The athlete will frequently note an increase in the
duration, frequency, or intensity of the training regi-
men. The pain is frequently worse after a period of rest
following the training period. Changes in footwear,
equipment, or training surface may be present.- The physical examination may reveal swelling or
crepitation along the tendon sheath. The degenerative
tendon is often tender to palpation or painful with
compression (impingement signs). Range of motion
may be restricted (Almekinders, 1998). - Diagnostic tests include radiographs to exclude stress
fractures or osteoarthritis. Ultrasound or magnetic
resonance imaging can be useful in tendons that are
not easily palpated (rotator cuff).
TREATMENT
- Removing or modifying the mechanical overload (rel-
ative rest) is the most important component of treating
chronic tendon injuries. Correcting training errors and
equipment problems should also be accomplished. - Prolonged immobilization should be avoided. Imm-
obilization results in deceased tendon strength and
stiffness owing to proteolytic degradation of collagen
(Hyman and Rodeo, 2000).
•Physical therapy is often prescribed for chronic tendon
disorders. Stretching and strengthening (particularly
eccentric exercises) are thought to be beneficial but
there are few good studies that support this assertion.
Modalities such as heat, ice, and ultrasound may also
improve the patient’s symptoms but there is little evi-
dence that these techniques accelerate tendon healing. - NSAIDs are frequently taken for chronic tendon dis-
orders. A recent review of the literature stated that five
of nine placebo-controlled studies demonstrated the
efficacy of NSAIDs in the treatment of tendinopathy
(Almekinders and Temple, 1998). There is no evi-
dence that NSAIDs improve the healing process in
tendon degeneration and there is evidence in muscle
injury that NSAIDs may be harmful to tissue healing
(Mishra et al, 1995). Short-term use of NSAIDs may
be indicated to provide analgesia for the athlete. - The use of corticosteroids injections in the treatment of
tendinopathy is controversial. The rationale of using a
local anti-inflammatory medication for a disease
process that involves tissue degeneration is question-
able. Corticosteroids may decrease inflammation in the
paratenon, reduce adhesions between the tendon and
the peritendinous tissue, or block nociceptors in the
damaged tendon (Paavola et al, 2002); however, only
three of eight placebo-controlled studies in the litera-
ture demonstrate the efficacy of corticosteroid injec-
tions (Almekinders and Temple, 1998). Direct
injections into the tendon substance should be avoided
as they result in elevated tissue pressure and tissue
damage. The use of corticosteroid injections around
weight-bearing tendons such as the Achilles tendon and
patellar tendon is controversial. There have been case
reports of tendon rupture but there are no controlled
studies and rupture of the tendon may have occurred
without an injection. It is difficult to make recommen-
dations on the use of corticosteroid injections owing to
the paucity of scientific evidence regarding their use.- The surgical treatment of chronic tendon injury is usu-
ally reserved for those cases that do not resolve with four
to six months of nonsurgical treatment. The surgical pro-
cedures usually involve debridement of the degenerative
tendon tissue. Occasionally complete resection and
repair or grafting is required (Almekinders, 1998).
Removal of the involved paratenon or release of the
tendon sheath is occasionally necessary. Bony promi-
nences may require removal (Haglunds, acromion).
Clinical series in the literature demonstrate the success of
surgical management but there are a very few controlled
studies.
REFERENCES
Almekinders LC, Temple JD: Etiology, diagnosis, and treatment
of tendonitis: An analysis of the literature. Med Sci Sports
Exerc8:1183–1190, 1998.
Almekinders LC: Tendinitis and other chronic tendinopathies.
J Am Acad Orthop Surg6:157–164, 1998.
Armstrong RB: Mechanisms of exercise-induced delayed onset
muscular soreness: A brief review.Med Sci Sports Exerc
16:529–537, 1984.
Backman C, Boquist L, Friden J, et al: Chronic Achilles
paratenonitis with tendinosis: An experimental model in the
rabbit. J Orthop Res8:541–547, 1990.
Beiner JM, Jokl P: Muscle contusion injuries: Current treatment
options. J Am Acad Orthop Surg9:227–237, 2001.
Beiner JM, Jokl P, Cholewicki J, et al: The effect of anabolic
steroids and corticosteroids on healing of muscle contusion
injury. Am J Sports Med27:2–9, 1999.
Best TM: Soft-tissue injuries and muscle tears. Clin Sports Med
16:419–434, 1997.
Garrett WE, Jr, Nikolaou PK, Ribbeck BM, et al: The effect of
muscle architecture on the biomechanical failure properties of
skeletal muscle under passive extension. Am J Sports Med
16:7–12, 1988.
Garrett WE, Best TM: Anatomy, physiology, and mechanics of
skeletal muscle, in Buckwalter JA, Einhorn TA, Simon
Sheldon (eds.): Orthopaedic Basic Science, 2nd ed. Chicago,
American Academy of Orthopaedic Surgeons, 2000, p 683.
Hess GP, Capiello WL, Poole RM, et al: Prevention and treatment
of overuse tendon injuries. Sports Med8:371–384, 1989.
Hyman J, Rodeo SA: Injury and repair of tendons and ligaments.
Phys Med Rehabil Clin N Am11:267–288, 2000.60 SECTION 1 • GENERAL CONSIDERATIONS IN SPORTS MEDICINE