Hey doc, my tendinitis has been going on for months. Why won’t it get better?
If you're tendinitis has been going on for more than 3 weeks, it's probably not tendinitis. Anything lasting longer than 3 weeks is considered chronic. Tendinitis refers to an acute injury leading to inflammation. In the acute phase these injuries respond well to ice, rest, physical therapy and anti-inflammatories. If it last longer than 3 weeks, the term used to describe the pain would be “tendinosis”. Tendinosis refers to a chronic tendon injury with degeneration at the cellular level without the presence of inflammation. In some cases, people experience chronic tendon pain without any causative event and term “tendinopathy” is used to describe this type of pain. In any case if the pain lasts longer than 3 weeks it has become chronic and inflammation is not your problem, thus anti-inflammatories aren't of much use.
The chronic process of tendinosis is frustrating for the patient and oftentimes the practitioner. Most of my patients will have participated in an aggressive physical therapy program with inconsistent results. In chronic cases of tendinosis, the tendon breaks down and cellular debris is deposited within the framework of the tendon. If you can imagine the tendon as a rope and in the process of tendinosis it has become frayed and weakened. Then imagine small stones being deposited within the fibers of the rope leading to abnormal strain when a stretching force is applied to the rope. A similar thing happens in tendinosis when cellular debris is deposited within the tendon. The result is chronic pain with inability to heal as there is no inflammation present.
So wants to be done?
Regenerative medicine such as stem cells, platelet rich plasm (PRP) and prolotherapy are great for these cases. Regenerative medicine works by reminding the tissue that it’s sick which promotes healing. This can be accomplished with stem cells, platelet rich plasma or prolotherapy injections. The intent of these injections is to cause an intentional trauma to the affected area and then allow the body to do its thing. In order to ensure proper placement, this procedure must be done with ultrasound guidance as it is difficult to hit a target if you can't see it. Once the target or pathology is identified a needle can be directed into the affected area and the regenerative solution placed.
In most cases regenerative injections for tendinosis are coupled with aggressive physical therapy techniques such as dry needling, Augmented Soft Tissue Mobilization (ASTYM), myofascial techniques, and strengthening. In some cases, more than 1 set of injections may be needed depending on severity. It took some time to get this way and may require some effort to get it better.
So how do I avoid tendinosis?
There are generally 2 good ways to develop tendinosis. The first of which is chronic overuse or repetitive overuse. This consists of athletes, household athletes, and industrial athletes or anybody else that performs repetitive movements day in and day out. In these cases, the tendon slowly degenerates such that injury is not perceived until it's too late. A good way to avoid this is to cross train or mix up your daily routine such that the same muscle tendon complex does not succumb to overuse.
The second way tendinosis develops is from what I call, random acts of fitness. These are the people that decided to put a new roof on their house but they're not roofers. So, they start swinging a hammer for 3 days straight until they can no longer hold a hammer secondary to elbow pain. They then ice and take a lot of anti-inflammatory medications which reduces the body’s ability to heal but they never really slow down or participate in physical therapy. They may even get a cortisone injection which acts as a Band-Aid and allows them to go out and swing a hammer again without ever actually healing any tissue. At some point in life we all fall into this category. Who doesn’t want to run a marathon at some point in their life with very little training.
In order to prevent random acts of fitness one must be in tune with their body and heed painful cues that may be telling them to stop doing what they're doing and let things heal. Regardless of how the injury happens, a great non-medicinal strategy is that of eccentric exercises. These consist of lengthening a muscle tendon complex over a distance. For instance, instead of performing a concentric exercise such as a biceps curl. An eccentric exercise for the biceps would be starting with a weight in the already curled position and then allowing the weight to extend and lengthen the bicep in a controlled manner.
Stretching is another way to avoid succumbing to a random act of fitness. Stretching is best done when the muscles are warm. This entails a gentle warm up such as jogging or elliptical for 10 minutes prior to stretching. Imaging your muscles as wax. Muscles, just like wax, need to be warm prior to changing their shape. Thus if you warm the muscle up prior to assuming a difficult position, the stretch will be much more effective and possible prevent injury. If you are already injured and would like to get back in2it, let me know and I will let you know your options.