Tendinosis vs Tendonitis; does is matter?

This post is still a draft as I need to expand and add additional references.  I wanted to post however because I want others to consider this issue, and my recommendations won’t change much.  Please provide any feedback in support or to the contrary.  I’m just trying to understand and help those in pain…

Concern

  • I have been seeing several patients who seem to be taking longer to recover than expected.  Many times there have been secondary surgeries that have occurred and still members have trouble recovering.
  • In these cases there seems to be a recurrent theme, in the presence of “tendinosis” that has been apparent on their MRI’s.  As I was not totally familiar with this term, I decided to do a literature search to get a better understanding.  I needed to make sure that this was a condition distinct from tendonitis, a term that I am very familiar with.

 Findings

  • First, it has become clear that tendinosis and tendonitis are clinically distinct conditions.  The former being characterized by the lack of healing.  Histologically, the tendon seems devoid of inflammation, and thus healing.
  • This is a clinical condition that does not respond to NSAIDs or steroids (which makes sense as there is no inflammation), and in fact there has been some concern raised that the NSAIDs may contribute to this condition [2,4,9]
  • There seems to be some confusion concerning this amongst some practitioners who seem to use this term interchangeable and should not.  Its important, because practitioners may be using NSAIDs when they should not be.
  • Risk factors for this condition appear to be excess sugar, saturated fat, elevated uric acid, and obesity [1,3,9].
  • Not really an age related phenomena as it has been identified in those that are young. [9]
  • There is some concern that this condition is also due to trauma/and overuse however there is some suggestion that this may not be he case noting the presence of this condition occuring in areas of the tendon with lower tensile strains.[12]   Also overuse tends to respond to rest, where this is not really the case with tendinopathy. [9]

 My Thoughts

  • For the vast majority of people that present with this, I don’t think that it is due to trauma or over-use (unless at the extremes of exposure).  I think these events may allow for the condition to unmask itself, but the event is really not the cause. Note that for most, exercise is thought to build a person up, not break them down (unless they metabolically deficient).
  • This acts more like a nutritional deficiency or toxicity than something due to trauma or over-use.
  • I am not sure which  path is playing a greater role: an act of omission (nutritional deficiency), or an act of commission (toxicity), but these two circumstances may be working together.

 Recommendations

1) Correct Possible Error of Omission (deficiency): 

  • Make sure the injured person is taking a general purpose multivitamin 2-3 times per day.  Not a mega vitamin (something closer to a one a day).  May be better to break this in half and take three times per day with a meal.  Supplements that need to be include are Vit D, Vit C, Zinc, Iodine (if iodized salt has been eliminated from the diet), and Omega 3 Fatty Acids.  Other nutritional considerations include: adequate protien, B Complex, Vitamin A, and Vitamin E.  One of my preferred supplements is Protegra which contains A,C,E, and zinc.

2) Correct Possible Error of Commission (toxicity):

  • Stop use of NSAIDs and change to tylenol for pain relief.  If not able to stop the NSAID, decrease to the lowest dose possible to control symptoms
  • Decrease consumption of sugar generally and fructose specifically.  Note that increasing the amount of fiber consumed will slow the absorption of sugar and minimize the generation of advance glycation end-products (AGEs) [1]  If you want to know about the problems with sugar please watch:  “Sugar: The Bitter Truth”.
  • Decrease the amount of animal protein that is consumed, which may be causing problems in two ways 1) creating an acidic environment with an adverse effect on the body’s pH balance, and 2) increase the amount of saturated fat which one is exposed to which may also be a risk factor for tendinosis [1]

3) Support Efficient Repair

  • Aerobic conditioning (exercise) not directed at the joint or area of concern.  This gives a general signal to the body of the need to repair and also speeds circulation to bring and remove items to the area of concern in a more accelerated manner.  The benefits of this general signal of repair was noted in Achilles’ tendon repair, where surgical repair on one side seemed to help the other side as well [ref].
  • Mild stretching and no strengthening directed at the joint of concern for 30-60 days.  It is important to correct any errors of commission or omission before engaging the tissue that is not healing as to not worsen the problem.

Reflections:

  • As I reflect on this I am noticing how this plan differs from care as usual, and I am reminded of a fire fighter that I consulted with who was complaining of shoulder pain after an injury.  He had been forced to retire 12 months after his injury, as he failed to recover with both physical therapy and surgery.  It was now 18 months post injury and he was requesting another surgery, as he was still in pain.    This plan was supported by both the firefighter and the surgeon.  The firefighter was directed to the movie “Forks Over Knives”, and decided to give a trial of change in both diet and lifestyle.  In 4 weeks he was nearly pain free. Let me state that again, in four weeks with a good diet (decrease sugar and animal protein, added greens like avocado, spinach, kale, and purples like beets and purple cabbage) and exercise (running 3 miles a day) his condition resolved to the point that he felt that he could come back to work.  Had we gone down this road one year earlier…???   Had this always been the road, he may never have hurt himself in the first place…???

Check out this one minute video.  I am not alone in my thinking and observations :)  NSAIDS and Healing.

Here is one more about sugar:  Toxic Sugar

References (more to come)

  1. Michelle Abate et al., Management of limited joint mobility in diabetic patients, Diabetes Metab Syndr Obes. 2013; 6: 197–207.  Published online 2013 May 7. doi:  10.2147/DMSO.S33943
  2. Caring Medical and Rehabilitation, Sports Injuries NSAIDS why we don’t recommend them, Internet 2013 // http://www.caringmedical.com/sports_injury/nsaids.asp
  3. Mechelle Abate et al., Occurence of Tendon Pathologies in Metabolic Disorders, Rheumatology, 2013:52(4):599-608  //http://www.medscape.com/viewarticle/781970
  4. Kai-Ming Chan et al., Anti-Inflammatory managment for tendon injuries – friends or foes, Sports Medicine, Arthroscopy, Rehabilitaiton, Therapy and Technology, 2009, 1:23 // http://smarttjournal.com/content/1/1/23
  5.  Elzi Volk, Connective Tissue Part 1 – Tissue in Action, ThinkSteroids.com, Feb 1999 // http://thinksteroids.com/articles/connective-tissue-01/
  6. Elzi Volk, Connective Tissue Part 2 – Pathphysiology of Connective Tissues, Influence of Nutrition and Pharmaceuticals, Thinksteroids.com, March 1999, // http://thinksteroids.com/articles/connective-tissue-02/articles/connective-tissue-02/
  7. Elzi Volk, Connective Tissue Part 3 – Role of Micronutrients in Connective Tissue Healing, Thinksteroids.com, April 1999, //  http://thinksteroids.com/articles/connective-tissue-03/
  8. Elzi Volk, Connective Tissue Part 4 – Glycosaminoglycans, Thinksteroids.com, May1999, // http://thinksteroids.com/articles/connective-tissue-04/
  9. Sai-Cheun Fu, Deciphering the pathogenesis of tendinopathy: a three-stages process, Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2010, 2:30 // http://www.smarttjournal.com/content/2/1/30
  10. Michelle Abate et al, Review: Pathogenesis of tendinopathies: inflammation or degeneration, Arthritis Research & Therapy, Vol 11 No 3 // http://arthritis-research.com/content/11/3/235
  11. Martti Rechardt et al., Lifestyle and metabolic factors in relation to shoulder pain and rotator cuff tendinitis, BMC Musculoskeletal Disorders 2010, 11;165 // http://wwwbiomedcentral.com/1471-2474/11/165  // it should be noted in this article the use of the term tendonitis.  Authors used a clinical and not a radiological diagnosis, and these cases may well have represented those with tendinosis.
  12. Ho-Joog Jung, Role of biomechanics in the understanding of normal, injured, and healing ligaments, and tendons, Sports Medicine, Arthroscopy, Rehabilitation, Therapy and Technology, May 2009, 1:9 // http://www.smarttjournal.com/content/1/1/9
  13. Stefan Lakemeier et al, Expression of matrix metalloprotienases 1,3, and 9 in degenerated long head biceps tendon in the presence of rotator cuff tears: an immunohistological study, BMC Musculoskeletal Disorders 2010, 11:271 // http://biomedcentral.com/1471-2474/11/271
  14. Steven Fenwich et al., The vasculature and its role int he damaged and healing tendon, Arthritis Research 2002, Vol 4 no 4
  15. James Gaida, Asymptomatic Achilles tendon pathology is associated with a central fat distribution in men and peripheral fat distribution in women; a cross sectional study , BMC Musculoskeletal Disorders, 2010, 11:41 // http://www.biomedcentral.com/1471/-2474/11/41
 
 
 

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