What doctors wish patients knew about tendinitis

Whether you’re chasing home runs like Yankees slugger Giancarlo Stanton or just chasing your kids around the yard, tendinitis doesn’t play favorites. This painful tendon inflammation can strike anyone—regardless of age or fitness level. 

While it’s often brushed off as a sign of “getting older,” tendinitis is linked to overuse, improper movement or even sudden increases in activity. The good news? With the right knowledge, it’s treatable—and often preventable.

The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.

In this installment, George C. Umeh, MD, a sports medicine physician at Bayhealth Orthopaedics in Milford, Delaware, took the time to discuss what patients should know about tendinitis.

Bayhealth is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“Tendinitis is characterized as inflammation within the tendon, going from tendon pain to swelling and impaired function,” said Dr. Umeh. “A lot of times there’s the misnomer of tendinitis versus tendinopathy. Tendinitis is the acute inflammation of the tendon, so it’s what happens right away. 

George Umeh, MD

“It can be caused by microtears within the tendon, which come from overuse or repetitive motions. Imagine having those steel ropes and they have a little million fibers in them,” he added. “Tendinitis is where you get micro tears within that and it causes inflammation, which then causes pain.”

“Something you see a bit more for patients over a long term—which we’re using this term more now—is tendinopathy, and that describes chronic tendon degeneration,” Dr. Umeh said. “So, maybe you start to have inflammation acutely in the interim, but then over time when it’s become a chronic problem, it’s less of the inflammatory process that’s causing it. 

“It’s more like the tendon didn’t really heal as well and the collagen, which is the main fabric or the main buildup of the tendon, is now causing a breakdown,” he added. 

“What causes tendinitis to develop, is it’s an inflammatory process to start and then sometimes it can also be a degenerative process,” said Dr. Umeh, “similar to what you see with other degenerative things within the body such as disc disease or arthritis.”

“Over time, you keep using that tendon because your tendon is anchored to your muscle and anchored to the bone,” he said. “So, when you put it under a lot of stress with weights or activity or whatever you’re doing, it stretches that tendon.”

“Then once it gets those little damages, our body has inflammation process which goes to help heal it and can lead to things such as swelling and pain,” said Dr. Umeh. “But if you’re still having that swelling, it doesn’t really get a chance to heal appropriately.”

“The most common areas of your body where tendinitis may occur depend on the spore, but the one you see the most is your shoulder. So, that’s rotator cuff tendinopathy,” said Dr. Umeh. “That’s a lot of when people say the rotator cuff is bothering them and they have difficulty with overhead activities. You can see that a lot with overhead athletes—such as baseball and tennis players—and laborers.”

“Your rotator cuff muscles are four muscles that attach into your shoulder,” he said. “And they basically help you stabilize your shoulder and help you with movement such as overhead activities, bringing your shoulders away from your body, reaching to get things overheard, putting on a jacket, taking off your shirt, those kinds of things.” 

“Basically, any type of activity where you’re having your shoulders above your head for the most part,” Dr. Umeh said.

Then there is “patella tendinopathy, which is also known as jumper’s knee,” said Dr. Umeh. “You see that a lot with jumping athletes such as basketball or volleyball players. You also see it a lot in runners too because of the mechanism of running.”

“Then the one misnomer, especially for people who are runners, is Achilles tendinopathy,” he said, noting “that is damage within your Achilles tendon, which is the major tendon that goes from your calf and then inserts into your heel.”

With tendinitis, “it feels like a little bit of a headache wherever the joint is bothering you. You may get out of bed, your Achilles is really stiff, it continues to feel stiff and after you walk for a bit or ambulate throughout the day, it actually does start to get better,” Dr. Umeh said. “That gives us an idea that it might be related to tendonitis or tendinopathy.” 

Another form of tendinitis that sports medicine physicians see is “tennis elbow, which is right at the elbow. And that really is with repetitive wrist extension,” said Dr. Umeh. “We call it tennis elbow because the thought is that when you go to swing a tennis racket, you’re extending your forearm to the elbow.”

“That is one I will see for elbow-pain patients when they come in. It’s the first thing we’re thinking of,” he said. “The fact that you’re using it a lot—it’s not really giving the appropriate time for it to heal and manage well, so it just gets worse and worse.”

The other area tendinitis can develop in “that is common too is called tenosynovitis,” said Dr. Umeh, “which is inflammation of the tendons in the wrist, causing pain, swelling and stiffness.”

“You see that a lot for hairstylists, gamers and people who are using their phones because of the position where you’re holding your phone or doing those things where your wrist is going to be in that position,” he said. 

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While the main cause of tendinitis is overuse, “there are a couple of risk factors that can predispose it,” said Dr. Umeh. “For example, age you get older, your tendons are more degenerated, so it’s likely to have a change in structure. 

“Studies have shown that it is also more prevalent for women compared to men. Although, there is not an exact link,” he added. “There can also be genetic factors and conditions such as obesity, type 2 diabetes, high cholesterol that can lead to higher instances because now it is slowing your healing.”

Tendinitis requires “a clinical diagnosis from history and a physical exam. We listen to what the patient is saying, and we may get assessment of their strength within that particular tendon that’s bothering them and if they have pain, it is range of motion as well,” Dr. Umeh said. “A lot of these things can give a diagnosis.”

“Also, pain directly at the tendon is not really a symptom where you need imaging,” he said, noting that “X-rays don’t show tendons, so they aren’t really helpful in that sense. But X-rays can rule out a bone issue.”

“An ultrasound can help you take a look at the tendons. Sometimes we will do that because it’s more cost effective, you can get it quicker and it can give you a good look at the tendons to see if there are micro tears and if there’s little damage on the ultrasound,” Dr. Umeh said.

When it comes to treatment of tendinitis, “physical therapy is definitely the cornerstone for it. A lot of times whether I’m giving them home exercises, I’m referring patients to a formal physical therapist,” Dr. Umeh said. “That’s usually the first thing I will always recommend for treating tendinitis.”

“There are different types of training that have been shown to help such as eccentric exercises, which emphasizes the lengthening of the muscle under tension,” he said. “So, imagine you’re doing a bicep curl and when you go to curl up, you let it down slowly. ... That’s been shown to be really helpful for repairing the tendinitis.”

With tendinitis, “it’s not something that often needs surgery,” said Dr. Umeh. “It’s actually very rarely needed because more times than not this is just little damage so there’s not much that surgery is going to do to fix it. 

“You don’t want it to get to a point where it then progresses to a tendon rupture because then that’s a lot of times where it does potentially need surgery to get it fixed,” he added. 

“Patients will often ask if cortisone injections are a good option. I may do them sometimes for the shoulder,” Dr. Umeh said. “But the thing with that is that the more you do them, the more likely it is to damage the rotator cuff. 

“I might do it to give a patient a short-term pain relief, but it’s not something that I would give them on a chronic treatment plan because then it’s just going to lead to further damage of that tendon,” he added. “So, if they come in and say they want to go to physical therapy, but their shoulder is really bothering them, I might give them a cortisone injection at that appointment so they can continue to do therapy and at least have a relief of pain while that muscle gets stronger.”

“Sometimes we talk about wearing braces to help offload the tendon,” said Dr. Umeh. “You can use a brace for your knee and your elbow.” 

For example, “there are these tennis elbow braces and a counterforce brace that can help alleviate the tendon,” he added.

There are also “extrinsic factors—mechanical overloads—that can lead to tendinitis such as engaging in activities that require repetitive movements,” said Dr. Umeh. “If you’re not doing the movements right, then that can put strain on the tendon that you don’t want to happen.”

“The other thing we see too is a lot of times if you have an athlete or someone who says they are going to train for a marathon and they are just going to run 10 miles tomorrow, if you haven’t really run in the past week and try to ramp up, that is when you start to have those injuries too,” he said. “If you have such a sudden increase in activity intensity and you don’t really have good rest between those periods, that can also put you at risk for tendinitis.

“This is when you want to have a good regimen or plan,” Dr. Umeh added. This is especially important “if you’re going from someone who is very sedentary to now wanting to get back into activity because you don’t want to end up getting hurt in the process. Then you’re out longer.”

“Diet can also play a role in it too because your tendons are made of collagen,” said Dr. Umeh. “It’s been shown that having good protein and vitamin C or sometimes you can take collagen supplements to help support tendon repair.”

“Things like excessive alcohol and smoke also play a role. Avoiding excessive alcohol and smoking can also be good to making sure the tendon heals appropriately,” he said.