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Emergency and Acute Medicine - Tendonitis
Tendonitis is a term historically used to describe painful tendon conditions, although the more accurate terms today are tendinopathy or tendinosis, reflecting the chronic degenerative rather than purely inflammatory nature of most tendon disorders. These conditions are typically part of an overuse syndrome characterized by chronic pain, tendon thickening, and impaired function. Acute irritation may last from 48 hours to 2 weeks, whereas chronic tendinopathy involves collagen degeneration, fibrosis, and disorganized healing that persists for more than 3 months. The underlying pathology involves repeated microtrauma to the musculotendinous unit, leading to failed repair and proliferation of abnormal tissue.
The primary cause of tendinopathy is mechanical overload or repetitive stress. Intrinsic factors such as poor flexibility, muscle weakness, or imbalance contribute to injury, while extrinsic factors include excessive activity, improper technique, or sudden increases in training intensity. At the cellular level, tendons show collagen disorganization, increased vascularity, and release of inflammatory mediators that contribute to pain and swelling, even in the absence of true inflammation.
Patients typically present with a history of repetitive activity or overuse involving a specific movement. Pain is the hallmark symptom and often follows a characteristic pattern: it improves briefly with initial movement but worsens after continued activity. Classic inflammatory signs such as warmth, redness, and swelling may be present. On examination, there is localized tenderness over the tendon, pain with movement, reduced range of motion, and sometimes instability. Differentiating between tendonitis and tenosynovitis can be difficult clinically, and both are generally grouped under tendinopathies.
Several common clinical syndromes are associated with tendinopathy. In the shoulder, supraspinatus tendinopathy results from impingement between the humerus and acromion, causing pain with overhead movement. Calcific tendonitis, often affecting the rotator cuff, involves calcium deposition within the tendon and may cause acute pain during resorption phases. Bicipital tendinopathy presents with anterior shoulder pain radiating down the arm and is worsened by resisted supination or forward flexion. Lateral epicondylitis, or tennis elbow, causes pain over the lateral elbow exacerbated by gripping or wrist extension, while medial epicondylitis affects the flexor tendons.
In the wrist and hand, De Quervain tenosynovitis involves inflammation of the thumb tendons and produces pain with thumb movement, especially during the Finkelstein test. Trigger finger occurs when thickening of the tendon sheath causes catching or locking of the finger during motion. In the lower limb, Achilles tendinopathy is a common overuse injury, particularly in active individuals, presenting with posterior ankle pain, stiffness, and reduced mobility. Achilles tendon rupture may present with a sudden “popping” sensation and inability to plantarflex, although it is sometimes missed initially.
Diagnosis is primarily clinical, based on history and physical examination. Imaging is used selectively to exclude other conditions. Radiographs may show calcifications or rule out fractures, while ultrasound is useful for detecting tendon thickening and fluid collections. MRI provides detailed assessment of tendon structure and surrounding tissues. Laboratory tests are generally unnecessary unless infection or systemic disease is suspected.
Management focuses on conservative treatment. Initial therapy includes rest, ice, and nonsteroidal anti-inflammatory drugs, along with temporary immobilization if needed. Gradual rehabilitation with range-of-motion and strengthening exercises, particularly eccentric loading exercises, is essential for recovery. Most cases improve over 6 to 12 weeks. Additional treatments may include local injections, splinting, or emerging therapies such as prolotherapy or shock-wave therapy for calcific tendonitis.
Specific conditions may require tailored management. De Quervain tenosynovitis responds well to thumb spica splinting and NSAIDs. Trigger finger may require corticosteroid injection or surgical release if persistent. Achilles tendon injuries require rest, orthotics, and in the case of rupture, immobilization and orthopedic referral.
Most patients can be managed as outpatients, with referral indicated for complete tendon rupture or failure of conservative therapy after several months. Prevention of recurrence is an important aspect of long-term care, including activity modification and correction of biomechanical factors. A key clinical point is that certain medications, particularly fluoroquinolone antibiotics, have been associated with increased risk of tendinopathy and tendon rupture.
Tendonitis is a term historically used to describe painful tendon conditions, although the more accurate terms today are tendinopathy or tendinosis, reflecting the chronic degenerative rather than purely inflammatory nature of most tendon disorders. These conditions are typically part of an overuse syndrome characterized by chronic pain, tendon thickening, and impaired function. Acute irritation may last from 48 hours to 2 weeks, whereas chronic tendinopathy involves collagen degeneration, fibrosis, and disorganized healing that persists for more than 3 months. The underlying pathology involves repeated microtrauma to the musculotendinous unit, leading to failed repair and proliferation of abnormal tissue.
The primary cause of tendinopathy is mechanical overload or repetitive stress. Intrinsic factors such as poor flexibility, muscle weakness, or imbalance contribute to injury, while extrinsic factors include excessive activity, improper technique, or sudden increases in training intensity. At the cellular level, tendons show collagen disorganization, increased vascularity, and release of inflammatory mediators that contribute to pain and swelling, even in the absence of true inflammation.
Patients typically present with a history of repetitive activity or overuse involving a specific movement. Pain is the hallmark symptom and often follows a characteristic pattern: it improves briefly with initial movement but worsens after continued activity. Classic inflammatory signs such as warmth, redness, and swelling may be present. On examination, there is localized tenderness over the tendon, pain with movement, reduced range of motion, and sometimes instability. Differentiating between tendonitis and tenosynovitis can be difficult clinically, and both are generally grouped under tendinopathies.
Several common clinical syndromes are associated with tendinopathy. In the shoulder, supraspinatus tendinopathy results from impingement between the humerus and acromion, causing pain with overhead movement. Calcific tendonitis, often affecting the rotator cuff, involves calcium deposition within the tendon and may cause acute pain during resorption phases. Bicipital tendinopathy presents with anterior shoulder pain radiating down the arm and is worsened by resisted supination or forward flexion. Lateral epicondylitis, or tennis elbow, causes pain over the lateral elbow exacerbated by gripping or wrist extension, while medial epicondylitis affects the flexor tendons.
In the wrist and hand, De Quervain tenosynovitis involves inflammation of the thumb tendons and produces pain with thumb movement, especially during the Finkelstein test. Trigger finger occurs when thickening of the tendon sheath causes catching or locking of the finger during motion. In the lower limb, Achilles tendinopathy is a common overuse injury, particularly in active individuals, presenting with posterior ankle pain, stiffness, and reduced mobility. Achilles tendon rupture may present with a sudden “popping” sensation and inability to plantarflex, although it is sometimes missed initially.
Diagnosis is primarily clinical, based on history and physical examination. Imaging is used selectively to exclude other conditions. Radiographs may show calcifications or rule out fractures, while ultrasound is useful for detecting tendon thickening and fluid collections. MRI provides detailed assessment of tendon structure and surrounding tissues. Laboratory tests are generally unnecessary unless infection or systemic disease is suspected.
Management focuses on conservative treatment. Initial therapy includes rest, ice, and nonsteroidal anti-inflammatory drugs, along with temporary immobilization if needed. Gradual rehabilitation with range-of-motion and strengthening exercises, particularly eccentric loading exercises, is essential for recovery. Most cases improve over 6 to 12 weeks. Additional treatments may include local injections, splinting, or emerging therapies such as prolotherapy or shock-wave therapy for calcific tendonitis.
Specific conditions may require tailored management. De Quervain tenosynovitis responds well to thumb spica splinting and NSAIDs. Trigger finger may require corticosteroid injection or surgical release if persistent. Achilles tendon injuries require rest, orthotics, and in the case of rupture, immobilization and orthopedic referral.
Most patients can be managed as outpatients, with referral indicated for complete tendon rupture or failure of conservative therapy after several months. Prevention of recurrence is an important aspect of long-term care, including activity modification and correction of biomechanical factors. A key clinical point is that certain medications, particularly fluoroquinolone antibiotics, have been associated with increased risk of tendinopathy and tendon rupture.
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