• Formerly known as “tendinitis”, tendinopathy is now an umbrella term that encompasses tendinitis, tendinosis and tenosynovitis.
• Tendinopathy is a clinical syndrome characterized by chronic pain and decreased function, usually due to repeated mechanical loading (known as overuse) with non-inflammatory changes in the tendon from healing.
• Commonly involved sites include the rotator cuff, elbow, first dorsal compartment of the wrist, hip, knee, and ankle.
• A wide variety of patients with tendinopathies may present to the emergency department due to overuse, and increased participation in athletic activities and activity in younger individuals.

History:

• Determine if there are risk factors present:

• Ask about recent changes to activity, equipment, or medications.
• Almost all patients with tendinopathy present with pain.
• Latency is a common pattern in tendinopathies. It is a short-lived increase in pain during initial loading of the tendon, followed by a decrease in pain as the exercise continues. However, the pain is worse than baseline a few hours after exercise or the next day.

Physical Examination:

• A thorough MSK examination should be performed in the affected region including passive/active range of motion, joint stability and strength.
• Palpation of the tendon, noting crepitus or warmth, is important. In more superficial tendons, tendon thickening may be appreciated.
• Assessing for signs of edema, effusion, erythema, atrophy, deformity, asymmetry, or trauma can be helpful.
• Physician should attempt to reproduce the patient’s pain.

Investigations:

• Although the diagnosis is usually made on clinical grounds, outpatient ultrasound or MRI can be useful in confirming the diagnosis of tendinopathy.
• Plain radiographs may be ordered to rule out suspected bone abnormalities.
• Laboratory exams are not usually indicated unless tendinopathy is in multiple sites or without apparent overuse etiology. In these cases, metabolic risk factors (A1C, lipids, uric acid) and inflammatory markers (RF, ESR, CRP) can be ordered.

Diagnostic considerations:

• The differential diagnosis for tendinopathy includes tendon rupture, ligamentous injury, arthritis (inflammatory, osteoarthritis), fracture, tumors, osteochondritis, bursitis, septic arthritis, foreign body, osteomyelitis, nerve entrapment syndromes, and tendon sheath infections.

Management:

• In all cases, it is important to ensure that the patient has been referred for appropriate follow-up care with a physiotherapist or an exercise specialist for rehabilitation, which is the most important component of treatment.
• Identification and cessation of the cause of the pain and optimization of extrinsic risk factors should be discussed with the patient.
• Short-term therapies:
  • Application of ice, relative rest (+/- splinting), compression, and elevation can be helpful.
  • NSAIDs (oral or topical) can be used for analgesia (5-7 days).
  • Corticosteroid injections may be helpful, but may lead to higher risk of relapse (Do NOT inject corticosteroids into major tendons such as the patellar or Achilles tendons).
• Nitroglycerin patches have been shown to be helpful in some cases (rotator cuff, Achilles) and may be used off-label, if the patient has failed conservative measures or in conjunction with physiotherapy.  These should ideally be done in follow-up with a sports medicine specialist.

Disposition:

• Most patients can be discharged home with proper discharge instructions and appropriate follow-up.
• Set patient expectations that tendinopathies can take weeks to months to resolve.
• Early consultation with a sports medicine physician can be beneficial for athletes and other patients with sports-related tendinopathy for diagnostic and treatment recommendations.
• Exceptions to this would be the elderly and disabled patients, who may have difficulty with activities of daily living due to their tendinopathy.

1. Scott, A. & Rees, J. (2021). Overview of overuse (persistent) tendinopathy. UptoDate. Retrieved December 15, 2021 from https://www.uptodate.com/contents/overview-of-overuse-persistent-tendinopathy

   
   

2. Geiderman, J.M. & Katz, D. (2018). Tendinitis and tendinosis.  In Rosen’s emergency medicine: concepts and clinical practice (9th ed., pp. 445-463). Elsevier.

   
   

3. Hogrefe, C. & Martin Jones, E. (2018). Tendinopathy and bursitis.  In Rosen’s emergency medicine: concepts and clinical practice (9th ed., pp. 1392-1401). Elsevier.

   
   

4. Tendinopathy. (2021, December 15). In ClinicalKey for University of British Columbia [Clinical Overview]. https://www.clinicalkey.com/#!/content/clinical_overview/67-s2.0-6a7e7e17-5cde-41cc-beaf-3bc48f0aeacf