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New Treatments for Tendinosis

What is tendinosis?

Tendinosis or tendinopathy is a degenerative condition of the tendon caused by repetitive microtrauma and a failed healing response.  The tendon is the strong tissue that connects muscle to the bone.  It is made of bundles of collagen fibrils.  When a tendon is repetitively subjected to loads exceeding its capacity, some of the fibers begin to fail making the whole tendon weaker.  The body tries to begin a healing response, but sometimes, because of continued stress, the age of a tendon, or other factors the tendon does not heal. 

Tendinosis vs. tendonitis

Tendinosis, sometimes called tendinopathy, is different than “tendonitis.”  Tendonitis is an acute inflammation of the tendon and occurs in response to a new activity or stress.  Tendinitis will typically resolve with rest, ice, and anti-inflammatory medication.  Tendinosis, on the other hand, is a long-standing degenerative process, and when tendinopathic tendons are biopsied there are no inflammatory cells present.   Instead, the tendon is degenerative and the healing response has failed.  Sometimes scar tissue or calcium deposits in the tendon are the result of the failed healing response. 

What about anti-inflammatory medication?

Treatments targeting inflammation have limited effectiveness in the treatment of tendinosis since there is no inflammation present.  Anti-inflammatory medications such as ibuprofen, naproxen, and similar prescription medications are good pain relievers which is why people with tendinosis may experience temporary relief when taking them.  They will not, however, cure the problem of tendinosis.  In fact, anti-inflammatory medication may actually impair tendon recovery as inflammation is the first stage of the healing process.  

Newer treatments for tendinosis are all designed to stimulate healing.  This can be done in a variety of ways. 

Needling of the tendon or tenotomy

Some studies have shown that repetitively poking or needling the tendon and causing it to bleed may induce healing.  Blood is made up of several elements.  An important element for the healing of tendons are the platelets.  Platelets are packed with growth factors that can jump start the stalled healing process in tendinosis.  In a tenotomy procedure, the area is numbed with local anesthetic and then the tendon is needled or repeatedly poked to create small fenestrations and cause the tendon to bleed.  Tendons are relatively avascular and do not have a lot of blood vessels in them. Sometimes the needling procedure alone is enough to stimulate healing.  Sometimes the needling or tenotomy is combined with other procedures. 

Autologous Blood Injections

In autologous blood injections, a small amount of blood (2-3 cc) is taken from the patients arm and injected back into the degenerative portion of the tendon using ultrasound guidance after the tenotomy.  In studies that have looked at autologous blood injections there is a reported 80% - 95% satisfaction rate, and about a 5% - 15% failure rate.  Studies report one to three injections with most patients receiving two injections.  This treatment aims to stimulate the bodies own healing process to essentially grow new tendon.  From the recruitment of the first new tenocyte (tendon cell) it takes 12 weeks to grow a new tendon fiber.   If a patient has not experienced significant improvement in their symptoms at 6 – 12 weeks a second injection is typically recommended. 

Platelet Rich Plasma

Platelet rich plasma is taking autologous blood injections one step further.  Approximately 30cc of blood are drawn from the patient and then just the platelets are removed from the blood using a special technique.  This platelet rich plasma, or PRP is then injected back into the degenerative area of the tendon under ultrasound guidance.  PRP has 5 – 9 times the growth factors that autologous blood does. 

Is there a role for cortisone injections?

Cortisone is a potent anti-inflammatory so for acute tendinitis it can be useful.  It is also catabolic, meaning it dissolves scar tissue.  In tendons where there is a lot of scar tissue, even if there is not inflammation, there may be a role.  Your doctor can discuss which options are best for your situation. 

What conditions can be treated?

• Patellar tendinosis (jumper’s knee)
• Achilles tendinosis
• Lateral or medial epicondylsis (tennis or golfer’s elbow)
• Hamstring tendinosis
• Adductor tendinosis
• Plantar fasciosis
• Rotator cuff tendinosis

Risks of tenotomy, autologous blood or PRP injection:

• Bleeding
• Infection
• Pain from the procedure
• Tendon rupture
• Lack of improvement

What to expect with tenotomy, autologous blood or PRP injection

• Mild increased pain or discomfort for a few days to a week after the injection which is usually relieved by ice or acetaminophen (Tylenol).  Applying an ice pack or cold compress periodically for 15-20 minutes to the injected area is recommended for the first 24 hours after the procedure.
• You should avoid non-steroidal anti-inflammatory medications for the next 3 months.  These include ibuprofen (Advil/Motrin), naproxen (Aleve), aspirin (unless recommended by a physician for other health problems), and prescription anti-inflammatory medications.   
• You should plan to rest from all exercise for 1 week after the injection.
• In the second week, you may engage in light cross-training activities (such as riding a bike, swimming, and elliptical) if tolerated.  Activities should be pain free or only mildly uncomfortable. 
• In the third week, you can gradually increase your activity level, duration, and intensity as tolerated assuming minimal or no discomfort. 
• You should schedule a follow-up appointment at 4 weeks.
• Return to sports that involve running or jumping will depend on your clinical improvement, the type of problem you had, the procedure you got and whether or not you get a second injection but is usually around 12 weeks.    

To schedule an appointment

Call Hall Health Sports Medicine Clinic at 685-1044 and speak to the sports medicine patient service representative.  They will schedule you for the appropriate time slot.  Typically the first appointment will be a consultation with a physician to confirm or make a diagnosis and discuss if you are a good candidate for this type of procedure.  An ultrasound may be performed to assess the tendon.  If there is no answer at the clinic, please leave a message and someone will call you back within 24 hours. Directions to the clinic can be found here.

Authored by: Kim Harmon, M.D.
Last updated: 4/8/09