Tendinopathy, Tendonitis, What's The Deal?

This article was written by Dr. Kevin Sprouse. Dr. Sprouse is a team physician for the Cannondale Drapac Pro Cycling Team.  He has a degree in exercise science and has board certifications in both Sports Medicine and Emergency Medicine.  He practices at Podium Sports Medicine in Knoxville, TN.

 

If you’ve been an athlete for any period of time, chances are good that you’ve had to deal with tendinopathy at one point or another.  In fact, even non-athletes are often plagued by this condition.  What is “tendinopathy”?  You may know it by its former name, “tendonitis”…but we don’t call it that anymore.  Regardless of what you call it though, it has sidelined many an athlete.  We’re going to briefly discuss what it is, how to avoid it, and how to treat it if you do happen to be affected.

 

Muscles are attached to bones by tendons, which are very strong, rope-like bands of inelastic tissue.  When a muscle contracts, it moves a bone by transmitting force through the tendon.  These tendons can handle large loads and are amazing structures, but we have come up with all sorts of ways to treat them poorly and make them angry.  They are live structures, made of collagen fibers, and are responsive to the loads placed on them.  If we don’t use them properly, they can become dysfunctional and painful.  This dysfunction and pain create a condition known as tendinopathy.

 

We used to refer to this as “tendonitis”, but as I mentioned, this has gone the way of medical antiquity.  (If your doctor still calls it “tendonitis”, you might want to look for a new doc.)  In medicine, the suffix “-itis” refers to an inflammatory condition.  However, in “tendonitis” there is no inflammation.  If you look at this tissue under a microscope, you’ll find none of the hallmark inflammatory cells.  So treating it like an inflammatory condition is unlikely to provide much relief or improve your overall picture.  Anti-inflammatory medications don’t work, and ice has largely fallen out of favor.  Cortisone injections serve only to mask the pain for a brief time.

 

So if tendinopathy is not inflammation, what is going on with the tendon?  Despite being a common and age-old medical problem, research into tendinopathy is just now in it’s heyday.  Only now are we starting to learn the causes and treatments for this prevalent condition.

 

In most cases, tendinopathy is caused by inappropriate loading of the muscle and tendon.  This can result from overuse, such as an increase in a runner’s mileage that is far too extreme.  It can also occur as a result of misuse, such as poor gait patterns in a runner, a bad bike fit, or performing deadlifts with poor mechanics.  As I mentioned earlier, tendons are living structures.  If they are used in a manner which causes undue stress, they will respond in a dysfunctional manner.  That may mean that they tear, or it could be that they start to produce more collagen in a hurried, disorganized fashion to adapt to the load.  This extra collagen may prevent the load from tearing the tendon, but if it is not laid down in an organized manner, it will not function properly.  It is thought that this improper function leads to the stimulation of pain receptors.

 

The best prevention for tendinopathy is the application of appropriate loading.  This occurs with a progression that is sensible and form that is meticulous.  Interestingly, it seems that the same advice can serve as the best prescription for treatment.  There are very few tissues in the body that flourish with complete rest.  Movement and load create stimuli that trigger adaptation.  The key to healthy tissue is to move well and load appropriately.  Of course, there are complexities beyond this.  There are stages of tendinopathy, and treatment should vary based on those.  But these specifics are where you should seek individualized care from a sports physician and/or physical therapist.  If you don’t fix your movement patterns, you will not conquer your tendinopathy.

 

Interestingly too, it appears that there may be a role for nutrition in the healing of tendons.  I’m the first to admit that the evidence is not yet robust, but there are a few foods or supplements that may be helpful.

 

 

• Hydration - it’s simple, but often overlooked. Stay hydrated to encourage optimal function and healing.
• Vitamin C - there are numerous studies demonstrating the effectiveness of Vitamin C in healing soft tissue injuries. It doesn’t take a huge dose to see the benefits though.  I’ll generally recommend 1g of Vitamin C per day while recovering from such an injury.
• There is some evidence that manganese, zinc, Vitamin B6, and Vitamin E are important for tendon health. Even more important than these specific substances though, is the concept that diet is crucial to soft tissue health and healing.  A complete and balanced diet is a requirement, and there is likely a role for a high-quality multivitamin in such cases.
• Collagen protein or bone broth: These have become quite trendy in some fitness circles, but the evidence for their effectiveness is not really there. The idea is that your body needs collagen to repair tendons, and if you consume more collagen you may heal faster.  There are some small animal studies that suggest this may be true, but the jury is still out.  That said, there does not appear to be a downside.  I’ll often recommend a high-quality collagen protein to athletes recovering from tendon injury, with the caveat that it is not truly “evidence-based”.
• Bromelain - Bromelain is a term used for a collection of protease enzymes found in pineapples. It has been studied since the 1960s with multiple experiments demonstrating a benefit to soft tissue healing.  While it is no “silver bullet”, it is likely of some benefit in speeding the process of recovering from tendinopathy.

 

 

Ultimately, tendon health is much like your general, overall health.  Activity is good, but it needs to occur with a reasonable frequency and a measured load.  And nutrition is crucial.  You must move well and provide your body with what it needs to adapt.  Fortunately, we are making big gains in our understanding of the specifics.  We now have a much better understanding of proper movement patterns and healthy diet.  We now have the tools to better prevent and treat tendinopathy, and we even have a better name for it.