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Insertional tendinopathy

Last updated: October 13, 2020

Summary

Insertional tendinopathy is a common disorder caused by repetitive tendon strain and subsequent poor tendon healing. Tendinopathies are typically seen in athletes and people who regularly perform repetitive movements (e.g., typing, assembly-line work, etc.). The Achilles, patellar, humeral epicondylar, and rotator cuff tendons are most commonly affected. Tendinopathies are characterized by pain, especially on movement, and thickening of the affected tendons. The diagnosis is usually established clinically, but can be confirmed with tendon thickening, which is detectable on ultrasound and MRI. Imaging, including x-ray, may also be indicated to rule out possible associated trauma of the bone. Conservative treatment with rest and physiotherapy is successful in most cases, but corticosteroid injections can be used short-term if these methods fail. Surgical debridement of scarred tendon tissue is reserved for patients who do not improve despite at least 6 months of conservative treatment.

Epidemiology

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Overuse or overload injury (repetitive, excessive strain), degeneration [3]
  • Skeletal abnormalities with strain on tendons (e.g., genu varum)
  • Acute trauma (laceration, rupture)
  • Risk factors
    • Occupation: athletes, jobs requiring manual labor or repetitive movements involving the same muscle
    • Errors in physical training (e.g., sudden increase in exercise intensity, inadequate rest, hard/uneven training grounds, ill-fitting/inappropriate footwear)
    • Previous tendon injuries
    • Recent use of fluoroquinolones

Pathophysiology

  • Contraction of a skeletal muscle transmission of force through the tendon to the bone at the point of tendon insertion
  • Repetitive strain → microtrauma of the tendon → improper healing → disorientation of the tendon's collagen fibers tendinopathy
  • Hypovascularity → predisposition to hypoxic tendon degeneration [4]

Unlike in cases of tendinitis or tenosynovitis, inflammation plays a negligible role in the development of tendinopathy.

Overview of insertional tendinopathies

Upper limbs

  • Lateral epicondylitis (tennis elbow) [5]
    • Definition: overuse injury of the hand, esp. finger extensor tendons which originate in the lateral humeral epicondyle [5]
    • Etiology
      • Most commonly due to repeated or excessive pronation/supination and extension of the wrist (e.g., backhand shots in racket sports)
      • Can also be idiopathic
    • Clinical features
  • Medial epicondylitis (golfer's elbow)
    • Definition: overuse injury of the hand, esp. finger flexor tendons which originate in the medial humoral epicondyle
    • Etiology
    • Clinical features
      • Pain over the medial epicondyle and along the flexor muscles, increases with activity
      • Thickening of the tendons
      • Test: Pain is elicited on asking the patient to flex the wrist against resistance, with the elbow held in extension.
  • For rotator cuff tendinitis, see “Soft tissue lesions of the shoulder.”

An EXTended game of tennis will ruin the Lawn: repeated EXTension of the elbow (e.g. tennis) causes Lateral epicondylitis.
A FLexible game of golf allows Mulligans: repeated FLexion of the elbow (e.g., golf) causes Medial epicondylitis

Lower limbs

  • Iliotibial band syndrome (runner's knee)
    • Definition: common overuse injury of the distal portion of the iliotibial band (over the lateral femoral epicondyle)
    • Etiology: repetitive flexion and extension of the knee (e.g., during running)
    • Clinical features
      • Pain in the lateral knee (due to friction of iliotibial band against femoral epicondyle)
        • Sharp pain when the foot strikes the ground
        • Dull, constant pain at rest
      • Noble test: patient lies on their side and the examiner passively flexes the patient's leg while exerting constant pressure on the lateral femoral epicondyle with his thumb → test is positive if pain is elicited
  • Patellar tendinitis (jumper's knee) [6]
    • Definition: overuse injury of the patellar tendon at the distal portion of the patella
    • Etiology: repeated jumping (e.g., volleyball, basketball)
    • Clinical features
      • Usually unilateral but can be bilateral
      • Commonly seen in adolescents [6]
      • Pain over the anterior aspect of the knee, which worsens with running/walking uphill or when moving after prolonged sitting/standing
      • Tenderness on applying pressure to the inferior border of the patella
  • Achillodynia (Achilles tendinopathy)
    • Definition: overuse injury of the Achilles tendon
    • Etiology: athletes/individuals who have recently increased their exercise intensity
    • Clinical features: pain and tenderness 2–6 cm above the insertion of the Achilles tendon [7]
  • Osteitis pubis

Diagnostics

Treatment

Corticosteroid injections are generally avoided in insertional tendinopathy since they may cause tendon rupture!

References

  1. Maffulli N, Wong J, Almekinders LC. Types and epidemiology of tendinopathy.. Clinics in Sports Medicine. 2003 .
  2. Ferretti A. Epidemiology of jumper's knee.. Clinics in Sports Medicine. 1986 .
  3. Wilson JJ. Common Overuse Tendon Problems: A Review and Recommendations for Treatment. American Family Physician. 2005; 72 (5): p.811-818.
  4. JOHN J. WILSON and THOMAS M. BEST. Common Overuse Tendon Problems: A Review and Recommendations for Treatment. American Family Physician. 2005 .
  5. L Ohberg, R Lorentzon, H Alfredson. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. British Journal of Sports Medicine. 2004 .
  6. R Kayser, K Mahlfeld, C E Heyde. Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging. British Journal of Sports Medicine. 2005 . doi: 10.1136/bjsm.2005.018416 . | Open in Read by QxMD
  7. CHUMBLEY EM, O'CONNOR FG, NIRSCHL RP. Evaluation of Overuse Elbow Injuries. American Family Physician. 2000; 61 (3): p.691-700.
  8. Rutland M, O'connell D, Brismée JM et al. Evidence-supported rehabilitation of patellar tendinopathy. North American journal of sports physical therapy. 2010; 5 (3): p.166-78.
  9. MICHAEL F. MAZZONE and TIMOTHY MCCUE. Common Conditions of the Achilles Tendon. American Family Physician. 2002 .
  10. Ismail AM, Balakrishnan R, Rajakumar MK, Lumpur K. Rupture of patellar ligament after steroid infiltration. Report of a case.. The Bone & Joint Journal. 1969 .