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Tendonitis

Introduction

Tendonitis is inflammation (swelling) of a tendon. It can cause pain and stiffness in the affected area.

Tendonitis can affect tendons around the:

  • shoulder
  • elbow
  • wrist
  • finger
  • thigh
  • knee
  • back of the heel

Read more about the symptoms of tendonitis.

Usually, painkillers and an ice pack relieve symptoms before the tendonitis goes away after a few days. It's important to stop doing the activity, such as sport, that caused it. More persistent cases of tendonitis may need physiotherapy or shock wave therapy.

Read more about treating tendonitis.

Tendonitis is quite common and can affect anyone. Tendons become less elastic and weaker over time, making tendonitis more common in elderly people.

What are tendons?

Tendons are tough, rubbery cords that link muscles to bones. They help move the bones and joints when the muscles contract. For example, the tendons you can see on the back of your hands move your fingers and are joined to the muscles in the forearm.

Some tendons are covered with a protective sheath of tissue called synovium. Between the synovium and the tendon is a small amount of greasy fluid. This helps the tendon move easily and prevents friction.

Tenosynovitis

If the sheath surrounding the tendon (rather than the tendon itself) becomes inflamed, the condition is called tenosynovitis. Tendonitis and tenosynovitis can occur at the same time.

Experts use the term "tendinopathies" to describe tendon injuries collectively.

Causes of tendonitis

Tendonitis is caused by:

Read more about the causes of tendonitis.  

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Symptoms

Symptoms of tendonitis include:

  • pain that becomes worse if you move the affected area
  • a sensation that the tendon is grating or crackling as it moves (this may be felt on examination)
  • swelling, sometimes with heat or redness
  • weakness in the affected area, because of the pain
  • a lump that develops along the tendon

If symptoms persist, the tendon may rupture (split) and a gap may be felt in the line of the tendon. Movement of that area will become more difficult.

Types of tendonitis and tenosynovitis

Tendonitis can occur in many different parts of the body. If the sheath surrounding the tendon, rather than the tendon itself, becomes inflamed, the condition is called tenosynovitis.

Supraspinatus tendonitis (shoulder)

Supraspinatus tendonitis is inflammation of the tendon around the top of the shoulder joint.

It causes pain when you move the arm, particularly if you lift it high.

The pain may also occur when you are lying on the shoulder at night. It is often part of a condition called rotator cuff syndrome, where other tendons in the same area are also affected. See Shoulder pain for more information about common shoulder disorders.

Calcific tendonitis (shoulder)

Calcific tendonitis is when crystals of a mineral called calcium phosphate form in the supraspinatus tendon in your shoulder. It can cause long-term mild pain, combined with short episodes of more severe pain. The pain may also spread down your arm or up into your neck.

Calcific tendonitis may also cause weakness or stiffness of your shoulder. It is very similar to supraspinatus tendonitis, but the calcium crystals will be visible on an X-ray (see diagnosing tendonitis for more information).

Biceps tendonitis (upper arm)

Biceps tendonitis affects the tendon that attaches the muscle on the front of your upper arm (bicep) to your shoulder. This can cause pain in your shoulder and upper arm, which may be worse if you lift or reach overhead. 

Tennis elbow and golfer's elbow

Tennis elbow is pain in the side of the elbow. Golfer's elbow is pain in the middle of the elbow.

These conditions cause pain when you move your elbow, particularly when you lift it against a force. The pain is usually around the elbow but may spread down your forearm towards the wrist. You may have less grip strength because of the pain, and your elbow may feel stiff.

De Quervain's tenosynovitis (thumb)

De Quervain's tenosynovitis is inflammation of the sheath that surrounds the thumb tendons, which run between the wrist and the thumb. There is obvious swelling and thickening of the sheath and it becomes very painful to move your thumb.

Trigger finger or thumb

Trigger finger or thumb is where the finger or thumb become fixed in a bent position and there is a clicking sensation when it is straightened out. This is because of thickening and inflammation of the tendon sheath in the palm of the hand. It may also be caused by a small lump forming along the tendon.

Achilles tendonitis (heel)

Achilles tendonitis is inflammation of the tendon between the heel and the calf muscle. It is commonly caused by a sports injury. It may also be caused by wearing shoes that do not fit or support the foot properly, causing you to walk awkwardly. It can also be associated with rheumatoid arthritis.

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Causes

Tendonitis is caused by overusing a tendon or injury. It may be the result of:

  • a sports injury – for example, sports that involve throwing or using a racquet may increase your risk of tendonitis in your elbow
  • repetitive strain injury (repeated overuse of muscles) – for example, using a computer mouse may be linked to tendonitis in your wrist 

A tear in the tendon because of an injury may also cause inflammation (swelling).

Medical conditions

For reasons that are not known, tendonitis tends to occur more commonly in people with diabetes than in the general population.

Also, tenosynovitis (inflammation of the sheath surrounding the tendon) is sometimes associated with rheumatoid arthritis.

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Diagnosis

Tendonitis or tenosynovitis (inflammation of the sheath surrounding the tendon) can be diagnosed by your GP based on your symptoms and an examination.

Your GP may ask:

  • where the pain is and how severe it is
  • whether you have recently injured yourself, for example while exercising, or whether you have a job or hobby that requires frequent use of that body part
  • whether exercise makes the pain worse

Your GP may ask you to move the affected body part so they can see if your range of movement is affected. Sometimes, the tendon sheath becomes thickened and a creaky sound may be heard when you attempt to move the tendon.

Imaging tests

If there is any doubt about the diagnosis, an imaging test can be done to give more information about your injury. For example:

  • An X-ray may show calcium deposits around a tendon, which would indicate calcific tendonitis, or may reveal that you have fractured or broken a bone.
  • An ultrasound scan or a magnetic resonance imaging (MRI) scan can be used if a more detailed image is needed, for example if it is not clear which tendon in your elbow is injured.
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Treatment

An episode of tendonitis may last for only a few days, but it can be more persistent and last for several weeks or months.

There are several different treatment options, although what's best for you may depend on which tendon you have injured.

Self-care

You can treat tendonitis yourself using the self-care techniques below.

Rest the tendon

Stop doing the activity that caused tendonitis, such as sport or typing, or at least reduce the amount you do. This will help prevent any further inflammation (swelling) or damage.

It's important to rest the affected area. This will allow the inflammation to settle. Some form of support, such as a bandage, splint or brace, may help as this will reduce movement.

How long you need to rest may depend on which tendon is affected and how severely it is damaged. For example, if you have golfer's elbow, which causes pain in the middle of your elbow, you may need to rest your elbow for at least six weeks.

Ice packs

You can ease the pain and swelling by applying an ice pack to the affected area. Do not put ice directly on your skin as this may cause a cold burn. Wrap it in a towel or put a towel over the injured area before applying the ice pack. If you do not have an ice pack, wrap ice cubes or a bag of frozen vegetables in a towel and use this.

Hold the ice pack on the affected area for around 15-20 minutes several times a day. You can also use an ice pack after exercise to try and prevent symptoms occurring.

Painkillers

Tendonitis can be treated with mild non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. These are effective at providing short-term pain relief and are available as a medicine that you swallow or as a gel that you apply directly to the affected area. 

These should not be used for long periods and are not recommended for people with asthma, or kidney or liver disease. 

Other painkillers, such as paracetamol, will also help ease the pain. If your pain is more severe, a stronger painkiller, such as codeine, can be prescribed.

Therapies and injections

Physiotherapy 

Physiotherapy, often referred to as physio, uses physical methods such as massage and manipulation to promote healing and wellbeing. There are many different physiotherapy techniques, such as:

  • special exercises to stretch and strengthen the tendon and surrounding muscles
  • massaging the affected area
  • using high-frequency sound waves (ultrasound)
  • using narrow beams of light (lasers)

Physiotherapy can be used to relieve pain and may result in more long-term improvement than corticosteroid injections.

Corticosteroid injections

Corticosteroids are medicines that contain steroids, a type of hormone, and can be used to reduce inflammation. If there is swelling and evidence of inflammation, corticosteroids can be injected around the affected tendon or into the tendon sheath.

Possible side effects of corticosteroid injections include:

  • thinning of the skin
  • lightening of the skin

Although corticosteroid injections can relieve pain, they do not have a long-term effect and it is common for the pain to return. You can have another injection, but you will need to wait at least six weeks. You cannot have more than three injections into the same area in a year as this can increase the risk of the tendon rupturing (splitting).

Local anaesthetic injections

Local anaesthetic is used during minor surgical procedures to numb a body part. In some types of tendonitis, local anaesthetic can be injected into the affected area as well as corticosteroids.

Extracorporeal shock wave therapy

Extracorporeal shock wave therapy (ESWT) is a treatment option for tendonitis that has not responded to other treatments. ESWT involves passing shock waves through your skin to the affected area. This may be carried out over one or more sessions and local anaesthetic may be used to numb the area first.   

ESWT may relieve the pain caused by tennis elbow or Achilles tendonitis, but it is not clear if ESWT is better than some other treatment options. If you are considering this treatment, you may be asked to take part in a clinical trail (a type of medical research) to look at how effective the treatment is over time. There are also possible risks, such as:

  • the tendon rupturing – in one study, this happened to 2 out of 49 people who had ESWT for Achilles tendonitis 
  • temporary redness or swelling
  • pain during the treatment
  • feeling sick

The National Institute for Health and Clinical Excellence (NICE) has produced guidelines on the use of:

Surgery

In some types of tendonitis, surgery may be a possible treatment. However, as most cases of tendonitis improve with time, it is not usually necessary. You may want to try other treatments for up to a year before considering surgery.

Tennis elbow

Several different surgical techniques have been used for tennis elbow, such as:

  • removing a damaged part of muscle from the elbow
  • removing part of a ligament in your elbow – ligaments are tough bands of tissue that link two bones together at a joint
  • damaging a nerve in your elbow so you no longer feel pain there

The benefits of surgery for tennis elbow have not yet been proven. It may improve your symptoms, but this could be because your condition was getting better anyway, or may be due to the placebo effect. This is when you feel better after having a "dummy" treatment, rather than a "real" treatment.

After surgery, you should be able to start playing sport again within four to six months.

Calcific tendonitis

If calcium deposits have formed in the tendon in your shoulder, you can have surgery to remove these. This can be done using a technique called Arthroscopy. An arthroscopy is a form of keyhole surgery that is used to look inside a joint and repair any damage that has occurred. Only a very small cut is made in your body.

Biceps tendonitis

Biceps tendonitis affects the tendon that attaches the muscle on the front of your upper arm (bicep) to your shoulder. You can have surgery to reattach the end of the tendon to the bone in your upper arm (humerus). This may be considered if you are in severe pain or if you have torn the tendon.

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Prevention

Exercises

Exercising the affected area will strengthen the muscles around the tendon and prevent further problems. See a physiotherapist for advice on the best stretching and strengthening exercises to do.

If you play sport or exercise a lot, you can try to prevent tendonitis by warming up and stretching properly before you start to exercise. You should also do exercises and stretches to cool down when you finish. 

If a sporting activity has caused tendonitis in the past, you may be able to make changes to prevent this happening again. For example, you may be able to use different sports equipment, or your sports coach may be able to advise you about a different technique. 

Physiotherapists and Occupational therapists can give useful advice about joint protection.

Avoid repetitive movements

Avoid repetitive movements of the affected area. If this is not possible, it is very important to have regular rests.

If you have tendonitis and have to use repetitive movements in your job, ask your employer to provide rest periods and different duties for you. It may be possible to move your computer keyboard or mouse into a more comfortable position. See preventing repetitive strain injury for more advice.

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