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Tendinopathies

  What we used to call tendinitis is now to be defined by tendinopathy. This appellation comprises several pathologies concerning the tendon, its attachments and its periphery. The injuries differ by the type of tissues that are damaged, which determines the prognosis and treatment.

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Jocelyn-William LOUBRIAT

Definition

Tendinosis refers to damage to the tendinous structure.
Enthesopathy refers to damage to the attachment of the tendon to the bone.
Paratenonitis comprises damage to the peripheral elements of the tendon: tendinous sheath (peritendinitis), synovial sheath (tenosynovitis), bursa (bursitis). Only these affections are real inflammatory damage, as denoted by the suffix “itis” in “tendinitis”.

 

Mechanism of the lesion

The tendon, its attachments with the bone (enthesis) and its peripheral elements (sheaths, bursae), suffer from strains of traction, rubbing, compression due to muscle contraction and the normal use of our body.
Just as climbing ropes wear out even if they are used in appropriate conditions, the tendon also tends to wear out. However, ropes are inert, whereas the tendon is alive and is able to regenerate as long as its physiology is not disturbed.

Arthroscopy of the long biceps tendon 
courtesy of Dr. Laporte

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Wear of a rope (©Béal)

If the strain load exceeds the tissue’s regeneration capacities, a tendinopathy occurs.
The possibility of an injury related to exterior traumatism should not be ignored either as, for example, when falling, the tendon may directly collide with a blunt element (i.e. a rock). This traumatism can damage the structures and disturb the tissue’s regeneration balance and thus lead to a tendinopathy.
Diagnosis

Even if the tendinitis is gone, its triad persists:
- pain when stretching,
- when contracting the muscle against resistance,
- and when palpating.
The modulation of pain at each test will lead the diagnosis to one or another type of tendinopathy.

Tendinosis: strong pain when stretching and contracting the muscle, less when palpating. This can combine with cysts or nodules on the body of the tendon.

Enthesopathy: pain when contracting the muscle and palpating. No pain when stretching.

Paratenonitis: pain when stretching (increased by the manual pinching of the sheath) and when palpating. No pain when contracting. This can combine with crackling felt when palpating and with permanent pain that can cause insomnia, with a potentially visible inflammatory reaction (redness, heat, swelling) and functional discomfort in everyday life.

An appropriate clinical examination by a specialist can be completed by supplementary tests such as scan and MRI.
echo-transversale
Ultrasound image of a section of injured tendon (left) compared to healthy tendon(right)
Prognosis

Repeated incidences can soon become pathological.
At the beginning, signs appear during warm-up and then disappear during the session.
If they persist after the warm-up, this is a sign of sharp worsening.

Tendinopathies are real injuries of the fibrous structures. At a certain level of evolution, some types of damage are irreversible. The fragility of the tissues may even cause the rupture of the tendon.

Early medical support, as soon as the first pains appear, contributes to the return to a normal state.

Neglecting the first signs will favor the evolution into irreversible damage and thus into chronicity.

We will deal with how to treat these affections next month in the “treatment” section.

References :

BRUCHARD A., DUEE T. : Les lésions tendineuses : conceptualisation et clinique. Profession Kinésithérapeute n°19, 2008.
CHANUSSOT J.C., DANOWSKY R.G. : Traumatologie du sport, Ed. Masson, 5ème éd., Paris, 1999.

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