bicep tendon. At 17 weeks, I'm very close to 100% I think.

I had golf elbow (from weight lifting) a few years ago. As I recall it took about 3 months to fully recover from that. It has not returned.
 
I think that sometimes, in my experience anyway, NSAIDS mask the pain and you can be tempted to think the injury is not as serious as it is, and therefore play through it. I would be very wary about using them too much.

Six months on now, from the SAD surgery and I played three sets with my mixed partner, took one set off of him, and happily enough felt no pain whatsoever afterwards.
 

arche3

Banned
I had severe tennis elbow from too much tennis, poly strings, and my wife making me help her garden one summer. It look me over a year time recover.
 
Detailed Technical Paper on Tendon Healing & Remodeling

Biology of Tendon Injury: Healing, Modeling and Remodeling (2006)
P. Sharma1 and N. Maffulli2

http://www.ismni.org/jmni/pdf/24/14MAFFULLI.pdf

This paper is very technical but also has some interesting discussions often related to Achilles tendon injuries.

[You can search for terms in a .pdf document by right clicking and selecting "Find". Is that an Adobe software feature? ]
 
Current Concepts in Examination and Treatment of Elbow Tendon Injury, Todd Ellenbecker

Current Concepts in Examination and Treatment of Elbow Tendon Injury, 2012, Todd Ellenbecker, R. Nirschl, and Per Renstrom
Update 2/25/2014 - available free
http://www.thera-bandacademy.com/elements/clients/docs/ellenbecker2013-sportshealth-elbow__635071763835825895.pdf


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Abstract
http://sph.sagepub.com/content/early/2012/10/29/1941738112464761.abstract

Not free
http://sph.sagepub.com/content/early/2012/10/29/1941738112464761.full
 
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2017
Review: Emerging concepts in the pathogenesis of tendinopathy
Benjamin J.F. Dean,a,∗ Stephanie G. Dakin,a Neal L. Millar,b and Andrew J. Carra
Author information ► Article notes ► Copyright and License information ► Disclaimer
This article has been cited by other articles in PMC.

Go to:
Abstract
Tendinopathy is a common clinical problem and has a significant disease burden attached, not only in terms of health care costs, but also for patients directly in terms of time off work and impact upon quality of life. Controversy surrounds the pathogenesis of tendinopathy, however the recent systematic analysis of the evidence has demonstrated that many of the claims of an absence of inflammation in tendinopathy were more based around belief than robust scientific data. This review is a summary of the emerging research in this topical area, with a particular focus on the role of neuronal regulation and inflammation in tendinopathy.
Keywords: Tendon, Tendinopathy, Tendinitis, Inflammation, Pain, Pathogenesis
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5714045/


2008
The Basic Science of Tendinopathy
Yinghua Xu, MBBS and George A. C. Murrell, MD, DPhil
Author information ► Article notes ► Copyright and License information ► Disclaimer
This article has been cited by other articles in PMC.

Go to:
Abstract
Tendinopathy is a common clinical problem with athletes and in many occupational settings. Tendinopathy can occur in any tendon, often near its insertion or enthesis where there is an area of stress concentration, and is directly related to the volume of repetitive load to which the tendon is exposed. Recent studies indicate tendinopathy is more likely to occur in situations that increase the “dose” of load to the tendon enthesis – including increased activity, weight, advancing age, and genetic factors. The cells in tendinopathic tendon are rounder, more numerous, and show evidence of oxidative damage and more apoptosis. These cells also produce a matrix that is thicker and weaker with more water, more immature and cartilage-like matrix proteins, and less organization. There is now evidence of a population of regenerating stem cells within tendon. These studies suggest prevention of tendinopathy should be directed at reducing the volume of repetitive loads to below that which induces oxidative-induced apoptosis and cartilage-like genes. The management strategies might involve agents or cells that induce tendon stem cell proliferation, repair and restoration of matrix integrity.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2505234/
 
@Chas Tennis - have you found any more favorite tendon healing articles/resources, since your last post here a few years ago? Thanks!
I have not been too active lately on researching the basic tendinitis and tendinoisis.

For Post Surgery Recovery. I had rotator cuff surgery in March 2017. I had two suitcases and was in a hurry traveling. I got on an escalator with a hand on each suitcase and lost my balance. I grabbed the moving rail and then my shoulder started hurting. This was an immediate tear, small, full thickness tear of the supraspinatus tendon. The supraspinatus location is probably the most common rotator cuff injury. Overuse was not a factor. I'm playing tennis again and the shoulder feels good.

My conclusion is that when you are first injured stop stressing the injured tendon immediately, including during a tennis match. See a Dr. I know that most injured tennis players have probably played for a time long enough to be involved in the complications of tendinosis/tendinopathy as described in the publications here. Information can change that -

* New Tendon Injury - We can especially tell everyone before they have a tendon injury that if they get a new injury to stop stressing their injuries immediately and see a well qualified Dr for a diagnosis and treatment. Knowing this will be the critical information for many people for minimizing defective healing tendinosis and avoiding a long term chronic condition.

* Beyond New Tendon Injury - For the very large number of people already dealing with chronic tendon injuries, they should find a well qualified Dr and research information on treatments for themselves.
 
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Tendinopathy: Why the Difference Between Tendinitis and Tendinosis Matters

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312643/

This article mentions the goal of regaining normal tendon tensile strength from tendinosis. It references an earlier publication. I am skeptical of that. See additional sources.

"The primary treatment goals for tendinosis are to: break the cycle of injury; reduce ground substance, pathologic vascularization, and subsequent tendon thickening; and optimize collagen production and maturation so that the tendon regains normal tensile strength "
 
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ByeByePoly

G.O.A.T.
"Stretch and keep moving, though conservatively. Lightly stretching and moving the affected area through its natural range of motion while minimizing pain will prevent shortening of the related muscles (preserving active range of motion and flexibility). It can also increase circulation, thereby assisting the healing process. Stretching can also elongate the muscle-tendon unit, reducing the tension placed on the tendon during activity, thereby reducing the chemical changes that cause degeneration. "

So perhaps light hitting is maintaining range of motion, rather than allow muscles we use in tennis to shorten if we don't touch a racquet for months or a year+.

We are all still guessing.

Edit: It occurs to me that it would not be very likely to make a current TE injury worse from relaxed shadow swings and serves. Perhaps the best TE PT is shadow swinging a racquet. We get TE from contact right ... not just swinging. Maybe that would even be better than the flexbar .... maybe swinging a racquet involves the right kind of eccentric load to get back to playing tennis.

I know one thing, post TE I continue to put rollerbar massage at the very top of the list keeping TE away. I got a little forearm stiffness without even playing tennis for 10 days or so, and can feel immediate release with a couple minutes of massage.
 
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"Stretch and keep moving, though conservatively. Lightly stretching and moving the affected area through its natural range of motion while minimizing pain will prevent shortening of the related muscles (preserving active range of motion and flexibility). It can also increase circulation, thereby assisting the healing process. Stretching can also elongate the muscle-tendon unit, reducing the tension placed on the tendon during activity, thereby reducing the chemical changes that cause degeneration. "

So perhaps light hitting is maintaining range of motion, rather than allow muscles we use in tennis to shorten if we don't touch a racquet for months or a year+.

We are all still guessing.
Who are you quoting? What is the injury?

Most injuries, even with a correct diagnosis, can't be assumed to have simple fixes such as experienced by someone else with an injury of the same name, for example another tendon injury. One tendon tear may be minor and another may be separating from the bone. Exercises and stretching might cause additional injury. That is why a well qualified Dr should diagnose the injury and select the treatment. Medically trained physical therapists should tell the patient how to perform the exercises.

In 2017, I had 6 months of physical therapy after rotator cuff surgery. The supraspinatus tendon attachment and bone were cleaned up and the tendon reattached to the humerus with stitches. After 6 months of progressive stretching I was ready for light strength exercise. Full recovery to start more normal activity was 9 months after surgery. The physical therapist supervised the progression.

I had a small complete thickness tear and the Dr said that I could play tennis with the injury but that the size of the tear would probably increase. My chance of a successful surgical outcome with a "small complete thickness tear 10 mm" was 95%. The success rates went down a lot as the size of the tear increased. I had played platform tennis about 3 times after my injury - breaking my rules - before deciding that I had a serious injury.

Many of the publications in this thread are from medical researchers. There is always uncertainty with medical injuries.

The critical point of this thread is that a new tendon injury, including undiagnosed injuries, may have defective healing in a very short time - two or three weeks after injury - if the early healing is stressed. Most people with tendon pain may already be well past this brief window and tennis can be very stressful especially if tennis caused the injury. Post #1.
 
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ByeByePoly

G.O.A.T.
Who are you quoting? What is the injury?

Most injuries, even with a correct diagnosis, can't be assumed to have simple fixes such as experienced by someone else with an injury of the same name, for example another tendon injury. One tendon tear may be minor and another may be separating from the bone. Exercises and stretching might cause additional injury. That is why a well qualified Dr should diagnose the injury and select the treatment. Physical therapists should tell the patient how to perform the exercises.

In 2017, I had 6 months of physical therapy after rotator cuff surgery. The supraspinatus tendon attachment and bone were cleaned up and the tendon reattached to the humerus with stiches. After 6 months of progressive stretching I was ready for light strength exercise. Full recovery to start more normal activity was 9 months after surgery. The physical therapist supervised the progression.

I had a complete small complete thickness tear and the Dr said I could play tennis but that the size of the tear would probably increase. My chance of a successful surgical outcome with a "small complete thickness tear 10 mm" was 95%. The success rates went down a lot as the size of the tear increased. I had played platform tennis about 3 times after my injury before deciding that I had a serious injury.

Many of the publications in this thread are from medical researchers. There is always uncertainty with medical injuries.

The critical point of this thread is that a new tendon injury, including undiagnosed injuries, may have defective healing in a very short time - two or three weeks after injury - if the early healing is stressed. Most people with tendon pain may be well past this brief window and tennis can be very stressful. Post #1.
That was from the article you just linked about TE. I am talking just about TE. Interesting in that article it suggested that that first couple of week tendonitis theory was probably wrong. First tendonosis (sp??).

My guess is the vast majority won’t go see a doc or pay for MRI or PT for TE. I didn’t... but my doc was ready to approve a MRI anytime I wanted. I was going to if I didn’t see any improvement in 2-3 months.
 
That was from the article you just linked about TE. I am talking just about TE. Interesting in that article it suggested that that first couple of week tendonitis theory was probably wrong. First tendonosis (sp??).

My guess is the vast majority won’t go see a doc or pay for MRI or PT for TE. I didn’t... but my doc was ready to approve a MRI anytime I wanted. I was going to if I didn’t see any improvement in 2-3 months.
Your quote is from Reference 3, a 2000 publication by Kahn et al.

The first post of this thread is based on a well know publication also by Kahn et al in 2002. I had seen that publication referenced and discussed and that is why I found it.

My interpretation of the later Kahn publication was that Tendinitis preceded Tendinosis. The title was "Time to abandon the “tendinitis” myth". Based on the title maybe the views by Kahn et al were changing at that time? I am skeptical of several of the comments that use Kahn's earlier publications before 2002, but may eventually learn more. Some of the other posts in this thread above also disagree with post #1.

In "Time to abandon the “tendinitis” myth" it says

"Animal studies show that within two to three weeks of tendon insult tendinosis is present and inflammatory cells are absent.7" I interpret this to mean tendinitis with inflammatory cells starts at "insult" or injury and tendinosis is present in 2 or 3 weeks. Read the publication. This means don't stress healing tendon injuries right after you are injured for best healing. The word 'tendinosis' can describe defectively healed tendons that vary greatly in tissue quality.

See also the post above that describes tendinosis, #15. I don't recall publications on cured tendinosis. It's probably scar tissue or more weakened tissue as described.
 
The NCBI collection, PMC, are free online publications.

If I search in the box next to the PMC tendinosis I get 5,700 finds

These are selected quality publications. They don't all agree.
 

ByeByePoly

G.O.A.T.
Your quote is from Reference 3, a 2000 publication by Kahn et al.

The first post of this thread is based on a well know publication also by Kahn et al in 2002. I had seen that publication referenced and discussed and that is why I found it.

My interpretation of the later Kahn publication was that Tendinitis preceded Tendinosis. The title was "Time to abandon the “tendinitis” myth". Based on the title maybe the views by Kahn et al were changing at that time? I am skeptical of several of the comments that use Kahn's earlier publications before 2002, but may eventually learn more. Some of the other posts in this thread above also disagree with post #1.

In "Time to abandon the “tendinitis” myth" it says

"Animal studies show that within two to three weeks of tendon insult tendinosis is present and inflammatory cells are absent.7" I interpret this to mean tendinitis with inflammatory cells starts at "insult" or injury and tendinosis is present in 2 or 3 weeks. Read the publication. This means don't stress healing tendon injuries right after you are injured for best healing. The word 'tendinosis' can describe defectively healed tendons that vary greatly in tissue quality.

See also the post above that describes tendinosis, #15. I don't recall publications on cured tendinosis. It's probably scar tissue or more weakened tissue as described.
fyi ... my comments above based on your link in post #28 was from the following ... page 5 and 6. I did not follow the references ...assumed the post #28 article was most current.

"The suggestion that tendinitis precedes tendinosis is at odds with the fact that a healthy tendon is up to twice as strong as the muscle, making the body of the tendon unlikely to tear before the muscle unless the tendon has already been weakened by degenerative changes(6).

The idea that tendinitis is the first stage of tendinosis seems to presume that micro-tears and inflammation are a precursor to collagen degeneration. Histopathologic analyses show that torn fibers, scar tissue, and calcification are only found in conjunction with tendinosis some of the time, and inflammatory cells are rarely found in conjunction with tendinosis, supporting the hypothesis that tendinitis occurs secondarily to tendinosis(1,2,3,5,7). Excessive and/or repetitive tensile forces on the tendon are likely what instigate the chemistry of degenerative changes associated with tendinosis(8). Arnoczky et al. have

reportedly shown that tensile forces placed on the tendon are directly related to persistent activation of a stress activated protein kinase (c-Jun N-terminal kinase (JNK)); the persistent activation of JNK has been related to the initiation of programmed cell death(8). "
 
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