Introduction
Background
Tendonitis is an inflammatory condition characterized by pain at tendinous insertions into bone. The term tendinosis refers to the histopathologic finding of tendon degeneration. The term tendinopathy is a generic term used to describe a common clinical condition affecting the tendons, which causes pain, swelling, or impaired performance. Because of the fact that most pain from tendon conditions is not actually inflammatory in nature, tendinopathy may be a better term than tendonitis.
Common sites of tendinopathy include the following:
- Rotator cuff of the shoulder (ie, supraspinatus) and bicipital tendons
- Insertion of the wrist extensors (ie, lateral epicondylitis, tennis elbow) and flexors (ie, medial epicondylitis) at the elbow
- Patellar and popliteal tendons and iliotibial band at the knee
- Insertion of the posterior tibial tendon in the leg (ie, shin splints)
- Achilles tendon at the heel
Pathophysiology
Tendons transmit the forces of muscle to the skeleton. As such, they are subjected to repeated mechanical loads, which are felt to be a major causative factor in the development of tendinopathy. Pathologic findings include tendon inflammation, mucoid degeneration, and fibrinoid necrosis in tendons. Microtearing and proliferation of fibroblasts have also been reported. However, the exact pathogenesis of tendinopathy is unclear.
Mortality/Morbidity
Chronic tendinopathy can lead to weakening of the tendon and subsequent rupture.
Age
Middle-aged adults are most susceptible to the development of tendinopathy.
Clinical
History
- Lateral epicondylitis
- Pain at the lateral aspect of elbow is present and becomes worse with grasping and twisting.
- A history of playing racquet sports or manual labor is common.
- Medial epicondylitis
- Medial epicondylitis is common in Little League pitchers, golfers, bowlers, and carpenters.
- Pain is located at the medial aspect of the elbow.
- Rotator cuff tendinopathy
- This is associated with a history of participating in overhead activities such as painting, swimming, and throwing sports.
- Deep ache in shoulder and painful range of motion are typical symptoms.
- Bicipital tendinopathy
- Pain is in the anterior shoulder in the bicipital grove.
- Pain worsens when flexing the shoulder or supinating the forearm.
- Patellar tendinopathy
- Patellar tendinopathy, also referred to as jumper's knee, is associated with insidious onset of well-localized anterior knee pain. Patellar tendinopathy is common in those who participate in jumping sports (eg, basketball, volleyball, high jumping) and running. Anatomy of the patellar tendon is shown in the illustration below.
The proximal patellar tendon is most commonly affected in jumper's knee.
- Pain worsens when changing position from sitting to standing or when walking or running uphill.
- Popliteus tendinopathy
- This type of tendinopathy is associated with lateral knee pain.
- Running downhill is a risk factor.
- Iliotibial band syndrome
- Iliotibial band syndrome is the most common overuse syndrome of the knee and results in lateral knee pain.1 The iliotibial band is depicted in the illustration below.
Iliotibial band at the lateral femoral condyle, with the posterior fibers denoted.
- This syndrome may be observed in cyclists, dancers, long-distance runners, football players, and military recruits.
- Typically pain begins after completion of a run or several minutes into a run. Pain is aggravated by running down hills, lengthening stride, or sitting for long periods of time with the knee flexed.
- Shin splints
- Pain is located at the anteromedial aspect of the lower leg. Shin splints have been associated with overpronation.
- Runners running on hard surfaces without proper footwear are predisposed to this condition.
- Achilles tendinopathy
- Heel pain is evidence of Achilles tendinopathy.
- Runners and other athletes have an increased incidence of Achilles tendinopathy. Increased mileage, change in running surface, and poor footwear are associated factors.
Physical
- Lateral epicondylitis
- Pain on palpation over the lateral epicondyle of the elbow
- Pain at the elbow with resisted dorsiflexion of the wrist
- Medial epicondylitis
- Pain on palpation of the medial epicondyle of the elbow
- Pain at the elbow with resisted flexion of the wrist
- Supraspinatus tendinopathy (rotator cuff tendinopathy)
- Pain on palpation over the greater tuberosity where the supraspinatus tendon inserts
- Jobe test for supraspinatus function: With both arms abducted to 90°, held slightly in front of the body, and arms fully pronated comparative resistance is placed on both arms to compare strength and presence of pain. Inability to hold the arm up or presence of pain is suggestive of rotator cuff disease.
- Hawkins test: Supraspinatus tendon impingement is suggested if pain occurs with forcible internal rotation with the patient's arm passively flexed and forward at 90°. The Hawkins test is shown in the image below.
Hawkins test. The examiner forward flexes the arms to 90° and then forcibly internally rotates the shoulder. This movement pushes the supraspinatus tendon against the anterior surface of the coracoacromial ligament and coracoid process. Pain indicates a positive test result for supraspinatus tendonitis.
- Bicipital tendinopathy
- Pain to palpation over the anterior shoulder
- Focal tenderness over groove on humerus between the greater and lesser tuberosities
- Pain with biceps resistance test (ie, shoulder flexion against resistance with elbow extended and forearm supinated)
- Positive Yergason or Speed test (ie, pain with resisted supination of the wrist or with the elbow flexed at 90° and the arm adducted against the body); these tests are shown in the images below.
Yergason test.
Speed test.
- Patellar tendinopathy - Tenderness at patellar tendon insertion into lower pole of the patella
- Popliteus tendinopathy
- Tenderness at the posterior-lateral joint line
- Tendon palpated most easily when lateral ankle of the affected leg rests on the opposite knee
- Lateral collateral ligament most prominent in this position; the popliteus is palpated just anterior to it and above the joint line
- With patient supine, the knee flexed to 90°, and the leg rotated internally, resisted external rotation elicits pain (diagnostic maneuver described by Webb)
- Iliotibial band syndrome
- Pain localized to lateral femoral condyle
- With patient supine and knee flexed to 90°, have patient extend knee while exerting pressure over the lateral femoral condyle
- Pain at 30° of knee flexion with compression of the iliotibial band
- Positive Renne test finding (ie, flexing knee while standing with weight on affected knee resulting in pain at approximately 30° of flexion)
- Positive Ober test result: The patient lies down with the unaffected side down and unaffected hip and knee at a 90° angle. If iliotibial band is tight, the patient will have difficulty adducting the leg beyond midline and may experience pain at the lateral aspect of the knee. The Ober test is shown below.
The Ober test.
- Pain localized to lateral femoral condyle
- Shin splints - Pain referred to anteromedial aspect of lower leg
- Achilles tendinopathy
- Localized tenderness approximately 6 cm proximal to the Achilles insertion on the heel
- Pain with resisted plantar flexion of the ankle and passive dorsiflexion of the ankle
- Crepitus may be palpable with severe cases
Causes
Overuse is the most common etiology.
- Physical work-related factors
- Intense, repeated, and sustained exertion
- Awkward, sustained, or extreme postures
- Insufficient recovery time between activities
- Vibration
- Cold temperatures
- Psychosocial work-related factors
- Monotonous work
- Time pressure
- High work load
- Lack of peer support
- Poor supervisor-employee relationship
- Oral and parenteral fluoroquinolone treatment
- Multiple case reports of tendinopathy (particularly Achilles tendinopathy) and some reports of tendon rupture in patients receiving oral and parenteral fluoroquinolone treatment have suggested a relationship between these agents and the development of tendinopathy.2
- The Food and Drug Administration has added a warning about the risk of tendinopathy and tendon rupture on the label of fluoroquinolones marketed in the United States.
- Risk factors include concomitant steroid therapy and renal insufficiency.3
- Tendinopathy can occur within a few days or up to 6 months following the completion of a course of quinolones.2 A direct relationship exists between length of treatment and severity of symptoms.
- Tendon rupture can occur without a history of specific trauma.
- The pathologic mechanisms responsible for tendinopathy from fluoroquinolone use are multifactorial. Studies have implicated ischemic, toxic, and matrix-degrading processes.
- The Achilles tendon is commonly involved, but shoulder and hand involvement has been reported. Unlike with other etiologies, bilateral tendinitis is common.
- Multiple case reports of tendinopathy (particularly Achilles tendinopathy) and some reports of tendon rupture in patients receiving oral and parenteral fluoroquinolone treatment have suggested a relationship between these agents and the development of tendinopathy.2
More on Tendonitis |
 Overview: Tendonitis |
| Differential Diagnoses & Workup: Tendonitis |
| Treatment & Medication: Tendonitis |
| Follow-up: Tendonitis |
| Multimedia: Tendonitis |
| References |
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References
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Further Reading
Keywords
tendonitis, pain at tendinous insertions, lateral epicondylitis, tennis elbow, medial epicondylitis, calcific tendinitis, rotator cuff tendonitis, patellar tendonitis, popliteus tendonitis, iliotibial band syndrome, shinsplints, Achilles tendonitis, supraspinatus tendonitis, bicipital tendonitis, Yergason test, Speed test, Renne test, tendonopathy, tendinopathy, tendinitis
