Tendons are flexible bands of tissue that connect muscles to bones. They help your muscles move your bones. Tendinitis is the severe swelling of a tendon.

Tendinitis usually happens after repeated injury to an area such as the wrist or ankle. It causes pain and soreness around a joint. Some common forms of tendinitis are named after the sports that increase their risk. They include tennis elbow, golfer's elbow, pitcher's shoulder, swimmer's shoulder, and jumper's knee.

Doctors diagnose tendinitis with your medical history, a physical exam, and imaging tests. The first step in treatment is to reduce pain and swelling. Rest, wrapping or elevating the affected area, and medicines can help. Ice is helpful for recent, severe injuries. Other treatments include ultrasound, physical therapy, steroid injections, and surgery.

Tendinitis is swelling and pain in a tendon, which is tissue that connects muscles to bones. It is a common condition, usually caused by repeated injuries to a tendon.

Points To Remember About Tendinitis

• Tendinitis is pain and swelling in a tendon, a band of tissue that connects muscle to bone.
• It’s a common condition, often caused by repetitive activities, such as tennis or playing a musical instrument, or injuries.
• Recovering from tendinitis usually involves resting, supporting the sore tissues, and taking medicines to reduce swelling. Depending on how bad your injury is, you may need physical therapy or surgery.
• You can reduce your risk of tendinitis by warming up before exercising and strengthening the muscles around your joints.

You’ve probably heard of such sports injuries as tennis elbow or jumper’s knee. These are just 2 examples of tendinitis, a painful condition caused by overusing and straining the joints in your body.

Tendons are the tough but flexible bands of tissue that connect muscle to bones. You have about 4,000 tendons throughout your body. Tendons make it possible for you to bend your knee, rotate your shoulder, and grasp with your hand.

Tendinitis is inflammation of a tendon. (When you see “itis” at the end of a medical word, it means inflammation.) In tendinitis, the tendon gets inflamed and can rub against bone, making movement painful.

Tendinitis is usually caused by repeated motion, stress, or injury to certain muscles or joints. A sports or job-related injury is a common way to get tendinitis, but the condition can happen to anyone. Your risk for tendinitis also increases with age. “Tendons lose health as we get older and become less able to handle the load,” says Dr. Evan Flatow, an orthopedist at Mount Sinai Roosevelt Hospital in New York.

Any activity that requires repetitive wrist turning or hand gripping, jumping or bending, pulling, pushing, or lifting can irritate the tendons. Some of the most common places to get the condition are in the shoulders, elbows, hands, wrists, knees, and ankles. Gardeners, carpenters, musicians, and other people whose work regularly places stress around the same tendons are at increased risk for developing tendinitis.

If treated early, tendinitis is usually a short-term condition. But it can come back if the tendon is aggravated over and over again. If tendinitis keeps affecting the same area over time, the tendon can weaken and tear or break.

If you have pain or swelling—and especially if you can’t move a joint at all—contact a primary care doctor or an orthopedist. They can perform tests to pinpoint the exact areas of inflammation. You may also get an MRI scan or X-ray to check for a tear in the tendon or rule out other conditions, such as arthritis.

The first step in treating tendinitis is to reduce pain and swelling. Be sure to rest the swollen tendon so it can heal. “We have to break the cycle of inflammation to allow therapy to work,” Flatow says. A doctor may prescribe medicines that relieve inflammation (such as aspirin or ibuprofen), give steroid injections, or give you a splint or brace. Then gentle exercises can help strengthen the tendon.

If a tendon becomes torn, surgery might be needed to repair the damage. NIH-funded researchers such as Flatow are working to develop new ways to repair and regenerate tendons without surgery.

Regular physical activity helps keep muscles, bones, and tendons strong, and can lower your risk of injury and tendinitis. But be careful not to overdo it so you don’t injure yourself.

“Keep joints limber,” Flatow advises. “Warm up and stretch before physical activity to prevent sudden injury.” Take care of your tendons so they can keep you painlessly bending and flexing your muscles long into old age.

Preventing Tendinitis

• Exercise regularly to strengthen muscles around the joints.
• Begin new activities or exercise routines slowly and gradually increase the intensity.
• Position your body properly when doing daily tasks.
• Take frequent breaks from repetitive exercises and motions.
• Stop activities that cause pain.
• Use padding, gloves, or grip tape to cushion joints while using tools and sports equipment.

To move the skeleton, the tension created by the contraction of the fibers in most skeletal muscles is transferred to the tendons. The tendons are strong bands of dense, regular connective tissue that connect muscles to bones. The bone connection is why this muscle tissue is called skeletal muscle.Tough, fibrous, cord-like tissue that connects muscle to bone or another structure, such as an eyeball. Tendons help the bone or structure to move.

Exercise and Stretching

When exercising, it is important to first warm up the muscles. Stretching pulls on the muscle fibers and it also results in an increased blood flow to the muscles being worked. Without a proper warm-up, it is possible that you may either damage some of the muscle fibers or pull a tendon. A pulled tendon, regardless of location, results in pain, swelling, and diminished function; if it is moderate to severe, the injury could immobilize you for an extended period.

Recall the discussion about muscles crossing joints to create movement. Most of the joints you use during exercise are synovial joints, which have synovial fluid in the joint space between two bones. Exercise and stretching may also have a beneficial effect on synovial joints. Synovial fluid is a thin, but viscous film with the consistency of egg whites. When you first get up and start moving, your joints feel stiff for a number of reasons. After proper stretching and warm-up, the synovial fluid may become less viscous, allowing for better joint function.

About Tendons

A tendon is a flexible band of tissue that connects muscles to bones.

Tendons can be small, like those found in the hand or ankle, or large, like the Achilles tendon in the heel.

Tendons help create movement by making the muscles push or pull the bones in different ways.

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

Some types of tendinitis are named after the activities that often cause them. Here are some common types:

• Tennis elbow, which is an injury to the outer elbow tendon, often caused by repetitive wrist turning or hand gripping.
• Golfer’s elbow, which is an injury to the inner elbow tendon, often caused by repetitive wrist turning or hand gripping.
• Biceps tendinitis, which causes pain in the front or side of the shoulder that may travel down the arm, and sometimes pain when the arm is raised overhead.
• Rotator cuff tendinitis, which causes pain at the tip of the shoulder and the upper, outer arm; pain may become worse when reaching, pushing, pulling, lifting, raising the arm, or lying on the shoulder.
• Jumper's knee, more common among people who play sports that require jumping, such as basketball, which causes the knee tendon to become inflamed or tear from overuse.
• Achilles tendinitis, which is tendinitis in the tendon on the back of the heel.

Tennis elbow is the common term for a painful elbow disorder.

The technical name for tennis elbow is "lateral epicondylitis". This term refers to an inflammation that is occurring near a small point or projection of the upper arm bone (humerus) just above the elbow joint on the outer side of the arm. However, pain can also occur in the forearm and wrist.

The pain from tennis elbow comes mainly from injured or damaged tendons near the elbow. Tendons are strong bands of tissue that connect muscles to bones. When repeatedly stressed or overused, tendons can become inflamed and degenerate. This results in a painful condition called tendinopathy, the medical term for disorder of a tendon. Tennis elbow is simply a specific type of tendinopathy that occurs in a particular part of the elbow.

Damaged tendons can occur on either side of the elbow. When it happens on the outside of the elbow, which is most common, it is called tennis elbow. When it happens on the inside, it is called "medial epicondylitis" or "golfer's elbow."

Tennis elbow is an injury to the tendon in the outer elbow. Golfer's elbow affects the inner tendon of the elbow. Any activity that involves a lot of wrist turning or hand gripping, such as using tools, shaking hands, or twisting, can bring on these conditions. Pain occurs near the elbow. It can also travel into the upper arm or forearm.

What Are Bursitis and Tendinitis?

Bursitis and tendinitis are both common conditions that cause swelling around muscles and bones. They occur most often in the shoulder, elbow, wrist, hip, knee, or ankle.

A bursa is a small, fluid-filled sac that acts as a cushion between a bone and other moving body parts such as muscles, tendons, or skin. Bursae are found throughout the body. Bursitis occurs when a bursa becomes swollen.

A tendon is a flexible band of tissue that connects muscles to bones. Tendons can be small, like those found in the hand or ankle, or large, like the Achilles tendon in the heel. Tendons help create movement by making the muscles push or pull the bones in different ways. Tendinitis is the severe swelling of a tendon.

What Causes These Conditions?

People get bursitis by overusing a joint. It can also be caused by direct trauma. It usually occurs at the knee or elbow. Kneeling or leaning your elbows on a hard surface for a long time can make bursitis start. Tendinitis usually occurs after repeated injury to a certain area such as the wrist or ankle. Tendons become less flexible with age and become more prone to damage.

Doing the same kinds of movements every day or putting stress on joints increases the risk for both conditions. People like carpenters, gardeners, musicians, and athletes often get bursitis or tendinitis.

Infection, arthritis, gout, thyroid disease, and diabetes can also cause swelling of a bursa or tendon. Both bursitis and tendinitis are more frequent the older you get.

What Parts of the Body Are Affected?

Tendinitis causes pain and soreness around a joint. Some common forms of tendinitis are named after the sports that increase their risk. They include tennis elbow, golfer's elbow, pitcher's shoulder, swimmer's shoulder, and jumper's knee.

The main function of the biceps muscle is forearm supination and elbow flexion. The biceps also contribute 10 percent of the total power in shoulder abduction when the arm is in external rotation. Consequently, biceps tendinitis, a condition describing inflammation of the tendon that attaches the biceps muscle to the bone, can impair patients' ability to perform many routine activities. 

Treatment / Management

Nonoperative Management

The initial management of LHB tendinopathy is nonsurgical. A period of rest and activity modification is beneficial in the acute setting, coupled with nonsteroidal anti-inflammatory drugs (NSAIDs).

Physical therapy

Successful physical therapy regimens target the underlying source(s) contributing to the LHB tendon pathology. Potential factors predisposing to biceps-related shoulder injuries include glenohumeral internal rotation deficit (GIRD) in overhead-throwing athletes/baseball pitchers, poor trunk control, scapular dyskinesia, and internal impingement.

Strengthening protocols should focus on restoring muscle balance across the shoulder girdle, including rotator cuff and periscapular muscle strengthening programs. Focused stretching on the anterior shoulder structures, including pectoralis minor, should also be considered. Other modalities, such as dry needling, have demonstrated promise in preliminary animal studies.

Injections

Corticosteroid injections are considered in the setting of persistent symptoms despite the aforementioned therapies. There is some controversy with respect to the type of technique used (ultrasound-guided versus blind injection) and the exact location utilized for the injection (subacromial, intra-articular, bicipital groove/sheath).  Theoretically, in the setting of concomitant shoulder pathologies, an intra-articular injection would also reach the LHB tendon in the bicipital groove, as the sheath is contiguous with the glenohumeral joint synovial tissue.

Direct injection is targeted to the sheath itself, and not the LHB tendon directly. Although not definitively documented, an intratendinous LHB tendon injection may predispose the patient to tendon rupture. In a 2011 randomized controlled trial (RCT) comparing injection accuracy (with post-injection CT imaging to confirm injection placement by location) of ultrasound-guided versus blind bicipital sheath injections at their location in the groove.  Potential injection location results included (1) solely in the tendon sheath, (2) inside the tendon, in the tendon sheath, and surrounding (but outside) the tendon sheath, and (3) confined to only the area outside the tendon sheath. The ultrasound-guided injections resulted in 87% accuracy for injecting the tendon sheath alone (location "1"). By stark contrast, the blind injection was accurate only 27% of the time, and one-third of the time, the tendon itself and the entire bicipital sheath were missed altogether.

Surgical Management

For this review, the management of SLAP injuries will not be discussed.

Indications for surgical management include:

• Intra-operative findings of an inflamed tendon (i.e., the “lipstick” lesion), significant fraying, tearing, or hypertrophy

• Partial-thickness tears of the LHB tendon (>25% to 50%)

• Medial LHB subluxation

• LHB subluxation with associated subscapularis tear, or bicipital groove soft tissue compromise

Surgical Techniques

Biceps tenotomy 

• Provides reproducible results in terms of pain relief

• Minimal postoperative rehabilitation

The technique involves an initial diagnostic arthroscopy. The glenohumeral joint is inspected for any coexisting clinical pathology. The biceps tendon is examined under direct traction to visually inspect the intertubercular groove portion, which is a prime location of pathology. Next, a probe is used to evaluate the LHB tendon stability in the bicipital groove. Stability can be further assessed by internally rotating the arm and evaluating for any medial/inferior subluxation of the LHB tendon. In the setting of LHB tendon instability, this maneuver will lead to tendon entrapment within the joint. The entrapment is relieved with external rotation of the arm.

Arthroscopic inspection of the tendon allows for the estimation of the relative percentage of the LHB tendon that is compromised. A popular classification system utilized for the intra-operative grade corresponding to the degree of LHB tendon macroscopic pathology is the Lafosse grading scale:

• Grade 0: Normal tendon

• Grade 1: Minor lesion (partial, localized areas of tendon erosion/fraying, focal areas affect 50% of the tendon width)

• Grade 2: Major lesion (extensive tendon loss, compromising >50% of the tendon width)

Some surgeons solely debride the tendon in the setting of 50% tendinous compromise. Arthroscopic biceps tenotomy is performed by releasing the tendon as close as possible to the superior labrum. As long as the tendon is free from intimate soft tissue adhesions to surrounding structures, the tendon should retract distally toward the bicipital groove. If adhesions are present, all efforts should be made to mobilize the tendon in order to allow for retraction following the tenotomy. In cases where the LHB tendon is particularly hypertrophic and scarred to other soft tissue structures in the joint, this serves as a potential source of postoperative pain.

 Biceps tenodesis

• The preferred technique in younger patients, athletes, laborers, and those patients specifically concerned with postoperative cosmetic deformity

• Optimizes the length-tension relationship of the biceps muscle; mitigates postoperative risk of muscle atrophy, fatigue, and cramping

Various locations for the tenodesis itself, in addition to fixation technique, used provide equivalent results in terms of patient satisfaction and clinical outcomes. Following a standard diagnostic arthroscopy, a spinal needle is used to “tag” the tendon near its entrance into the bicipital groove. Once this is tagged with Fiberwire, the tenotomy is performed, and the residual “stump” is shaved back to the superior labrum.

Next, the arthroscope is taken into the subacromial space, and the tagging sutures help localize the residual LHB tendon's location. The bicipital groove is then opened up with a cautery device until the LHB tendon is visualized. Following mobilization of the tendon to the medial aspect of the bicipital groove, the osseous groove is cleared of all soft tissue in preparation for fixation. One technique involves interference screw placement approximately 1cm distal to the superior extent of the groove. During the fixation of the tendon, care is taken to utilize an arthroscopic grasper to maintain ideal tension on the proximal extent of the LHB tendon. Once fixation is complete, any residual tendon that remains prominent from the fixation point is carefully resected.

An alternative to the arthroscopic (or suprapectoral) tenodesis procedure is the open subpectoral approach. Several studies have compared outcomes between the all-arthroscopic and open subpectoral approaches. Although advocates for the latter approach cite the theoretical advantage of being able to remove the LHB tendon from the bicipital groove completely, the majority of studies report similar patient-reported outcomes and no difference in patient-reported pain scores.

Your rotator cuff is located in your shoulder area. It is made of muscles and tendons. It helps your shoulder to move and stay stable. Problems with the rotator cuff are common. They include tendinitis, bursitis, and injuries such as tears.

Rotator cuff tendons can become inflamed from frequent use or aging. Sometimes they are injured from a fall on an outstretched hand. Sports or jobs with repeated overhead motion can also damage the rotator cuff. Aging causes tendons to wear down, which can lead to a tear.

Some tears are not painful, but others can be very painful. Treatment for a torn rotator cuff depends on age, health, how severe the injury is, and how long you've had the torn rotator cuff.

Treatment for torn rotator cuff includes:

• Rest
• Heat or cold to the sore area
• Medicines that reduce pain and swelling
• Electrical stimulation of muscles and nerves
• Ultrasound
• Cortisone injection
• Surgery

"Jumper's knee," also called patellar tendinopathy, is a painful condition of the knee, mainly activity-related, caused by small tears in the patellar tendon that mainly occurs in sports requiring strenuous jumping and results in localized patellar tendon tenderness. The tears are typically caused by accumulated stress on the patellar or quadriceps tendon. As the name implies, the condition is common in athletes from jumping sports, where there is a high demand for the speed and power of leg extensors. These sports often lead to high eccentric quadriceps loadings, such as volleyball, track (long and high jump), basketball, long-distance running, and skiing. 

There is no evidence-based, preferred treatment of choice for a jumper's knee. Refractory response to treatment is also typical for the condition, often leaving the health professional and patients searching for alternative therapies.

Most patients with jumper's knee are managed through medical and rehabilitative treatment in the initial stages of the disease. Early recognition and diagnosis of jumper's knee are vital as they can have a progressive course. Although non-steroidal anti-inflammatory drugs were used traditionally, these have recently become less judicious as more physicians have come to realize that the disease is not inflammatory. Hence, NSAIDs may not provide a significant long-term benefit in tendinopathy. Corticosteroid injections are contraindicated as they bear a risk of patellar tendon rupture.

Non-surgical treatment focusing on the following: Relative rest rather than immobilization to avoid tendon and muscle atrophy. Cryotherapy provides analgesia and antagonizes the neovascularization process, contributing to the pathology. Modification of activities, and sports training, including adequate warm-ups and physiotherapy to increase the flexibility of quadriceps and hamstring muscles. 

Eccentric training has been suggested to play a key role in rehabilitating a jumper's knee. Eccentric training has been shown to have equally efficacious results as surgical treatment. It is recommended that eccentric training should be tried for twelve weeks before offering surgical treatment. According to Rodriguez-Merchan eccentric training appears to be the treatment of choice for patients suffering from patellar tendinopathy.

Athletes must avoid activities such as excessive jumping or impact loading of the knee, which only aggravates the situation. As the pain begins to subside, the intensity of rehabilitation therapy and sport-specific training can be slowly increased. Reduction of strain across the patellar tendon can be helpful using taping or infrapatellar straps. It reduces patellar tendon strain by altering the angle between the patella and patellar tendon. Given the refractory response to many initial treatments, new methods have recently emerged. These include dry-needling, sclerosing injections, platelet-rich plasma therapy, extracorporeal shock wave treatment, Aprotinin injection, a strong inhibitor of matrix metalloproteinases, and hyperthermia thermotherapy. More recently, a three stages rehabilitation protocol has been proposed with a focus on pain reduction followed by progressive loading. The three stages include; Modulation of pain and load management, followed by strengthening exercises and load progression, and finally, functional strengthening and return to sports.

Surgical treatment is usually indicated in cases of partial tendon tears and Blazina stage III, where pain continues during rest and activities. Also, it remains the last resort for chronic refractory cases unresponsive to conservative treatment. Traditionally, the gold standard for surgical treatment of patellar tendinopathy involved open debridement of the inferior pole of the patella, as well as debridement of the patellar tendon by excising the angiofibroblastic and degenerative areas. This is followed by reattachment of the tendon using sutures or anchors as indicated. Recently, knee arthroscopy has gained popularity for tissue debridement and release. The arthroscopic procedure has been described as being performed through a direct inferior patellar portal.

You are more likely to get tendinitis if you do the same kinds of movements every day or put stress on your joints. People like carpenters, gardeners, musicians, and athletes often get tendinitis. You are more likely to get tendinitis the older you get.

Tendinitis is usually caused by repeated injuries to a tendon. Infection, arthritis, gout, thyroid disease, and diabetes can also cause tendinitis.

Is there a test for tendinitis?

To diagnose tendinitis, your doctor will probably ask questions about your medical history and conduct a physical examination. Your doctor will probably ask you to describe your pain and will ask when and where you hurt and whether anything makes the pain better or worse.

Your doctor may also do other tests, such as:

• Touching the joint to see where your joint is swollen.
• X-rays, which do not show tendons, but can help rule out other problems.
• A magnetic resonance imaging test (MRI), which can show whether the tendon is swollen.
• Taking fluid from the swollen area to test for an infection.
• Injecting an anesthetic to see if the pain goes away.

Treating tendinitis can reduce pain and swelling. Some common treatments include:

• Resting and elevating the injured area.
• Limiting your activity to reduce further injury.
• Taking medicines that will reduce swelling, such as aspirin, naproxen, or ibuprofen.
• Gentle stretching and strengthening exercises.
• Applying compression to the injured area.
• Soft tissue massage.
• Putting a brace, splint, or band on the injured joint.

Your doctor may also recommend ice for sudden, severe injuries, but most cases of tendinitis are long term, and ice does not help.

If your tendinitis does not improve, your doctor may inject a medicine into the area surrounding the swollen tendon.

If your tendon is completely torn, you may need surgery. If your tendon is partially or completely torn, you may also need several months of physical therapy and exercises to restore your strength and prevent further injury.

Who Treats Tendinitis?

Diagnosing and treating tendinitis is a team effort involving you and several types of health care professionals. Depending on the severity of the condition, these may include:

• A primary care physician.
• Physical therapists, who help to improve joint function.
• Orthopaedists, who specialize in the treatment of, and surgery for, bone and joint diseases or injuries.
• Rheumatologists, who specialize in arthritis and other diseases of the bones, joints, and muscles.

Can I prevent tendinitis?

Here are some tips to help reduce the risk and severity of tendinitis:

• Warm up and stretch before exercising.
• Strengthen the muscles around your joints.
• Take breaks from repetitive tasks.
• Increase the gripping surface on tools by using gloves, grip tape or other padding. Use an oversized grip on golf clubs.
• Use two hands to hold heavy tools or hit a backhand in tennis.
• Don’t sit still for long periods, and have good posture.
• Begin new activities and exercises slowly.
• Strengthen muscles around the joint.
• Stop activities that cause pain.
• Cushion the affected joint. Use foam for kneeling, or elbow pads. Increase the gripping surface of tools with gloves or padding. Apply grip tape or an oversized grip to golf clubs.
• Consider talking with your doctor or physical therapist before starting new exercises and activities.