Treatment for Tendinosis (Not Tendinitis)
It started as a mild pain below the outside of my ankle after tennis. I stopped playing and rested for a few days. When I did play again, I took ibuprofen before and iced after. I even used my own handheld ultrasound—just like the physical therapists. Nothing helped. It only got worse. Off to the doctor I went.
The diagnosis? Tendinosis of the peroneous longus, the tendon that runs from the bottom of the foot, behind the ankle, and up the side of the leg.
Tendin-O-sis? I thought I was familiar with the common sports injuries, but this one was new.
What Is Tendinosis?
Tendinosis is a degeneration of the collagen fibers that make up a tendon. It's caused by a repetitive micro trauma that fails to heal. The tendon fibers fray and tear, and scar tissue develops when it does not properly heal. In my case, the constant side-to-side movement in tennis was causing me to roll over my ankle a bit farther than normal every once in a while. This was causing small frays in the fibers of the peroneous longus tendon. These small tears take 9-12 months to properly heal, and they would get re-injured long before that time. After several years of this recurring cycle, my pain started to develop.
With tendinosis, unlike tendinitis, there is no inflammation. Because of this, it's also more difficult and takes longer to treat.
How Is Tendinosis Different Than Tendinitis?
Tendinitis is an inflammation of the tendon. Inflammation is a response by your immune and vascular systems to protect tissue from pathogens or injury. This response is present in tendinitis--hence symptoms such as swelling, redness, or heat. With tendinosis, your body tissue has tears. It is not inflamed. The key difference between tendinosis and tendinitis is the lack of inflammation with tendinosis. Thus, treatments that target inflammation such as ice, ultra-sound therapy, and drugs such as ibuprofen and other NSAIDs have limited effectiveness when applied to tendinosis.
What are the symptoms of tendinosis?
The primary symptom of tendinosis is pain. The pain can range from mild stiffness to aching or burning around the joint. The pain is usually localized to the area where the tendon is damaged, but may radiate to nearby areas. For example, with my tendinosis of the peroeous longus, I felt pain in the bottom of my foot. The pain may be mild at first but will get worse over time if the tendinosis is untreated. Pain is usually worst after activity such as exercise that causes cellular damage to the tendon.
There may be mild swelling around the area of the tendinosis, but swelling is not always present.
If left untreated, a tendinosis can lead to a rupture of the afflicted tendon.
Consult Your Doctor
If you suspect you may have tendinosis, you should consult your doctor for a proper diagnosis. A medical professional can detect any swelling by touch. An ultrasound or MRI can detect lesions in the collagen matrix of the tendon. This is the definitive means to properly diagnose tendinosis.
How do I treat tendinosis?
Once you have been diagnosed with tendinosis, treatment is 1) rest; and 2) gradual progression of eccentric strengthening exercises in your pain free zone. There is some early research that indicates that Vitamin E may be beneficial to the healing process with tendinosis, but it's certainly not the solution in isolation.
You must rest from the exercise or activity that has caused tendinosis. Tendons take a long time to heal (9-12 months) and repeated trauma to your tendon will only make the tendinosis worse and ultimately lead to a rupture. For several weeks, you will need to rest from the activity that is causing the trauma to allow any swelling to go down and let the healing process begin.
Eccentric Strengthening Exercises
Eccentric exercises to strengthen the tendon and rebuild collagen are the most effective long term treatment. Eccentric exercises strengthen a tendon by elongating it under tension. These exercises often include the use of bands that create resistance for various exercise.
The exact exercises to treat your tendinosis are going to depend on the tendon that is effected and the severity of your tendinosis. Consult a physical therapist to get the proper exercise regimen.
Vitamin E as a dietary supplement may be helpful. Vitamin E stimulates the production of fibroblasts which play a critical role in regeneration and healing in the body.
Remember: You're Not Treating Inflammation
Do not use therapies such as ultrasound, icing, or NSAIDs (ibuprofen or aspirin). Although these will not harm your tendinosis, they are intended to treat inflammation. Since tendinosis lack inflammation, they are ineffective.
It Takes Time
It took a long time, but my diligence paid off. I started treatment with a break from tennis. During that time, I started eccentric exercises with light resistance under the direction of a physical therapist. I had two different exercises to perform three times a day. By the time I started playing tennis again, my physical therapist graduated me to higher resistance bands. In the end, I spent 9 months doing my exercises three times a day, but the effort paid off. My tendinosis is healed. I play pain-free, and I don't need to worry about causing a more serious rupture.