Tendinitis

Question 1

Inflammation of a tendon

Answer 1

● Tendons are made of regularly arranged, dense collagen fibrils

● They attach muscle to bone and are part of the musculotendinous unit

● Tendons appear in two shapes: cord-like structures and broad, sheet-like called aponeuroses

● A tendon that moves in a straight line is surrounded by a paratendon-blood vessels are coiled in the loose alveolar tissue which stretches along with the tendon

● A tendon that runs across a bony prominence is surrounded by a tendon sheath-this double-layered tubular structure is filled with synovial fluid

Question 2

Tendons

Answer 2

● The dense CT of tendons has a limited blood supply originating from muscles and bones

● Tendons are subject to great tensile stress

● When a load is placed on a tendon, the
waves of its collagen fibres straighten out

● The collagen fibres then temporarily deform

● Over time, a tendon can experience micro tearing, partial tearing or complete rupture, usually at the point of most reduced blood supply

Question 3

Causes of Tendinitis

Answer 3

● Chronic overload of the tendon, leading to microtearing and an inflammatory response in the tendon

Contributing Factors

● Muscle imbalances, lack of flexibility, improper equipment and training
errors

Question 4

Types of Tendon Overuse Injuries

Answer 4

Tendon overuse injuries have all been termed “tendinitis”
● Tendinitis
● Paratendinitis
● tendinosis

Question 5

Paratendinitis

Answer 5

● Inflammation of the paratendon or the tendon sheath where these structures are associated with a tendon, either of which may be irritated by the tendon as it rubs over a bony prominence

● Associated with tendon injuries

● Also called tenosynovitis or tenovaginitis

● Tenosynovitis is irritation of the inner surface of the tendon sheath by the roughened surface of the tendon

● Tendovaginitis is irritation and thickening of the sheath itself

Question 6

Tendinosis

Answer 6

● Degenerative changes occurring with chronic overuse tendon injuries, such
as “tennis elbow”

● Aging and avascularity may be contributing factors to tissue degeneration

● There are no signs of inflammation in the tendon itself, but biopsies have shown angiofibroblastic degenerative changes occurring (invasion of organized vascular tissue and a disorganization of collagen tissue in the tendon)

Question 7

Grades of Tendinitis

Answer 7

● Grade 1-pain after activity only

● Grade 2-pain at the beginning of activity
which disappears during activity then returns after activity

● Grade 3-pain at the beginning of activity,
during activity and after activity. Pain
may restrict activity

● Grade 4-pain with ADL’s and pain
continues to get worse

Question 8

Common Tendinitis Locations and Causes

Answer 8

● Supraspinatus tendon

● Infraspinatus tendon

● Subscapularis tendon

● Biceps long head tendon

● Common extensor tendon

● Common flexor tendon

● Abductor pollicis longus and Extensor pollicis brevis tendons

● Patellar tendon

● Popliteus tendon

● Tibialis posterior tendon

● Achilles tendon

Question 9

Supraspinatus Tendon

Answer 9

To palpate:

● The client is seated with their arm held
behind the back and the elbow in
flexion

● The humerus is maximally internally
rotated and maximally extended,
bringing the humeral attachment of
supraspinatus out from under the
acromion

● The tendon is palpated immediately
inferior to the AC joint

● The therapist palpates through deltoid
in the indentation between the
anterior and middle fibres

Question 10

Infraspinatus Tendon

Answer 10

To palpate: (infraspinatus and teres minor)

● The client is seated or prone with the
humerus flexed to 90 degrees,
adducted 10 degrees and externally
rotated 20 degrees

● This position brings the tendon out
from under the acromion

● The tendon is palpated immediately
inferior to the AC joint and the lateral
portion of the spine of the scapula

● The therapist palpates the tendon
through the posterior fibres of the
deltoid muscle

Question 11

Subscapularis Tendon

Answer 11

To palpate:

● The client is seated with the humerus at
their side and the elbow flexed to 90
degrees

● The tendon is palpated inferior to the
clavicle, lateral to the coracoid process
(medial to anterior deltoid)

● The tendon is palpated deep in the
deltopectoral triangle, between the
tendons of the long and short heads of
biceps

Question 12

Rotator Cuff Tendons

Answer 12

● Supraspinatus, infraspinatus, teres minor
and subscapularis are prone to tendonitis
with sports such as swimming, tennis, golf
or any throwing sport

● Occupations or activities that stress the
shoulder muscles with the arms in an
overhead position, such as drywall
installation or assembly line work

● Pain is usually experienced when the arm
is in more than 90 degrees of abduction

Question 13

Biceps Long Head Tendon

Answer 13

To palpate:

● The client is seated with the humerus
internally rotated 20 degrees or to a
“hands on lap” position

● The tendon is palpated inferior to the
clavicle, lateral to the coracoid process in
the same areas as the subscapularis
tendon

● Swimming and throwing sports where the
arm is adducted, compressing the tendon
can cause bicep tendinitis

Question 14

Common Extensor Tendon

Answer 14

To palpate:

● The client is seated with the elbow in
slight flexion

● The tendon is located distal to the lateral
epicondyle

● It may extend over top of the radial head
which can be located by the client
pronating and supinating the hand while
the therapist palpates for the moving
head

● Repetitive forceful extension, supination
and radial deviation are the movements
lost likely to provoke extensor tendinosis

● Wheelchair athletes and meat cutters are
also susceptible

Question 15

Common Flexor Tendon

Answer 15

To palpate:

● The client is seated with the elbow in
flexion and the wrist supinated

● The tendon is located distal to the medial
epicondyle

● Repetitive activity such as hammering or
using a screwdriver may cause injury to
the CFT

● Sports involving wrist flexion and
pronation such as golfing and overhead
serving in tennis are other causes

Question 16

Abductor Pollicis Longus & Extensor
Pollicis Brevis Tendons

Answer 16

To palpate:

● The sheaths of these two muscles is
palpated at the radial side of the wrist

● Activities requiring repetitive thumb use,
repetitive radial and ulnar deviation and
forceful gripping cause De Quervain’s
tenosynovitis

Question 17

Patellar Tendon

Answer 17

To palpate:

● Palpated immediately inferior to the
patella

● Pain is localized to the tendon

● Activities include running or jumping such
as track and field are causes

Question 18

Popliteus Tendon

Answer 18

To palpate:

● Palpated just inferior to the lateral
femoral condyle, directly posterior to the
lateral collateral ligament and biceps
femoris tendon

● It is palpated through the lateral
gastrocnemius muscle

● Activities such as downhill running or
downhill walking combined with foot
pronation cause this tendinitis

● Can be confused with ITB friction
syndrome

Question 19

Tibialis Posterior Tendon

Answer 19

To palpate:

● The foot is placed in plantarflexion

● The tendon in its sheath is palpated just
posterior and inferior to the medial
malleolus

● Pain runs along the medial border of the
tibia and along the course of the tendon

● Activities such as running, using step
machines or doing step aerobics
combined with excessive pronation can
cause this tendinitis

Question 20

Achilles Tendon

Answer 20

To palpate:

● The tendon lies between the
gastrocnemius-soleus complex and the
calcaneus

● Pain is felt along the tendon

● Activities such as running combined with
pronation, poor footwear or tight
gastrocnemius-soleus muscles cause this
condition

Question 21

Medical Treatment of Tendinitis & Tendon Tears

Answer 21

● For acute tendinitis, inflammation is controlled through rest, ice and NSAIDs

● Stretching, strengthening and a gradual return to activity are recommended

● Surgical repair is necessary with a total tendon rupture

Question 22

Other Tendon Pathologies

Answer 22

● Rotator cuff tendons may suffer:

○ Impingement syndrome
○ Partial or complete tears
○ Calcific tendinitis

● Trigger Finger

Question 23

Impingement Syndrome

Answer 23

● Inflammation, pain and edema in the tissues within the coracoacromial arch and
between the acromioclavicular and glenohumeral joints

● Painful compression of the tendons, especially supraspinatus, may occur when the humerus is abducted against the acromion

● The biceps tendon and the subacromial bursa may be affected as well

○ Stage 1-edema and hemorrhage of the subacromial bursa

○ Stage 2-tendinitis and fibrosis are present. Both stages are reversible with conservative
care such as rest, stretching and progressive strengthening

○ Stage 3-incomplete tears or complete tendinous rupture occurs. There may be
associated bony changes in the acromion and the AC joint. Surgery is usually indicated

Question 24

Rotator Cuff Tears

Answer 24

● Overuse, impingement and normal aging can lead to painful tearing of the rotator cuff tendons

● Tears may be partial or full thickness with
supraspinatus the most frequently injured

● Medically, tears are treated by open rotator cuff repair surgery in which the rotator cuff is exposed

Question 25

Calcific Tendinitis

Answer 25

● A late-occurring stage of rotator cuff tendinitis, usually developing in the supraspinatus tendon ● Supraspinatus functions to hold the head of the humerus in place and this constant pressure of the head of the humerus seems to “wring out” the blood supply to the poorly supplied tendon ● The tendon’s fibrocytes change to chondrocytes, collagen disintegrates and calcific deposits accumulate in the cells ● Over time, these deposits are set free into the intercellular spaces ● The deposits can be soft, toothpaste-like material or hard and chalky

Question 26

Trigger Finger

Answer 26

● Through overuse, flexor tendons of any finger may develop a thickened, nodular swelling ● This swelling is unable to move through the tendon sheath and gets caught ● The finger is stuck in flexion until it is passively extended by an external forces ● Rest, NSAIDs and stretching are the usual treatments

Question 27

Symptom Picture By nature, tendinitis is a chronic condition with an initial acute inflammatory stage

Answer 27

Acute: ● Gradual onset with tenderness local to the tendon, one or two days after activity ● Initially, pain diminishes with renewed activity which progresses to pain during activity as the severity increases ● Microtearing occurs with adhesion formation as the tendon attempts to heal ● Repetitive use tears these new adhesions, causing more inflammation and a cycle of reinjury ● Inflammation, heat and swelling develop along the tendon or tendon sheath ● Crepitus may develop with tenosynovitis and paratendinitis ● Decreased ROM of the affected muscle

Question 28

Symptom Picture By nature, tendinitis is a chronic condition with an initial acute inflammatory stage

Answer 28

Chronic: ● Pain occurs during and after activity ● Chronic inflammation, fibrosis and adhesions are present ● Chronic swelling or thickening may be observed if the tendon is superficial enough, as with the Achilles tendon ● Crepitus may be present ● Decreased ROM and decreased strength ● Flare-ups to the acute stage may occur with repeated overuse ● Tendon may degenerate to such a degree that tendon rupture occurs

Question 29

Health History Questions

Answer 29

● What activities or movements cause pain? ● Where is the pain located? ● What are your current symptoms? How long have these symptoms been present? ● What is the client’s recreational or occupational posture? ● Have you begun a new activity or increased duration or speed of a previous activity? ● Was there a previous injury to the affected limb? ● Has the condition been diagnosed by a physician? ● What parallel therapies are you taking? ● Are supports or braces being used during activities? ● Are you taking any meds?

Question 30

Observations

Answer 30

- Acute: ● Antalgic posture or antalgic gait may be present ● Swelling and redness may be noticeable if the tendon is superficial - Chronic: ● A postural assessment may be performed to determine sources of muscle imbalance ● Thickening of the tendon may be observed ● Muscle wasting and disuse atrophy occur with complete tendon tears

Question 31

Palpation

Answer 31

Acute: ● Point tenderness occurs over the tendon ● Heat and swelling may be palpated at the tendon ● HT and TPs are present in the affected muscle and its antagonists - Chronic: ● Pain occurs over or near the tendon ● Swelling adhesions are present. The tendon may feel granular or hard at the adhesion site ● HT and TPs occur as in the acute stage ● Crepitus may be palpated on movement of the tendon in its sheath ● A snapping sensation may be felt due to tight tendons that snap over bony prominences or bursae

Question 32

Testing

Answer 32

- Acute & Chronic: ● AF ROM of the affected limb is usually painless ● PR ROM may reveal pain on actions that fully tretch the affected tendon ● AR isometric testing is painful on contraction of the muscle of the affected tendon, especially if the muscle is contracted in a stretched position. Pain is local to the tendon and increases with the force of the contraction. The therapist may have to move the muscle through its range, testing isometrically in different positions to provoke a positive test. If this fails, the client puts the limb in the position that causes pain and isometric resistance is applied in this position

Question 33

Treatment Acute

Answer 33

● Positioning depends on the location of the tendinitis and the client’s comfort ● Hydrotherapy is cold ● Reduce edema on the affected limb ● Reduce HT and TPs in the proximal and antagonists muscles ● Reduce HT in the affected muscle with GTO on the unaffected tendon ● Distally, muscle squeezing and stroking are used ● Maintain ROM with passive relaxed ROM on the proximal and affected joints ● Mobilize hypomobile joints

Question 34

Treatment Chronic

Answer 34

● Positioning is chosen for comfort and for accessibility of the structures that are treated ● Hydrotherapy proximal to the tendinitis and on the lesion site itself include deep moist heat to soften adhesions and to increase local circulation ● Contrast hydrotherapy is useful to flush out edema ● Reduce fascial restrictions and any chronic edema ● Reduce HT and TPs in the proximal limb and antagonists and the affected muscle is treated working towards the lesion ● Reduce adhesions that may have formed in the tendon and between. Fascial techniques and muscle stripping are used over the lesion site to break down as many adhesions as possible before frictions are used. After frictions are applied, stretch and ice ● Mobilize hypomobile joints in the affected limb ● Restore ROM with PR ROM ● Stretch shortened muscles with passive stretches

Question 35

Self-care: Acute

Answer 35

● Educate the client regarding relative rest with activities that cause the tendinitis ● Hydrotherapy of ice immediately after activity ● Stretch shortened muscles with slow, pain-free stretches ● Strengthen weakened muscles with progressive strengthening that is pain-free, submaximal isometric exercises

Question 36

Self-care: Chronic

Answer 36

● Educate the client regarding relative rest with activities that cause the tendinitis ● Hydrotherapy of contrast bath is used ● Self massage may be used on the antagonists and affected muscles ● Stretch shortened muscles, progressing from isometric to isotonic exercise ● Eccentric exercises can be effective for a strengthening effect on the tendon