What is Tendinitis and 3 Strategies to Fix It. 

Tendinitis can be a little tricky to resolve at times.  You can get it anywhere a muscle attaches to a bone but it is very common at the achilles, lateral elbow, hip, knee, and shoulder.   In this blog post we want to help you identify how you may know if you have tendinitis, three strategies to relieve it, a few things you can do at home, and then a few things we do at PHYT For Function to treat it without a steroid injection or weeks and weeks of exercise. 

Tendinitis is an inflammation of the tendon where the muscle is connecting to the bone. This can be just an over use / irritation type thing or it can be from actual damage, changes to the tendon itself called Tendinosis.  You will see the word tendinopathy used to encompass both types of tendon pain and dysfunction.  

Identifying Tendinitis. 

To identify tendinitis type pain there are a few simple things that may suggest tendinitis.

First is location.  Tendon pain is usually right on the tendon.  The pain will be where the muscle inserts on the bone or just next to it.  It will hurt to touch that spot. It will hurt to contract those muscles. Usually, it will feel sore to stretch those muscles.  It usually doesn't travel up or down the arm or leg.  It shouldn't hurt in the joint or feel deep. Those things might be something else. 

Second is quality.  There a few things someone tells me that may signify tendon involvement.  Pain that hurts to start an activity, then warm up and goes away during, then gets sore again is a classic description.  Pain that is worse in the morning is another one.  The quality is usually a range of sharp to achy but almost always fairly local to the area.  It can be very intense.  It should be easy to identify, if you are having trouble finding it, it is probably not tendinitis.   It should not feel nervy or involve numbness or tingling.  Thats probably something else. 

Make sure you get your pain assessed by a medical professional if its not getting better on its own in two weeks. 

Treating Tendinitis.

There are three strategies to treating most types of tendon pain. 

1. Reduce pain. Aid in the transition from prolonged pro-inflammation to anti-inflammation and regeneration. 

2. Re-Load the tendon so it tolerates force without pain. 

3. Reduce stress above and below the tendon so it doesn't come back. 

 Treating New vs. Old tendon pain

New tendon pain 

We will define new tendon pain as less than 4 weeks. With new tendon pain we will treat it like most any new injury.  Something happened so we will trust the inflammatory and pain process to some level.  It means our body is working to fix the injury.  We have three goals when working to treat new tendon pain.   

First, we want to reduce other outside stress and inflammation.  System wide inflammation from other things has been shown to reduce tendon healing and may lead to the transition of more chronic type pain.  So want to reduce system inflammation as best we can.  Reduce stress as able, eat non-inflammatory to you foods, and get enough sleep.  Our goal is to make sure your body switches to a regenerative inflammatory process as the tendon pain heals.  We don't want to complicate that with outside inflammatory sources as best we can. 

Second, and this one is easier said than done, but try not to over reach emotionally.   We want to trust that your body will fix itself and try not to overreact and snow ball the emotions.  You know, that thing where you get hurt, and then mentally immediately take yourself to an outcome where you're never going to be able to use that limb again.  It may alter the way your nervous system and immune system react to the injury so try your best to take it for what it is in the moment and let the body over react.  Sometimes, I think we worry so much that we overprotect an injury and that makes it harder to get back to activities later.  I blame us medical professionals on this one sometimes too for making things seem scarier than they are at times.  

Thirdly, we want to encourage blood flow and relatively pain free movement as able.  Muscle tightness is your body protecting itself.  Too much tightness limits blood flow and things so keep it moving as best you can.  Keep the pain level of activities under a 4/10 during and after and that should keep you in a good place.  At home self massage with a massage gun at a very low intensity (2/10) for 90 seconds can be great.  This is also where some of our manual therapy techniques come in. Cupping, dry needling, and pin and stretch massage can be great.   

Old Tendon Pain. 

If you have had pain for more than 4-6 weeks we may treat it a little differently.  In this situation we may actually try to stress the tendon a bit to re-start that inflammatory / healing process.  This is where we use techniques like more aggressive massage to the tendon, eccentric exercise,  or dry needling to the tendon itself.  The idea here is that the initial pro-inflammatory process either didn't heal the tendon or you didn't transition to that regenerative phase.  To restart it we create new micro trauma to the involved area to kick start a new healing response.  As you may expect this comes with a little soreness but usually works quite well.  

The other component of long term tendon pain is nerve sensitivity.  We are seeing more and more research show that long term tendon pain leads to sensitization of the nerve.  This makes things that normally wouldn't hurt now feel very painful.  Rehab techniques like dry needling and nerve glides can be helpful with this.  You can find different nerve glide exercises on our YouTube page by searching PHYT For Function nerve glide. 

Dry Needling for tendon pain. 

Dry needling has been one of the most successful treatments for stubborn tendon pain I have been around.  The goal is to create a micro-trauma to trigger that immune response in the area. 

Here is a study that compared dry needling to cortisone injection for lateral elbow tenditintis that showed DN slightly more effective. The beautiful thing here is with dry needling you don't get the negative effects of cortisone. 

" However, compared with Corticosteroid injection, Dry needling was more effective."

In this study 108 patients with lateral elbow pain either received steroid injection or dry needling treatment.  At 3 weeks and 6 month follow ups both groups showed improvements.  Dry needling was slightly better and had less complications 4 people in the Corticosteroid group developed skin whitening or atrophy.  1 Person in the dry needling group withdrew because of pain of the dry needling treatment.  

https://pubmed.ncbi.nlm.nih.gov/32950674/

Reloading and Supporting the Tendon. 

As the pain resolves you want to rebuild the tendon so it will tolerate force without pain.  Some evidence is showing that tendinopathy make actually create a hole in the tendon. As your body fixes it it rebuilds connective tissue around it kind of like a woven patch to make it strong again.  We need force transmission through the tendon to make this happen.  The key is enough force to make this happen and not so much that you piss it off.  I would encourage working with a therapist to help you with this progression.  A couple key points though are make sure the pain stays below a 4/10.  I would suggest starting with things that load the tendon without a lot of movement like isometric exercises in limited ranges, progressing to more challenging ranges of motion and then then to slow eccentric exercises before adding concentric, higher loads, speed, and even plyometrics over time. The big takeaway is that long term rest is most likely not going to completely fix a tendon problem.

If the tendonitis is from an overuse movement problem I would also highly suggest working on mobility / flexibility above and below the tendon.  This will allow the tendon to move naturally.  A common example would be hip mobility causing the foot or ankle to move differently and creating an achilles issue.  

Strength at segments above and below the tendon also may be important.  An example here would be lateral elbow tendinopathy you would want to work scapular stability and grip strength to take demand off of the elbow in-between. 

 Conclusion. 

Tendinitis can be a tough thing to treat when it doesn't get better on it's own quickly.  We are learning more and more ways to treat it at it's different stages of new vs. old and different levels of injury and nerve involvement.  Dry Needling combined with progressive reloading has been one of the best things we have seen in the clinic to help with tendinitis type pain. I hope this article helps you better understand the stages of tendinitis, what it is, and how to fix it. 

If you have questions or would like to talk to a therapist about your specific tendinitis pain you can schedule a No Cost Phone Consult Here.  

This is not medical advice as no patient relationship is established i an email.  If pain is not getting better in a couple weeks make sure  you get it checked out by someone.  You  need to rule out pain coming from somewhere else or stress fracture type thing.  You also want to be sure you are actually treating a tendon problem if you want to get better fast. Treating the tendon when it's really a joint or spine thing isn't going to be successful so you want to find someone to help you out when things aren't resolving on their own. 

Written By Nicholas Sanders PT, DPT, CSCS, CIDN.