Innovative Treatments for Tendonopathy

Posted By SHL Librarian

Presented by: Eugene Roh, MD
Clinical Assistant Professor, Orthopedic Surgery
May 28, 2015

Tendons are bands of thick connective tissue that attach muscle to bone that can expand and push into the nerve when they become overused. The tendons act as a sort of spring, storing energy for movement. Tendonopathy is an umbrella term for the inflammation or irritation of a tendon, which causes pain and tenderness just outside a joint. When the condition is acute and short-term, it is referred to as tendinitis; when the pain continues for more than three months, it is considered chronic and is known as tendinosis.

Tendonitis is extremely common—as many as 10 million Americans have the condition, said Eugene Roh, MD, a clinical assistant professor of orthopedic surgery, who spoke at a presentation sponsored by the Stanford Health Library. The condition usually arises from repetition of a particular movement over time.

Most people develop tendinitis because their jobs or hobbies involve repetitive motions, which put stress on the tendons needed to perform the tasks. It can arise in any of the body’s tendons, but it’s most common around the shoulders, elbows, wrists, knees, and heels. It is referred to as tennis elbow, swimmer’s shoulder, jumper’s knee, even New Mom Syndrome (De Quervain’s tenosynovitis), which is caused by an inflammation of the tendons in the forearms from lifting a newborn baby.

Cellular Damage
Tendons are made up of collagen, a protein that forms connective tissue throughout the body. They create long parallel fibers that grow into the bone, creating an extremely strong connection. The collagen forms using a nearby blood supply; once the tendon is fully developed, it has no immediate blood supply so it does not repair easily once it it injured. Tendons usually fail by tearing away from the bone (such as rotator cuff injuries) or rupture within the tendon itself (Achilles tendon injury). The damage causes cellular changes in the collagen: As the body tries to compensate for these cellular changes it introduces a different type of collagen that is less strong and stable.

Diagnosis can be determined by a simple stretch or provocative test, which flexes the joint to test for pain. If needed, an ultrasound or magnetic resonance imaging (MRI) can show if there are small tears in the tendon tissue.

“We are using noninvasive and minimally invasive procedures,” Dr. Roh said. “The main idea is to induce blood supply and increase blood flow to the tendon to help the body repair itself.”

Treatment Options
Most cases of tendinitis can be successfully treated with rest, physical therapy, and over-the-counter medications to reduce pain, such as aspirin or ibuprofen, and Dr. Roh said that most acute tendinitis can be resolved in about a week. Some joints can be protected by limiting movement with a splint or brace. Sometimes a corticosteroid injection around a tendon is used to reduce inflammation and ease pain. Physical therapy should stretches and eccentric movements, which elongates the muscle with slow weight-resistance training.

Additional treatment options include nitroglycerine, which dilates the vessels to increase the blood supply to the damaged area and promote healing. This therapy works for shoulder and Achilles injury, though not for the patella (knee), and patients should be careful not to mix nitroglycerine with other types of blood vessel dilators like Viagra.

Dr. Roh is involved in refining a treatment that uses platelet-rich plasma (PRP) to treat chronic tendinosis. PRP involves taking a sample of blood and spinning it in a centrifuge to separate the white blood cells and platelets, red blood cells, and plasma. The solution is then re-injected into the area of chronic tendon irritation. The treatment appears to encourage a repair phase in the collagen, although the remodeling of fibers may take months to a year. PRP works best for tendinosis in the elbow, knee, and Achilles tendons, Dr. Roh said.

“We need to wait about two to three months to see if the injection is working,” he said. “You have to be patient because it takes time to rebuild the tissue.”

Another innovative option is percutaneous tenotomy using ultrasound. Like cataract surgery or dental cleaning, the FAST approach (Focused Aspiration of Scar Tissue) uses a pulsing needle that breaks down and removes tissue. It’s a quick procedure that with fast recovery time, and may eliminate the need for surgery for some patients.

About the Speaker
Eugene Roh, MD, is a clinical assistant professor of orthopedic surgery, who specializes in sports medicine and treating sports-related injuries with innovative non-surgical procedures. He is the team physician for the Stanford Athletic Department and director of the Physical Medicine and Rehabilitation Musculoskeletal Ultrasound Service. Dr. Roh received his MD from Yonsei University College of Medicine in South Korea. He did his fellowship at Harvard Medical School- Spaulding Rehabilitation Hospital and his residency at Stanford. He is board certified in sports medicine by the American Board of Physical Medicine and Rehabilitation.

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