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Both eccentric loading and extracorporeal shockwave therapy are currently being researched as possible treatments for tendinosis. One study found both modalities to be equally effective in treating tendinosis of the Achilles tendon and more effective than a 'wait and see' approach. Other treatments for which research is on-going includes vitamin E, vitamin B6, nitric oxide, Platelet Rich Plasma (PRP), and stem cell injections.
One study found increased achilles tendon healing in rats supplemented with high doses of vitamin C, which is needed for collagen synthesis.
Steroid injections are helpful in the short term (first approximately 4 weeks) however, their long term effectiveness is not known, and quality of evidence for its use remains poor and controversial.
Other, more conservative and non-surgical, treatment options available for the management and treatment of tendinopathy include: rest, ice, massage therapy, eccentric exercise, NSAIDs, ultrasound therapy, LIPUS, electrotherapy, taping, sclerosing injections, blood injection, glyceryl trinitrate patches, and (ESWT) extracorporeal shockwave therapy. Studies with a rat model of fatigue-damaged tendons suggested that delaying exercise until after the initial inflammatory stage of repair could promote remodelling more rapidly. There is insufficient evidence on the routine use of injection therapies (Autologous blood, Platelet-rich plasma, Deproteinised haemodialysate, Aprotinin, Polysulphated glycosaminoglycan, Corticosteroid, Skin derived fibroblasts etc.) for treating Achilles tendinopathy. As of 2014 there was insufficient evidence to support the use of platelet-rich therapies for treating musculoskeletal soft tissue injuries such as ligament, muscle and tendon tears and tendinopathies.
Treatment of tendon injuries is largely conservative. Use of non-steroidal anti-inflammatory drugs (NSAIDs), rest, and gradual return to exercise is a common therapy. Resting assists in the prevention of further damage to the tendon. Ice, compression and elevation are also frequently recommended. Physical therapy, occupational therapy, orthotics or braces may also be useful. Initial recovery is typically within 2 to 3 days and full recovery is within 3 to 6 months. Tendinosis occurs as the acute phase of healing has ended (6–8 weeks) but has left the area insufficiently healed. Treatment of tendinitis helps reduce some of the risks of developing tendinosis, which takes longer to heal.
Steroid injections have not been shown to have long term benefits but have been shown to be more effective than NSAIDs in the short term.
In chronic tendinitis or tendonosis laser therapy has been found to be better than conservative treatment at reducing pain; however, no other outcomes were assessed.
Both prolotherapy and PRP injections are being used more frequently with good clinical short and long term outcomes in tendonosis - research has been only slightly positive for these treatment modalities due to the poor design of many of the completed studies.
Many non-operative treatments have been advocated, including rest; oral administration of non-steroidal anti-inflammatory drugs; physical therapy; chiropractic; and local modalities such as cryotherapy, ultrasound, electromagnetic radiation, and subacromial injection of corticosteroids.
Shoulder bursitis rarely requires surgical intervention and generally responds favorably to conservative treatment. Surgery is reserved for patients who fail to respond to non-operative measures. Minimally invasive surgical procedures such as arthroscopic removal of the bursa allows for direct inspection of the shoulder structures and provides the opportunity for removal of bone spurs and repair of any rotator cuff tears that may be found.
Non-specific treatments include:
- Non-steroidal anti-inflammatory drugs (NSAIDs): ibuprofen, naproxen or aspirin
- Heat or ice
- A counter-force brace or "elbow strap" to reduce strain at the elbow epicondyle, to limit pain provocation and to protect against further damage.
Before anesthetics and steroids are used, conservative treatment with an occupational therapist may be attempted. Before therapy can commence, treatment such as the common rest, ice, compression and elevation (R.I.C.E.) will typically be used. This will help to decrease the pain and inflammation; rest will alleviate discomfort because golfer's elbow is an overuse injury. The patient can use a tennis elbow splint for compression. A pad can be placed anteromedially on the proximal forearm. The splint is made in 30–45 degrees of elbow flexion. A daytime elbow pad also may be useful, by limiting additional trauma to the nerve.
Therapy will include a variety of exercises for muscle/tendon reconditioning, starting with stretching and gradual strengthening of the flexor-pronator muscles. Strengthening will slowly begin with isometrics and progresses to eccentric exercises helping to extend the range of motion back to where it once was. After the strengthening exercises, it is common for the patient to ice the area.
Simple analgesic medication has a place, as does more specific treatment with oral anti-inflammatory medications (NSAIDs). These will help control pain and any inflammation. A more invasive treatment is the injection into and around the inflamed and tender area of a long-acting glucocorticoid (steroid) agent. After causing an initial exacerbation of symptoms lasting 24 to 48 hours, this may produce an improvement of the condition in some five to seven days.
The ulnar nerve runs in the groove between the medial humeral epicondyle and the olecranon process of the ulna. It is most important that this nerve should not be damaged accidentally in the process of injecting a golfer's elbow.
If all else fails, epicondylar debridement (a surgery) may be effective. The ulnar nerve may also be decompressed surgically.
If the appropriate remediation steps are taken - rest, ice, and rehabilitative exercise and stretching - recovery may follow. Few patients will need to progress to steroid injection, and less than 10% will require surgical intervention.
Although anti-inflammatories are a commonly prescribed treatment for tennis elbow, the evidence for their effect is usually anecdotal with only limited studies showing a benefit. A systematic review found that topical non-steroidal anti-inflammatory drugs (NSAIDs) may improve pain in the short term (up to 4 weeks) but was unable to draw firm conclusions due to methodological issues. Evidence for oral NSAIDs is mixed.
Evidence is poor for long term improvement from injections of any type, whether corticosteroids, botulinum toxin, prolotherapy or other substances. Corticosteroid injection may be effective in the short term however are of little benefit after a year, compared to a wait-and-see approach. A recent randomized control trial comparing the effect of corticosteroid injection, physiotherapy, or a combination of corticosteroid injection and physiotherapy found that patients treated with corticosteroid injection versus placebo had lower complete recovery or improvement at 1 year (Relative risk 0.86). Patients that received corticosteroid injection also had a higher recurrence rate at 1 year versus placebo (54% versus 12%, relative risk 0.23).
Complications from repeated steroid injections include skin problems such as hypopigmentation and fat atrophy leading to indentation of the skin around the injection site. Botulinum toxin type A to paralyze the forearm extensor muscles in those with chronic tennis elbow that has not improved with conservative measures may be viable.
Early stages may be treated conservatively using the R.I.C.E methods.
1. Rest
2. Ice
3. Compression
4. Elevation
Exercises involving eccentric muscle contractions of the quadriceps on a decline board are strongly supported by extant literature. A physical therapist may also recommend specific exercises and stretches to strengthen the muscles and tendons, eg. cycling or swimming. Use of a strap for jumper's knee and suspension inlays for shoes may also reduce the problems.
Should this fail, autologous blood injection, or platelet-rich plasma injection may be performed and is typically successful though not as successful as high volume saline injection (Crisp "et al."). Uncommonly it may require surgery to remove myxoid degeneration in the tendon. This is reserved for patients with debilitating pain for 6–12 months despite conservative measures. Novel treatment modalities targeting the abnormal blood vessel growth which occurs in the condition are currently being investigated.
New research shows that knee operations in most cases have no better effects than exercise programs, and that most knee operations thus can be avoided.
Treatment is possible with ice, cold compression therapy, wearing heel pads to reduce the strain on the tendon, and an exercise routine designed to strengthen the tendon (see eccentric strengthening, above). Some people have reported vast improvement after applying light to medium compression around ankles and lower calf by wearing elastic bandages throughout the day. Using these elastic bandages while sleeping can reduce morning stiffness but care must be taken to apply very light compression during sleep. Compression can inhibit healing by hindering circulation. Seeing a professional for treatment as soon as possible is important, because this injury can lead to an Achilles tendon rupture with continued overuse. Other treatments may include non-steroidal anti-inflammatory drugs, such as ibuprofen, ultrasound therapy, manual therapy techniques, a rehabilitation program, and in rare cases, application of a plaster cast. Steroid injection is sometimes used, but must be done after very careful, expert consideration because it can increase the risk of tendon rupture. There has recently been some interest in the use of autologous blood injections; however the results have not been highly encouraging and there is little evidence for their use.
More specialised therapies include prolotherapy (sclerosant injection into the neovascularity) and extracorporeal shockwave therapy may have some additional benefit. However, the evidence is limited.
Evidence for the treatment of lateral epicondylitis before 2010 was poor. There were clinical trials addressing many proposed treatments, but the trials were of poor quality.
In some cases, severity of tennis elbow symptoms mend without any treatment, within six to 24 months. Tennis elbow left untreated can lead to chronic pain that degrades quality of daily living.
Those suspected of having a rotator cuff tear are potentially candidates for either operative or non-operative treatment. However, any individual may move from one group to the other based on clinical response and findings on repeated examination.
No evidence of benefit is seen from early rather than delayed surgery, and many with partial tears and some with complete tears will respond to nonoperative management. Consequently, many recommend initial, nonsurgical management. However, early surgical treatment may be considered in significant (>1 cm-1.5 cm) acute tears or in young patients with full-thickness tears who have a significant risk for the development of irreparable rotator cuff changes.
Finally, a review of more than 150 published papers in 2010 concluded that no solid evidence indicated rotator-cuff surgery benefited patients more than nonoperative management, adding to management and treatment controversies.
Those with pain but reasonably maintained function are suitable for nonoperative management. This includes oral medications that provide pain relief such as anti-inflammatory agents, topical pain relievers such as cold packs, and if warranted, subacromial corticosteroid/local anesthetic injection. An alternative to injection is iontophoresis, a battery-powered patch which "drives" the medication to the target tissue. A sling may be offered for short-term comfort, with the understanding that undesirable shoulder stiffness can develop with prolonged immobilization. Early physical therapy may afford pain relief with modalities (e.g. iontophoresis) and help to maintain motion. Ultrasound treatment is not efficacious. As pain decreases, strength deficiencies and biomechanical errors can be corrected.
A conservative physical therapy program begins with preliminary rest and restriction from engaging in activities which gave rise to symptoms. Normally, inflammation can usually be controlled within one to two weeks, using a nonsteroidal anti-inflammatory drug and subacromial steroid injections to decrease inflammation, to the point that pain has been significantly decreased to make stretching tolerable. After this short period, rapid stiffening and an increase in pain can result if sufficient stretching has not been implemented.
A gentle, passive range-of-motion program should be started to help prevent stiffness and maintain range of motion during this resting period. Exercises, for the anterior, inferior, and posterior shoulder, should be part of this program. Codman exercises (giant, pudding-stirring), to "permit the patient to abduct the arm by gravity, the supraspinatus remains relaxed, and no fulcrum is required" are widely used. The use of NSAIDs, hot and cold packs, and physical therapy modalities, such as ultrasound, phonophoresis, or iontophoresis, can be instituted during this stretching period, if effective. Corticosteroid injections are recommended two to three months apart with a maximum of three injections. Multiple injections (four or more) have been shown to compromise the results of rotator cuff surgery which result in weakening of the tendon. However, before any rotator cuff strengthening can be started, the shoulder must have a full range of motion.
After a full, painless range of motion is achieved, the patient may advance to a gentle strengthening program. Rockwood coined the term orthotherapy to describe this program which is aimed at creating an exercise regimen that initially gently improves motion, then gradually improves strength in the shoulder girdle. Each patient is given a home therapy kit, which includes elastic bands of six different colors and strengths, a pulley set, and a three-piece, one-meter-long stick. The program is customized, fitting the needs of the individual and altering when necessary. Participants are asked to use their exercise program whether at home, work, or traveling.
Several instances occur in which nonoperative treatment would not be suggested:
- 20 to 30-year-old active patient with an acute tear and severe functional deficit from a specific event
- 30 to 50-year-old patient with an acute rotator cuff tear secondary to a specific event
- a highly competitive athlete who is primarily involved in overhead or throwing sports
These patients may need to be treated operatively because rotator cuff repair is necessary for restoration of the normal strength required to return to the preoperative, competitive level of function. Finally, those who do not respond to, or are unsatisfied with, conservative treatment should seek a surgical opinion.
In patients with bursitis who have rheumatoid arthritis, short term improvements are not taken as a sign of resolution and may require long term treatment to ensure recurrence is minimized. Joint contracture of the shoulder has also been found to be at a higher incidence in type two diabetics, which may lead to frozen shoulder (Donatelli, 2004).
Deteriorating changes start to appear with age, but attempting to slow down these changes is key in the prevention of Achilles tendinitis. Performing consistent physical activity will improve the elasticity and strength of the tendon, which will assist in resisting the forces that are applied.
It is essential to stretch and warm-up before beginning an exercise session in order to prepare and protect the tendon for work. Warm-ups enhance the tendon's capability of being stretched, further aiding in protection from injury. Prevention of recurrence includes following appropriate exercise habits and wearing low-heeled shoes. In the case of incorrect foot alignment, orthotics can be used as a preventative way to properly position the feet. Footwear that is specialized to provide shock-absorption can be utilized to defend the longevity of the tendon. Achilles tendon injuries can be the result of exceeding the tendon's capabilities for loading, therefore it is important to gradually adapt to exercise if someone is inexperienced, sedentary, or is an athlete who is not progressing at a steady rate.
Preventive exercises are aimed at strengthening the gastrocnemius and soleus muscles, typically by eccentric strengthening exercises. This eccentric training method is especially important for individuals with chronic Achilles tendinosis which is classified as the degeneration of collagen fibers. Eccentric exercises improve the tensile strength of the tendon and lengthen the muscle-tendon junction, decreasing the amount of strain experienced with ankle joint movements. These involve repetitions of slowly raising and lowering the body while standing on the affected leg, using the opposite arm to assist balance and support if necessary, and starting with the heel in a hyperextended position. (Hyperextension is typically achieved by balancing the forefoot on the edge of a step, a thick book, or a barbell weight. so that the point of the heel is a couple of inches below the forefoot.)
The most-often prescribed treatments for early-stage RSIs include analgesics, myofeedback, biofeedback, physical therapy, relaxation, and ultrasound therapy. Low-grade RSIs can sometimes resolve themselves if treatments begin shortly after the onset of symptoms. However, some RSIs may require more aggressive intervention including surgery and can persist for years.
General exercise has been shown to decrease the risk of developing RSI. Doctors sometimes recommend that RSI sufferers engage in specific strengthening exercises, for example to improve sitting posture, reduce excessive kyphosis, and potentially thoracic outlet syndrome. Modifications of posture and arm use (human factors and ergonomics) are often recommended.
Until recently, there was no specific treatment for osteitis pubis. To treat the pain and inflammation caused by osteitis pubis, antiinflammatory medication, stretching, and strengthening of the stabilizing muscles are often prescribed. In Argentina, Topol et al. have studied the use of glucose and lidocaine injections ("prolotherapy", or regenerative injection therapy) in an attempt to restart the healing process and generate new connective tissue in 72 athletes with chronic groin/abdominal pain who had failed a conservative treatment trial. The treatment consisted of monthly injections to ligament attachments on the pubis. Their pain had lasted an average of 11 months, ranging from 3–60 months. The average number of treatments received was 3, ranging from 1–6. Their pain improved by 82%. Six athletes did not improve, and the remaining 66 returned to unrestricted sport in an average of 3 months.
Surgical intervention - such as wedge resection of the pubis symphysis - is sometimes attempted in severe cases, but its success rate is not high, and the surgery itself may lead to later pelvic problems.
The Australian Football League has taken some steps to reduce the incidence of osteitis pubis, in particular recommending that clubs restrict the amount of bodybuilding which young players are required to carry out, and in general reducing the physical demands on players before their bodies mature.
Osteitis pubis, if not treated early and correctly, can more often than not end a sporting individuals career, or give them an uncertain playing future.
In horses tendinitis is called a bowed tendon from the appearance of the affected tendon after it heals without treatment. Mesenchymal stem cells, derived from a horse's bone marrow or fat, are currently being used for tendon repair in horses.
The condition is called "Golfer's Elbow" because in making a golf swing this tendon is stressed, especially if a non-overlapping (baseball style) grip is used; many people, however, who develop the condition have never handled a golf club. It is also sometimes called "Pitcher's Elbow" due to the same tendon being stressed by the throwing of objects such as a baseball, but this usage is much less frequent. Other names are "Climber's Elbow" and "Little League Elbow": all of the flexors of the fingers and the pronators of the forearm insert at the medial epicondyle of the humerus to include: pronator teres, flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, and palmaris longus; making this the most common elbow injury for rock climbers, whose sport is very grip intensive. The pain is normally caused due to stress on the tendon as a result of the large amount of grip exerted by the digits and torsion of the wrist which is caused by the use and action of the cluster of muscles on the condyle of the ulna.
Epicondylitis is much more common on the lateral side of the elbow (tennis elbow), rather than the medial side. In most cases, its onset is gradual and symptoms often persist for weeks before patients seek care. In golfer's elbow, pain at the medial epicondyle is aggravated by resisted wrist flexion and pronation, which is used to aid diagnosis. On the other hand, tennis elbow is indicated by the presence of lateral epicondylar pain precipitated by resisted wrist extension. Although the condition is poorly understood at a cellular and molecular level, there are hypotheses that point to apoptosis and autophagic cell death as causes of chronic lateral epicondylitis. The cell death may decrease the muscle density and cause a snowball effect in muscle weakness - this susceptibility can compromise a muscle's ability to maintain its integrity. So athletes, like pitchers, must work on preventing this cell death via flexibility training and other preventive measures.
Patellar tendinitis (patellar tendinopathy, also known as jumper's knee), is a relatively common cause of pain in the inferior patellar region in athletes. It is common with frequent jumping and studies have shown it may be associated with stiff ankle movement and ankle sprains.
The exact etiology of tendinopathy has not been fully elucidated and different stresses may induce varying responses in different tendons. There are multifactorial theories that could include: tensile overload, tenocyte related collagen synthesis disruption, load-induced ischemia, neural sprouting, thermal damage, and adaptive compressive responses. The intratendinous sliding motion of fascicles and shear force at interfaces of fascicles could be an important mechanical factor for the development of tendinopathy and predispose tendons to rupture. Obesity, or more specifically, adiposity or fatness, has also been linked to an increasing incidence of tendinopathy.
The most commonly accepted cause for this condition however is seen to be an overuse syndrome in combination with intrinsic and extrinsic factors leading to what may be seen as a progressive interference or the failing of the innate healing response. Tendinopathy involves cellular apoptosis, matrix disorganization and neovascularization.
Tendinopathy can be induced in animal models by a surgical injury to the tendon. In both sheep shoulder (infraspinatus) and horse forelimb (superficial digitor flexor) tendons, a mid-tendon transection caused pathology in the entire tendon after four and six weeks respectively.
Quinolone antibiotics are associated with increased risk of tendinitis and tendon rupture. A 2013 review found the incidence of tendon injury among those taking fluoroquinolones to be between 0.08 and 0.2%. Fluoroquinolones most frequently affect large load-bearing tendons in the lower limb, especially the Achilles tendon which ruptures in approximately 30 to 40% of cases.
Damage can occur to the ligaments surrounding and bridging the pubic joint (symphysis) as a result of the hormone relaxin, which is secreted around the time of birth to soften the pelvic ligaments for labor. At this time repetitive stress or falling, tripping, and slipping can injure ligaments more easily. The hormone usually disappears after childbirth and the ligaments become strong again. In some women the weakness persists, and activities such as carrying their baby or stepping up even a small step can cause a slight but continuous separation or shearing in the ligaments of the symphysis where they attach to the joint surfaces, even causing lesions in the fibrocartilage and pubic bones. Symptoms include one or more of the following: pain in the pubic area, hips, lower back, and thighs. This can take months (or even years) to go away.
X-rays taken during the early stages of osteitis pubis can be misleading - pain may be felt, but the damage doesn't appear on the films unless stork views (i.e. standing on one leg) are obtained. As the process continues and progresses, later pictures will show evidence of bony erosion in the pubic bones. Osteitis pubis can also be associated with pelvic girdle pain.
A repetitive strain injury (RSI) is an "injury to the musculoskeletal and nervous systems that may be caused by repetitive tasks, forceful exertions, vibrations, mechanical compression, or sustained or awkward positions".
Video game playing may be associated with vision problems. Extensive viewing of the screen can cause eye strain, as the cornea, pupil, and iris are not intended for mass viewing sessions of electronic devices. Using video games for too long may also cause headaches, dizziness, and chances of vomiting from focusing on a screen.
However, certain studies have shown that video games can be used to improve various eye conditions. An investigation into the effect of action gaming on spatial distribution of attention was conducted and revealed that gamers exhibited an enhancement with attention resources compared to non-gamers, not only in the periphery but also in central vision. Further studies in 2011, concluded that a combination of video game therapy alongside occlusion therapy, would greatly improve the recovery of visual acuity in those experiencing amblyopia.
Video game-related health problems can induce repetitive strain injuries, skin disorders or other health issues. Other problems include video game-provoked seizures in patients with epilepsy. In rare and extreme cases, deaths have resulted from excessive video game playing (see Deaths due to video game addiction).