Tendon Injury (Tendinopathy)

Topic Overview

Is this topic for you?

The heel and elbow joints are common sites of tendon injuries. For more information about tendon injuries in these areas, see the topics Achilles Tendon Problems and Tennis Elbow.

This topic does not address severe tendon tears or ruptures. To help you assess a tendon injury, see the topic Shoulder Problems and Injuries, Elbow Injuries, Knee Problems and Injuries, Finger, Hand, and Wrist Injuries, or Toe, Foot, and Ankle Injuries.

What is a tendon injury?

Tendons are the tough fibers that connect muscle to bone. For example, see a picture of the Achilles tendon , which connects the calf muscle to the heel bone. Most tendon injuries occur near joints, such as the shoulder, elbow, knee, and ankle. A tendon injury may seem to happen suddenly, but usually it is the result of many tiny tears to the tendon that have happened over time.

Doctors may use different terms to describe a tendon injury. You may hear:

• Tendinitis. This actually means "inflammation of the tendon," but inflammation is rarely the cause of tendon pain.
• Tendinosis. This refers to tiny tears in the tissue in and around the tendon caused by overuse.

Most experts now use the term tendinopathy to include both inflammation and microtears. But many doctors may still use the term tendinitis to describe a tendon injury.

What causes a tendon injury?

Most tendon injuries are the result of gradual wear and tear to the tendon from overuse or aging. Anyone can have a tendon injury, but people who make the same motions over and over in their jobs, sports, or daily activities are more likely to damage a tendon.

A tendon injury can happen suddenly or little by little. You are more likely to have a sudden injury if the tendon has been weakened over time.

What are the symptoms?

Tendinopathy usually causes pain, stiffness, and loss of strength in the affected area.

• The pain may get worse when you use the tendon.
• You may have more pain and stiffness during the night or when you get up in the morning.
• The area may be tender, red, warm, or swollen if there is inflammation.
• You may notice a crunchy sound or feeling when you use the tendon.

The symptoms of a tendon injury can be a lot like those caused by bursitis.

How is a tendon injury diagnosed?

To diagnose a tendon injury, a doctor will ask questions about your past health and your symptoms and will do a physical exam. If the injury is related to your use of a tool or sports equipment, the doctor may ask you to show how you use it.

If your symptoms are severe or do not improve with treatment, your doctor may want you to have a test, such as an X-ray, ultrasound, or MRI.

How is it treated?

In most cases, you can treat a tendon injury at home. To get the best results, start these steps right away:

• Rest the painful area, and avoid any activity that makes the pain worse.
• Apply ice or cold packs for 10 to 15 minutes at a time, as often as 2 times an hour, for the first 72 hours. Keep using ice as long as it helps.
• Take over-the-counter pain relievers such as ibuprofen or naproxen (NSAIDs) or acetaminophen if you need them.
• Do gentle range-of-motion exercises and stretching to prevent stiffness.

As soon as you are better, you can return to your activity, but take it easy for a while. Don't start at the same level as before your injury. Build back to your previous level slowly, and stop if it hurts. Warm up before you exercise, and do some gentle stretching afterward. After the activity, apply ice to prevent pain and swelling.

If these steps don't help, your doctor may suggest physical therapy. If the injury is severe or long-lasting, your doctor may have you use a splint, brace, or cast to hold the tendon still. See a picture of a night brace used for an Achilles tendon injury .

It may take weeks or months for a tendon injury to heal. Be patient, and stick with your treatment. If you start using the injured tendon too soon, it can lead to more damage.

To keep from hurting your tendon again, you may need to make some long-term changes to your activities.

• Try changing your activities or how you do them. For example, if running caused the injury, try swimming some days. If the way you use a tool is the problem, try switching hands or changing your grip.
• If exercise caused the problem, take lessons or ask a trainer or pro to check your technique.
• If your job caused the tendon injury, ask your human resource department if there are other ways to do your job.
• Always take time to warm up before and stretch after you exercise.

Frequently Asked Questions

Symptoms

Symptoms of tendinopathy can include:

• Pain, tenderness, redness, warmth, and/or swelling near the injured tendon. Pain may increase with activity. Symptoms of tendon injury may affect the precise area where the injured tendon is located or may radiate out from the joint area, unlike arthritis pain, which tends to be confined to the joint.
• Crepitus, or a crunchy sound or feeling when the tendon is used. This is usually uncomfortable or painful.
• Pain and stiffness that may be worse during the night or when getting up in the morning.
• Stiffness in the joint near the affected area. Movement or mild exercise of the joint usually reduces the stiffness. But a tendon injury typically gets worse if the affected tendon is not allowed to rest and heal. Too much movement may worsen existing symptoms or bring the pain and stiffness back.

The joint areas most commonly affected by tendinopathy are the shoulder, elbow, wrist, hip, knee, and ankle.

Sometimes tendon pain is caused by inflammation around calcium crystals in or around the tendon (calcific tendinitis). The cause of the deposits often isn't known. These crystal deposits can be quite painful and can become a chronic problem.¹

Symptoms of tendinopathy may be similar to those of inflammation of the bursa (bursitis). For more information, see the topic Bursitis.

Exams and Tests

To diagnose a tendon injury (also known as tendinopathy), your health professional will review your medical history and daily activities and conduct a physical examination to check your overall health, areas of pain and tenderness, and range of motion and strength. Your examination may also include checking your nerve function (feeling and reflexes) and blood circulation (pulses). If your symptoms are related to use of a tool or sports equipment, your health professional may want you to demonstrate how you use it.

If your medical history and physical exam indicate a tendon injury, you will probably not need more testing.

If your symptoms are severe or have not improved with treatment, additional tests may be helpful. These may include:

• X-rays, which can show any bone-related problems or calcification in tendons or joint structures.
• MRI (magnetic resonance imaging), which can show small tears and areas of tendon, ligament, cartilage, and muscle injury.
• Ultrasound, which can show thickening, swelling, or tears in soft tissues such as the bursae and tendons.

Treatment Overview

Initial treatment for a tendon injury (tendinopathy) generally includes rest and pain relievers. Acetaminophen can reduce pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce both the pain and inflammation you might have from a tendon injury. The goals of this early treatment are to:

• Reduce pain and inflammation of the tendon.
• Restore normal motion and strength.

If you are still having pain, stiffness, and weakness after initial treatment, your health professional may recommend some type of physical therapy. In addition, you may need to make long-term changes in the type of activities you do or how you do them to prevent your tendinopathy from returning. The goals of ongoing treatment are to:

• Reduce pain.
• Avoid further degeneration or tearing of the tendon.
• Encourage regeneration of the damaged tendon.

Treatment for tendinopathies

Take the following steps to treat tendinopathies:

• Rest the affected area, and avoid any activity that may cause pain. Get enough sleep. To maintain your overall health and fitness, continue exercising but only in ways that do not stress the affected area. Do not resume an aggravating activity as soon as the pain stops. Tendons require weeks of additional rest to heal. You may need to make long-term changes in the types of activities you do or how you do them.
• Apply ice or cold packs as soon as you notice pain and tenderness in your muscles or near a joint. Apply ice 10 to 15 minutes at a time, as often as twice an hour, for 72 hours. Continue applying ice (15 to 20 minutes at a time, 3 times a day) as long as it relieves pain. Although heating pads may feel good, ice will relieve pain and inflammation.
• Take pain relievers if needed. Use acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, or aspirin, as directed for pain relief. (Do not give aspirin to anyone younger than age 20 because of the risk of Reye syndrome, a central nervous system complication in children.) NSAIDs also reduce any inflammation you might have in or around the tendon (tendinitis). Do not rely on medicine to relieve pain in order to continue overusing a joint.
• Do range-of-motion exercises each day. Gently move your joint through its full range of motion, even during the time that you are resting the joint area. This will prevent stiffness in your joint. As the pain goes away, continue range-of-motion exercises and add other exercises to strengthen the muscles around your joint.
• Gradually resume your activity at a lower intensity than you maintained before your symptoms began. Warm up before and stretch after the activity. You can also try making some changes. For example, if exercise has caused your tendinopathy, try alternating with another activity. If using a tool is the problem, try alternating hands or changing your grip. Increase your activity slowly, and stop if it hurts. After the activity, apply ice to prevent pain and swelling.
• Avoid tobacco smoke. Tendon injuries heal more slowly in smokers than in nonsmokers. Smoking delays wound and tissue healing.

If these steps do not help to relieve pain, other treatment may be considered. Your health professional may:

• Prescribe physical therapy.
• Use a corticosteroid injection to relieve pain and swelling. But corticosteroid treatments usually are not repeated because of the potential for tendon damage.
• Prescribe a brace, splint, sling, or crutches for a brief period to allow tendons to rest and heal.
• Recommend a cast to rest and heal a badly damaged tendon. Casting or surgery is typically used to treat a ruptured tendon.

Medical researchers continue to study new ways to treat tendon injuries. In separate small clinical trials, nitric oxide and glyceryl trinitrate, applied topically (to the skin), showed promise at relieving pain caused by tendon injury.^{2, 3} In another study, the pain caused by calcific tendinitis (calcium built up in the tendons) was relieved by directing ultrasonic, or shock, waves at the injured tendon (shock wave therapy).⁴

Open or arthroscopic surgery is sometimes used to treat calcific tendinitis that has not responded to nonsurgical treatment and is causing pain.¹

Home Treatment

You can prevent a tendon injury (also known as tendinopathy) from developing or recurring by taking steps at home, work, and during activities to promote healing and protect your tendons.

Home treatment steps include:

• Rest the affected area and avoid any activity that may cause pain. Get enough sleep. To maintain your overall health and fitness, continue exercising but only in ways that do not stress the affected area. Do not resume an aggravating activity as soon as the pain stops. Tendons require weeks of additional rest to heal. You may need to make long-term changes in the types of activities you do or how you do them.
• Apply ice or cold packs as soon as you notice pain and tenderness in your muscles or near a joint. Apply ice 10 to 15 minutes at a time, as often as twice an hour, for 72 hours. Continue applying ice (15 to 20 minutes at a time, 3 times a day) as long as it relieves pain. Although heating pads may feel good, ice will relieve pain and inflammation.
• Take pain relievers. Use acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, or aspirin, as directed for pain relief. (Do not give aspirin to anyone younger than age 20 because of the risk of Reye syndrome, a central nervous system complication in children.) NSAIDs also reduce any inflammation you might have in or around the tendon (tendinitis). Do not rely on medicine to relieve pain in order to continue overusing a joint.
• Do range-of-motion exercises each day. Gently move your joint through its full range of motion, even during the time that you are resting the joint area. This will prevent stiffness in your joint. As the pain goes away, continue range-of-motion exercises and add other exercises to strengthen the muscles around your joint.
• Gradually resume your activity at a lower intensity than you maintained before your symptoms began. Warm up before and stretch after the activity. Increase your activity slowly, and stop if it hurts. After the activity, apply ice to prevent pain and swelling.
• Avoid tobacco smoke. Tendon injuries heal more slowly in smokers than in nonsmokers. Smoking delays wound and tissue healing.

To prevent tendon injuries from developing or from happening again:

• Warm up and stretch. Warm up before any activity, and stretch gently after you finish.
• Strengthen your muscles to reduce stress on the soft tissues. A physical therapist, an athletic trainer, or your health professional can teach you specific exercises for strengthening your injured area.
• Evaluate and change daily activities that tend to cause or aggravate your symptoms. In your daily routine, change activities involving repeated movements that may strain your muscles or joints. For example, start alternating hands or change the grip size of your tool.
• Try alternating your usual activities with some new ones. For example, if you like to walk for exercise and have had Achilles tendon problems, try swimming or doing water exercise on some days.
• Notice what you do and how you do it, and take action if necessary.
  • If you suspect that certain activities at your workplace are causing a tendon injury, talk to your human resources department for information on alternative ways of doing your job, equipment modifications, or other job assignments.
  • If a certain exercise or sport is causing a tendon injury, consider taking lessons to learn proper techniques. Also, have an athletic trainer or person who is familiar with sports equipment check your equipment to ensure that it is well suited to your size, strength, and ability. Demonstrate how you use your equipment, and ask for feedback about any mistakes you might be making.

Joint-specific tips

See the following for ways to ease a specific joint problem:

• Elbow pain
• Hip pain
• Knee pain
• Shoulder pain
• Wrist pain
• Ankle or heel pain

Other Places To Get Help

Organizations

Related Information

• Achilles Tendon Problems
• Bursitis
• Hip Problems, Age 12 and Older
• Knee Problems and Injuries
• Rotator Cuff Disorders
• Tennis Elbow

References

Citations

1. Hurt G, Baker CL (2003). Calcific tendinitis of the shoulder. Orthopedic Clinics of North America, 34(4): 567-575.

2. Paoloni J, et al. (2003). Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow. American Journal of Sports Medicine, 31(6): 915-920.

3. Paoloni J, et al. (2005). Topical glyceryl trinitrate application in the treatment of chronic supraspinatus tendinopathy. American Journal of Sports Medicine, 33(6): 806-813.

4. Wang C-J, et al. (2003). Shock wave therapy for calcific tendinitis of the shoulder. American Journal of Sports Medicine, 31(3): 425-430.

Other Works Consulted

• Colburn KK (2007). Bursitis, tendonitis, myofascial pain, and fibromyalgia section of The locomotor system. In RE Rakel, ET Bope, eds., Conn's Current Therapy 2007, pp. 1148-1151. Philadelphia: Saunders Elsevier.

• Khan KM, et al. (2002). Time to abandon the "tendinitis" myth. BMJ, 324(7338): 626-627.

• McMahon PJ, Kaplan LD (2006). Sports medicine. In HB Skinner, ed., Current Diagnosis and Treatment in Orthopedics, 4th ed., pp. 163-220. New York: McGraw-Hill.

• Stovitz SD, Johnson RJ (2003). NSAIDs and musculoskeletal treatment: What is the clinical evidence? Physician and Sportsmedicine, 31(1): 35-52.

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