Tendinopathy (tendonitis)

Muscle is joined to bone by a tendon, a tough cord of tissue. Tendinopathy leaves that cord disorganised inside and easily irritated, less able to bear load, and painful as a result. The older word "tendonitis" suggests a tendon that is simply inflamed, and specialists now prefer "tendinopathy". The underlying problem is a tendon whose structure has broken down under more load than it could adapt to; inflammation plays a part, but only a part, which is why treatment has moved away from anti-inflammatory medicines and towards loading the tendon.

The usual trigger is load that outruns a tendon's capacity to recover, often through:

• Training, activity or workload stepped up suddenly, or resumed too fast after a break
• Repetitive or sustained strain, from work as much as from sport
• Factors in the background: getting older, footwear or technique that does not suit, and conditions such as diabetes or raised cholesterol

Now and again, when tendon pain recurs or turns up at several sites, the explanation is not overuse but an inflammatory arthritis underneath, psoriatic arthritis for instance.

Because the tendon tolerates load less well, symptoms track how much the limb is used. Features may include:

• Pain around a tendon, which using the limb often makes worse
• A stiffness that follows rest and is there on waking
• Tenderness over the tendon, which is sometimes mildly swollen or thickened
• A gradual loss of strength, or certain movements that are hard to do

Frequently the diagnosis is clear from what you describe and what the examination finds. Treatment follows from knowing which tendon is at fault and what state it is in, and the same knowledge helps to exclude other reasons for the pain.

Tendons are among the structures ultrasound shows best. The tendon appears in detail, the changes of tendinopathy, a thickened tendon and areas where its fibres have lost their order, can be seen and the diagnosis confirmed, and treatment can be directed precisely. The scanner sits beside the examination couch, so the tendon is often examined during that same appointment; the ultrasound clinic page explains how.

Treatment usually rests on a structured programme: changes to activity, and graded exercise that loads the tendon in the right measure so that it can recover, with pain managed alongside. It is the treatment with the best evidence behind it, and it works only if it is kept up. An ultrasound-guided injection around the area is an option that may help selected people; the guidance is there so that the injection lands in the right place. The plan is agreed with you.

Overuse or strain, a mechanical cause, accounts for most tendon trouble, and the right plan tends to settle it. There are times, though, when what the pain is really signalling is an inflammatory arthritis. That becomes more likely when tendon problems keep returning, involve several different sites, arrive without a clear mechanical cause, or sit alongside other features such as psoriasis, swelling of a whole finger or toe, inflammatory back pain, or a family history of these conditions.

In those cases it is often the entheses that are inflamed: the anchorage points of tendon and ligament on bone. Psoriatic arthritis and axial spondyloarthritis belong to the spondyloarthritis family, and this pattern, enthesitis, is one of that family's hallmarks. It is worth spotting, because its treatment differs a good deal from what an overuse problem needs. The inflammatory changes that point towards this diagnosis can show up on ultrasound, so the scan has a role here as well, and Dr Borukhson can look for the wider pattern during the consultation.

Complete rest is not the goal: the tendon should keep working while it adapts. Measures that help include:

• Change the load, do not abandon it: cut back on whatever aggravates the tendon for a time, keep moving comfortably, and then build back gradually
• Do not drop the exercises: what a graded programme rewards is doing it regularly, far more than doing it hard, and the gains tend to show over weeks to months
• Deal with pain sensibly: simple painkillers have their place, and so does a look at technique, footwear and equipment
• Look after your general health: how well a tendon recovers depends partly on weight, smoking and conditions such as diabetes

Progress comes steadily, not overnight, and some ups and downs on the way are normal. Tendon problems tend to improve with the right loading: the early gains come within weeks, though full recovery can take up to six to twelve months, or longer where the problem is well established, and one that has been there a long time calls for patience. What applies here applies equally to tennis and golfer's elbow, to plantar fasciitis and to related conditions.

Danger is rare in tendon pain, yet a few patterns call for urgent attention. Get medical attention urgently, by the route each line names, for the patterns below; where a line says it is a 999 or A&E emergency, call 999 and do not drive yourself to A&E:

• A high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours, which can mean sepsis; that is a 999 or A&E emergency
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, which can mean meningitis or sepsis, as can a very bad headache, confusion or a first seizure with a fever or feeling unwell; that is a 999 or A&E emergency; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• An arm or a leg that suddenly turns numb, or suddenly turns weak when no snap, pop or sudden severe pain in it came first to explain it, a face that droops on one side, speech that slurs or will not come, or a sudden severe headache, which can mean a stroke; that is a 999 or A&E emergency, even if it stops after a short time
• Arm pain that comes on suddenly with pressure, heaviness or squeezing across the chest, or chest pain that spreads into an arm, which can mean a heart attack; that is a 999 or A&E emergency
• Arm pain that is brought on by exercise, stress, emotion or the cold, rather than by a particular movement of the arm, and stops within a few minutes of rest, which can mean angina, a sign of a heart problem; NHS 111 will tell you where to be seen
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine; that is a 999 or A&E emergency
• A sudden, severe pain in a tendon during an activity or an injury, or a snap, a pop or a sudden giving way, which can mean the tendon has ruptured, all the more if the limb is then left weak or cannot be used; NHS 111 will tell you where to be seen, unless the limb will take no weight at all, the joint cannot be moved or the injury has left it tingling or numb, which is a 999 or A&E emergency whatever the cause
• A movement lost, for instance the foot cannot push down, you cannot rise onto your toes, or the arm will not lift, which can mean a tendon has torn even without a snap; NHS 111 will tell you where to be seen, with the same exception as the line above
• Tendon pain that is very bad, or far worse than its usual ache; NHS 111 will tell you where to be seen
• Fever, or feeling unwell, together with an area that has gone red, hot, swollen or very painful, which needs assessment the same day, either at A&E or by calling NHS 111, since an infection in or around the joint has to be ruled out at once
• A joint that has become hot and swollen suddenly, even without a fever, which needs an answer the same day, from an urgent GP appointment, NHS 111 or a specialist clinic that can see you that day, since an infected joint does not always announce itself with a fever; a joint that will take no weight at all, or that cannot be moved, is a 999 or A&E emergency, whether or not there is a fever

Where none of those apply, a routine assessment is still worth arranging for tendon pain that persists despite sensible self-care, or for a pattern that does not look like plain overuse, since that can occasionally point to an underlying inflammatory cause such as enthesitis. Where a joint has swollen gradually and is not hot, or a whole finger or toe has, ask your GP or a specialist for that review promptly rather than waiting for a routine slot, since a swollen joint or digit can be the first sign of an inflammatory arthritis, which is not left to wait. If you cannot tell how urgent something is, asking is never a mistake.

A sore tendon that will not settle is worth assessing early, because the sooner the cause is confirmed and a recovery plan agreed, the less established the problem becomes. Persistent tendon pain merits a specialist opinion, with ultrasound where it adds to the picture.

How do you diagnose tendinopathy?

Mostly by listening and examining: which movements hurt, how the pain started and what the tendon does under load all point to the answer. Because several structures around a joint can produce similar symptoms, it helps to be sure which tendon is responsible before treatment is planned. Tendons show up well on ultrasound, which confirms the diagnosis and shows the state of the tendon, and because the scanner is part of Dr Borukhson's consultation the tendon can often be scanned at the same appointment.

How long does recovery take?

There is no single answer, because the tendon involved and the length of time the problem has been there both matter. A tendon rebuilds its tolerance to load gradually, so the early gains come within weeks, while full recovery can take up to six to twelve months, and longer for a long-standing problem. Consistency with the exercise programme, and patience while the tendon adapts, count for more than anything else. The right plan is what improves a tendon problem, and an assessment tells you what is realistic for yours.

How is tendinopathy treated?

Usually treatment centres on a structured programme, in which activity is adjusted and graded exercise gives the tendon the loading it needs to recover, with the pain managed at the same time. No other treatment has stronger evidence behind it, and it depends on being followed through. Rest by itself leaves the tendon no stronger, because a tendon regains its tolerance through loading, not through being spared. For selected cases, an injection around the area, placed under ultrasound guidance, may help. The programme is shaped to the tendon involved. You and Dr Borukhson settle the plan together.

Is tendinopathy the same thing as bursitis?

No. They can feel similar, because each causes pain in one spot near a joint, but different structures are involved. In tendinopathy the trouble is in the tendon itself, the cord tying muscle to bone; overuse is often behind it, and the pain tends to arrive when the limb is used. In bursitis it is a bursa that is inflamed, a little sac of fluid that cushions the joint, and pressing on the area often brings the pain on. Ultrasound helps to separate the two, and steers the treatment accordingly.

When is tendon pain worth a specialist opinion?

Given the right plan and enough time, an overuse tendon problem tends to settle; when the pain is not improving, though, it deserves a proper assessment, so that the cause is confirmed and a recovery plan agreed rather than allowed to slide. The case for a specialist review is strongest when the same pain returns again and again, turns up at several sites, has no obvious mechanical trigger, or comes with psoriasis or a swollen finger or toe, since those can occasionally point to an underlying inflammatory arthritis; a finger or toe swollen along its length, or a joint that has swollen gradually without turning hot, is worth that review promptly, from your GP or a specialist, rather than at a routine slot.