Chronic tendon injuries, or chronic tendinosis, can cause constant pain; however, new treatments are available.
How is chronic tendinosis different from tendonitis?
What are some symptoms of chronic tendinosis, and what treatments are available?
Learn more from Dr. Jennifer Pierce, a UVA specialist in chronic tendinosis.
Chronic Tendon Injuries: How Are They Diagnosed and Treated?
Featured Speaker:
Jennifer Pierce, MD
Dr. Jennifer Pierce is a board-certified radiologist who specializes in musculoskeletal radiology. Transcription:
Chronic Tendon Injuries: How Are They Diagnosed and Treated?
Melanie Cole (Host): Chronic tendon injuries or chronic tendinosis can cause constant pain. However, there are new treatments that are available. How is tendinosis different from what you hear about, tendinitis, and what are some of those symptoms of chronic tendinosis, and what treatments are available? My guest today is Dr. Jennifer Pierce. She’s a board certified radiologist who specializes in musculoskeletal radiology at UVA. Welcome to the show, Dr. Pierce. What is a chronic tendon injury or chronic tendinosis, and how does that differ from what people have heard so much about, tendinitis?
Dr. Jennifer Pierce (Guest): Well, thank you for having me, yes. The answer to your question, what is tendinitis and tendinosis, tendinitis means inflammation. And they found on a cellular level a lot of these damaged and degenerated tendons don’t have inflammation. So doctors use the term “tendinosis” because it just means that there’s disease or tendon pathology. So it really is the same term or two words for the same entity. Chronic tendon injury, this means that you have tendon-related symptoms like pain and burning and weakness for a certain timeframe, and that usually means longer that three to six months. Chronic tendon injury can be from a single traumatic event that lasts that long, the pain and the symptoms, or it can be brought on by just long-term repetitive overuse. That kind of typically happens unfortunately as we age.
Melanie: Are there certain areas that are more subject to these kinds of injuries than others?
Dr. Pierce: Well, tendons can degenerate as we age due to overuse, and I would say kind of going from head to toe, first the shoulder is a common area, the rotator cuff. That’s an area that we overuse and you can have a tendinosis there. The elbow, especially the outside or the lateral aspect of the elbow, commonly called tennis elbow. And that’s due to become an extensor tendonitis. It actually involves 1 to 3 percent of our population. Some other tendons would be hamstring tendon, Achilles tendon, and also the plantar fascia, which is on the sole or the heel of your foot.
Melanie: These are painful conditions and ones that I deal with daily myself, Dr. Pierce. What’s your first line of defense? What do you recommend people do? For example, they’ve got plantar fasciitis, which can be incredibly debilitating and painful, or rotator cuff tendon problems that just make them wake up in the night when they roll over on their shoulder. What do you tell them?
Dr. Piece: Well, they should go see their primary care doctor to make sure that that is really the issue, that it is the tendon issue. Because joint pain can be somewhat cryptic. It can be from the tendons. It can be for something inside the joint, like the cartilage, those kind of things. So once it’s decided it is the tendon, really asking questions and a physical exam so that we can pick out the tendon that’s causing the pain is really the first line of diagnosis. If there is a need, imaging—and that’s where radiologists come into play. They’re the doctors that look at imaging, such as x-rays, CTs, MRIs, and ultrasound. And sometimes those imaging modalities can really help their clinician diagnose tendinosis and tendon problem.
Melanie: Then what treatments are available? Because people tend to think, Dr. Pierce, of cortisone shots, and anti-inflammatories and ice, which is always a good one. What do you recommend for treatments? And as a radiologist, what do you see as some good long-term outcomes?
Dr. Pierce: Yes, tendon problem is a huge industry, and that really involves a lot of patients in our society. And you mentioned a lot of them. I think the first line, for example, like you mentioned is that RICE therapy—rest it, ice it, put that compression, and maybe elevate to that joint or tendon. But here at UVA, we are doing some other things. You mentioned the steroid injection and radiology. We are using image-guided techniques to actually make sure that needle is placed right in the tendon and placing the steroid. Another thing we’re doing is what’s called Tenex. That’s a company name, but it is called Percutaneous Needle Tenotomy. I don’t know if you’ve heard of that, and with ultrasound guidance. And what we do is we can look at the tendon with ultrasound and see actually the areas of degeneration, the true pathology in the tendon. And then with those areas, we can target it and place our needle right there, and that’s why it’s called image guidance. And when we place that needle there, what happens is this specialized needle has an inner needle and an outer needle, and that inner needle oscillates at a really high frequency, basically at 28,000 times per second. And it sort of acts like a jackhammer, if you will, but gently removes that area of disease or degenerated tendon that we can spot on our ultrasound imaging. And we put some saline there, and it helps to breathe and irrigates that irritated tendon. And people are doing very well, very good outcomes and long-term outcomes. You mentioned steroids. That has been good for patients but really short-term, maybe six weeks, maybe three months. But we found with this new procedure, patients are pain-free, for example, with tennis elbow problem, even one year out, maybe even two years out on some studies.
Melanie: Wow, Dr. Pierce. That’s absolutely fascinating and if someone is suffering from a soft tissue injury, whether it’s tennis elbow or golf elbow or tendinitis of the Achilles, this Tenex, how fast would they see results? Are they going to be pain-free? Does it take a couple of weeks for it to kick in? We know that cortisone shots may take a few days or up to a week. How fast does Tenex work?
Dr. Pierce: That’s a great question. Tenex is completely different than the steroid. It doesn’t respond as quickly. However, what I’ve noticed in my patients is that there’s a lot of variability. I’ve had patients that say that night it felt so much better, I didn’t need to take the pain medication. Most patients however are noticing that their strength, their decrease in pain and increase in flexibility really start kicking in about three to five weeks after the procedure, and then it even gets better and better. The pain-free situation, it’s usually even at a year and two-year follow-up, which is really incredible since a lot of the treatments that we’ve talked about before are more short-term.
Melanie: And what about prevention altogether? We only have a few minutes left, but is there prevention, or are some of these just age-related, tendon breakdown soft tissue from chronic overuse and various things that we do? Is there prevention?
Dr. Pierce: That’s a great question. I think if you keep doing the activity, you can start getting degenerated tissue, especially if there’s no strengthening. So what I recommend at the first signs of tendon pain, really go in, maybe get some physical therapy. There’s a lot of great information online to start strengthening that tendon and that kind of thing, but sometimes we can’t eliminate what you do on a daily basis, because we do use our tendons and our extremities, especially if you do a lot of labor and that kind of thing. So I would just make sure that you’re strengthening, you’re staying fit, and that kind of thing. And we can’t sometimes stop the degenerative process.
Melanie: We certainly can’t, but this has been such great information. In just the last few minutes, your best advice for people with soft tissue injuries and tendinosis treatments and why patients should come to UVA for their care.
Dr. Pierce: Yes. Well, at UVA radiology, we have lots of specialists. In fact, we have every specialist for all the medical specialties. Medicine is so vast, and so to have a specialist really focusing on that branch of medicine is important. At UVA, the radiology specialists are really working hand in hand with the clinical specialists. You have doctors talking to each other, and that’ll really give you the best care. In terms of MSK radiology, we offer comprehensive radiology, so from x-rays to CTs to ultrasound to MR. We read it all, and we can really use all those modalities to help diagnose things. And, especially with the procedures that I’ve been talking about, whether it’s steroid injection or the Tenex, we actually see where we place that needle so that image guidance is really great. We’re not blindly injecting. Especially for deeper tendons, it’s really helpful to see where you’re putting that needle.
Melanie: What great information. Thank you so much. You’re listening to UVA Health Systems Radio. For more information, you can go to uvahealth.com. That’s uvahealth.com. This is Melanie Cole. Thank you so much for listening and have a great day.
Chronic Tendon Injuries: How Are They Diagnosed and Treated?
Melanie Cole (Host): Chronic tendon injuries or chronic tendinosis can cause constant pain. However, there are new treatments that are available. How is tendinosis different from what you hear about, tendinitis, and what are some of those symptoms of chronic tendinosis, and what treatments are available? My guest today is Dr. Jennifer Pierce. She’s a board certified radiologist who specializes in musculoskeletal radiology at UVA. Welcome to the show, Dr. Pierce. What is a chronic tendon injury or chronic tendinosis, and how does that differ from what people have heard so much about, tendinitis?
Dr. Jennifer Pierce (Guest): Well, thank you for having me, yes. The answer to your question, what is tendinitis and tendinosis, tendinitis means inflammation. And they found on a cellular level a lot of these damaged and degenerated tendons don’t have inflammation. So doctors use the term “tendinosis” because it just means that there’s disease or tendon pathology. So it really is the same term or two words for the same entity. Chronic tendon injury, this means that you have tendon-related symptoms like pain and burning and weakness for a certain timeframe, and that usually means longer that three to six months. Chronic tendon injury can be from a single traumatic event that lasts that long, the pain and the symptoms, or it can be brought on by just long-term repetitive overuse. That kind of typically happens unfortunately as we age.
Melanie: Are there certain areas that are more subject to these kinds of injuries than others?
Dr. Pierce: Well, tendons can degenerate as we age due to overuse, and I would say kind of going from head to toe, first the shoulder is a common area, the rotator cuff. That’s an area that we overuse and you can have a tendinosis there. The elbow, especially the outside or the lateral aspect of the elbow, commonly called tennis elbow. And that’s due to become an extensor tendonitis. It actually involves 1 to 3 percent of our population. Some other tendons would be hamstring tendon, Achilles tendon, and also the plantar fascia, which is on the sole or the heel of your foot.
Melanie: These are painful conditions and ones that I deal with daily myself, Dr. Pierce. What’s your first line of defense? What do you recommend people do? For example, they’ve got plantar fasciitis, which can be incredibly debilitating and painful, or rotator cuff tendon problems that just make them wake up in the night when they roll over on their shoulder. What do you tell them?
Dr. Piece: Well, they should go see their primary care doctor to make sure that that is really the issue, that it is the tendon issue. Because joint pain can be somewhat cryptic. It can be from the tendons. It can be for something inside the joint, like the cartilage, those kind of things. So once it’s decided it is the tendon, really asking questions and a physical exam so that we can pick out the tendon that’s causing the pain is really the first line of diagnosis. If there is a need, imaging—and that’s where radiologists come into play. They’re the doctors that look at imaging, such as x-rays, CTs, MRIs, and ultrasound. And sometimes those imaging modalities can really help their clinician diagnose tendinosis and tendon problem.
Melanie: Then what treatments are available? Because people tend to think, Dr. Pierce, of cortisone shots, and anti-inflammatories and ice, which is always a good one. What do you recommend for treatments? And as a radiologist, what do you see as some good long-term outcomes?
Dr. Pierce: Yes, tendon problem is a huge industry, and that really involves a lot of patients in our society. And you mentioned a lot of them. I think the first line, for example, like you mentioned is that RICE therapy—rest it, ice it, put that compression, and maybe elevate to that joint or tendon. But here at UVA, we are doing some other things. You mentioned the steroid injection and radiology. We are using image-guided techniques to actually make sure that needle is placed right in the tendon and placing the steroid. Another thing we’re doing is what’s called Tenex. That’s a company name, but it is called Percutaneous Needle Tenotomy. I don’t know if you’ve heard of that, and with ultrasound guidance. And what we do is we can look at the tendon with ultrasound and see actually the areas of degeneration, the true pathology in the tendon. And then with those areas, we can target it and place our needle right there, and that’s why it’s called image guidance. And when we place that needle there, what happens is this specialized needle has an inner needle and an outer needle, and that inner needle oscillates at a really high frequency, basically at 28,000 times per second. And it sort of acts like a jackhammer, if you will, but gently removes that area of disease or degenerated tendon that we can spot on our ultrasound imaging. And we put some saline there, and it helps to breathe and irrigates that irritated tendon. And people are doing very well, very good outcomes and long-term outcomes. You mentioned steroids. That has been good for patients but really short-term, maybe six weeks, maybe three months. But we found with this new procedure, patients are pain-free, for example, with tennis elbow problem, even one year out, maybe even two years out on some studies.
Melanie: Wow, Dr. Pierce. That’s absolutely fascinating and if someone is suffering from a soft tissue injury, whether it’s tennis elbow or golf elbow or tendinitis of the Achilles, this Tenex, how fast would they see results? Are they going to be pain-free? Does it take a couple of weeks for it to kick in? We know that cortisone shots may take a few days or up to a week. How fast does Tenex work?
Dr. Pierce: That’s a great question. Tenex is completely different than the steroid. It doesn’t respond as quickly. However, what I’ve noticed in my patients is that there’s a lot of variability. I’ve had patients that say that night it felt so much better, I didn’t need to take the pain medication. Most patients however are noticing that their strength, their decrease in pain and increase in flexibility really start kicking in about three to five weeks after the procedure, and then it even gets better and better. The pain-free situation, it’s usually even at a year and two-year follow-up, which is really incredible since a lot of the treatments that we’ve talked about before are more short-term.
Melanie: And what about prevention altogether? We only have a few minutes left, but is there prevention, or are some of these just age-related, tendon breakdown soft tissue from chronic overuse and various things that we do? Is there prevention?
Dr. Pierce: That’s a great question. I think if you keep doing the activity, you can start getting degenerated tissue, especially if there’s no strengthening. So what I recommend at the first signs of tendon pain, really go in, maybe get some physical therapy. There’s a lot of great information online to start strengthening that tendon and that kind of thing, but sometimes we can’t eliminate what you do on a daily basis, because we do use our tendons and our extremities, especially if you do a lot of labor and that kind of thing. So I would just make sure that you’re strengthening, you’re staying fit, and that kind of thing. And we can’t sometimes stop the degenerative process.
Melanie: We certainly can’t, but this has been such great information. In just the last few minutes, your best advice for people with soft tissue injuries and tendinosis treatments and why patients should come to UVA for their care.
Dr. Pierce: Yes. Well, at UVA radiology, we have lots of specialists. In fact, we have every specialist for all the medical specialties. Medicine is so vast, and so to have a specialist really focusing on that branch of medicine is important. At UVA, the radiology specialists are really working hand in hand with the clinical specialists. You have doctors talking to each other, and that’ll really give you the best care. In terms of MSK radiology, we offer comprehensive radiology, so from x-rays to CTs to ultrasound to MR. We read it all, and we can really use all those modalities to help diagnose things. And, especially with the procedures that I’ve been talking about, whether it’s steroid injection or the Tenex, we actually see where we place that needle so that image guidance is really great. We’re not blindly injecting. Especially for deeper tendons, it’s really helpful to see where you’re putting that needle.
Melanie: What great information. Thank you so much. You’re listening to UVA Health Systems Radio. For more information, you can go to uvahealth.com. That’s uvahealth.com. This is Melanie Cole. Thank you so much for listening and have a great day.