Tendinitis? “That’s such an old term…no one uses that anymore!”
Tendinopathy? “Hmm…too vague. Get some diagnostic skills will ya?”
Tendinosis? “Now that’s more like it. Most tendon pathologies pass the inflammation stage and go directly to the degeneration stage…right?”
But do they?
Well maybe not! Franklyn-Miller et al recently published an editorial piece entitles “Fasciitis first before tendinopathy: does anatomy hold the key?” in the most recent issue of British Journal of Sports Medicine outlining the fact that most research articles have failed to mention the role of the enveloping fascia in tendon pathologies. Specifically, they state that in some conditions involving musculotendinous structures, inflammation of the fascia is actually present, similar to that of conditions such as plantar fasciitis (here we go again!)
Their argument stems from histological evidence of inflammatory infiltrates, the presence of a fascia-tendon interface, and the relatively high number of studies that make reference to the presence of a paratenon enveloping or overlying the Achilles tendon. In fact, this paratenon is actually the posterior fascia of the lower extremity! Note: this paratenon is frequently used as a landmark for guidance of therapeutic injections of the Achilles tendon.
Therefore, this posterior fascia or paratenon, may be a source of pain and inflammation in very early stage “tendon” pathologies and adhesion of this structure to its underlying tendon may actually lead to abnormal tendon loads and subsequent tendinopathy.
Thus, keeping in line with one of the main outcomes of my post yesterday on Greater Trochanter Pain Syndrome, finding the root cause of pain local to a specific area is perhaps one of the most important, yet difficult, skills of a clinician. Therefore, it may be wise to occasionally ask ourselves do we really know what we think we know?
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Question then:
How would our treatment – as conservative care providers – change with a determination that the inflammation is of the paratenon vs. the tendon proper?
Good question…
In general, if inflammation is specifically of the paratenon, then immobilization of the “tendon” will likely not be necessary and treatment may consist of traditional modalities targeting inflammation. Here, controlled exercises may still be performed for tendon strengthening if needed.
However, should the tendon proper be inflamed, then this tissue structure will likely need relative rest in addition to the above inflammatory modalities. As already noted, if the tendon is injured, it will in many cases go directly to degeneration and therefore aggressive eccentric strengthening may be necessary.
Then again, do I really know what I think I know? For all I know, the paratenon and tendon proper may not even move independently of each other and therefore, conservative treatment may not differ at all!
Just because someone has a tendon pathology does not necessarily immediately mean pain will be present. http://linkinghub.elsevier.com/retrieve/pii/S1058274601107561
(excuse the lack of tiny urls… on a different computer at the moment)
One would logically assume a rotator cuff tear would be painful, but this is not always the case.
According to a medical dictionary, a paratenon is just a fatty substance that helps the tendon move in its sheath. From looking at the deer hanging in the garage, I’m pretty sure paratenon isn’t the same thing as fascia.
If you happen to look into pain science, structures don’t cause pain. Pain is determined by the brain as a result of incoming information from nerves (chemical, temperature and mechanical information), lack of incoming information (such as when one has lost an extremity) or glitches in the interpretation of information going to the brain (centrally mediated pain).
Sometimes the actual cause of pain may not be easily identified, especially for people with chronic pain. Our health care costs continue to rise in the musculoskeletal area because of the continual search for a reason for pain. Multiple factors impact the perception of pain: fear, anxiety, depression, exercise history, previous experience of pain, job satisfaction, cultural factors, smoking history, placebo factors, nocebo factors… I’d be willing to bet most of the time we never really know the real reason for pain.
Interestingly, there have been some histology studies done on chronic pain in the Achilles tendon area. The tissue changes found with chronic pain in the Achilles tendon area is like anatomical restructuring – a greater infiltration of vascular and neurological structures intertwined within the tendon into tiny neovascular structures. With a particular type of exercise, the new neovascular structures are significantly reduced and pain is substantially decreased. I found that research interesting and continue to mull it around in my head to figure out specifically how this fact falls into place with what I’ve learned about pain science and the brain.
We do know what we think we know… it’s just a matter if what we think we know is correct.
~Snippets
Great responses!
But I still find the new research pertaining to the “relationship” between posterior fascia and the paratenon kinda interesting….