Tendons connect muscle to bone and help make joints move. Technically speaking, a tendon injury is a strain, while an injury to a ligament (ligaments connect bone to bone) is a sprain. But the two terms are most often used interchangeably.
There are 3 grades of tendon strains:
Grade 1. The tendon fibers are stretched but there’s no tear. There’s some pain and perhaps a trace amount of swelling. Joint strength is normal, though there may be some discomfort with movement. Ultrasound evaluation is usually normal.
Grade 2. The tendon fibers are partially torn. There is slightly more pain and more swelling. Joint movement is more painful, and there is often some weakness. There may be some black & blue bruising on the skin. Ultrasound often shows tendon damage.
Grade 3. The tendon fibers are completely torn (ruptured). There may be some tenderness but surprisingly there is often little pain. The amount of swelling and bruising can vary. There is significant weakness or even inability to move the affected joint. Ultrasound clearly shows the damage.
Tendinitis is different from a strain. Tendinitis is inflammation of the tendon, most commonly from repetitive stress or injury. The tendon is tender to touch, and movement causes pain. There may be some swelling.
Calcific tendinitis is a special form of tendinitis in which calcium deposits form in the tendon in response to persistent irritation. It’s almost as if the body is trying to form a callous to protect itself against the chronic irritation. Calcific tendinitis is most common in the Rotator Cuff tendons, but it can occur in any tendon. The calcium deposits can be seen on ultrasound and sometimes on x-ray.
As the tendinitis progresses however, the amount of inflammation gradually decreases and the tendon starts to degenerate or deteriorate. Eventually small tears can start to form in the tendon. (Think of how the knees on your jeans gradually thin out over time, and one day you may notice a small tear.) This starts to occur after around 12-15 weeks, if the tendinitis isn’t treated properly. This is called tendinosis.
Tendinitis is an acute problem; tendinosis is a chronic condition. Technically, there is no such thing as “chronic tendinitis” because the inflammation doesn’t persist chronically—it’s replaced by the degeneration. But tendinosis can cause the same, or even worse, pain and disability than acute tendinitis.
Ultrasound evaluation of tendinosis typically shows a thickened tendon. There may be small tears present.
Treatment for tendons depends on the nature of the problem. Acute Grade 1-2 strains are best treated by physical therapy and activity modification. Bracing or splinting may also be helpful. We strongly discourage the use of NSAIDs such as Advil, Aleve, Motrin, meloxicam, etc., because a number of studies show that these can actually hinder the proper repair of the tissue. For the same reason we also try to avoid cortisone injections. Complete Grade 3 tears typically need surgery.
Treatment for tendinitis and tendinosis also varies. Tendinitis, which is a more acute problem, again is best treated initially by physical therapy, activity modification, and occasionally bracing/splinting. But tendinosis tends to respond less favorably to conservative treatments. More often, tendinosis, including chronic Grade 2 tears, is best treated by Regenerative Medicine treatments, including prolotherapy/Prolozone, PRP, and stem cell treatments.
Another treatment option for chronic tendinosis is the TenJet procedure. This procedure uses fine jet sprays of water to break up and suck out the damaged tissue, leaving the healthy tissue alone. This allows healing to occur. This is a great treatment option for calcific tendinitis.
Once the acute injury begins to heal, proper rehab exercises are a key to full recovery. Studies have shown that eccentric strength training is a great stimulus to help repair and strengthen tendons. When you lift a weight there are two phases—lifting the weight (the concentric phase) and letting the weight back down (the eccentric, or “negative,” phase). With eccentric strength training you lift the weight normally, but then let it down very slowly, over 4-6 seconds.