THE LATEST RESEARCH IN TENDINOPATHIES
When the earliest clinical trials begin to appear in the early-mid fifties, serious doubts were raised about cortisone’s seemingly "magic" powers. For instance, in one early experiment (1954), more than half the patients who received a cortisone shot for tennis elbow or other tendon pain suffered a relapse of the injury within six months. But that cautionary study (as well as others) didn’t slow the ascent of cortisone injections as a mainstream treatment because of their propensity for immediate pain relief. Here we are in 2011, and believe it or not, cortisone shots continue to be the gold standard for TENNIS ELBOW, SHOULDER PAIN, and other MUSCLE / TENDON problems, as well a WHOLE HOST OF OTHERS. Why do I bring all of this up?
In a study scheduled for publication in the December issue of the Archives of Physical Medicine and Rehabilitation, researchers reported that lower doses of corticosteroids were just as effective as higher doses in terms of reduction of pain, improved range of motion, and duration of effectiveness. But what does this really mean? Are these patients really improving, or is the whole thing a house of cards ---- an illusion built with smoke and mirrors? I would contend that the question the researchers are attempting to answer is not a valid question to be asking in the first place. Allow me to explain.
The researchers were trying to determine which dose of corticosteroid is best for the shoulder ---- a 20 mg injection or a 40 mg injection. The question is moot. It's kind of like asking which will make you sicker, drinking one gallon of turpentine, or drinking two. If you think that I am over-exaggerating the situation, jump in my time machine and allow me to take you back just one short year.
The biggest ever meta-analysis of its kind appeared in one of the world's oldest and most respected medical journals, The Lancet, one year ago last month. Listen to the results of this study, which was essentially a study of numerous other previously done studies on the same thing (say that three times fast!). "3,824 studies were identified and 41 met inclusion criteria, providing data for 2,672 participants. We showed consistent findings between many high-quality randomized controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms... Despite the effectiveness of corticosteroid injections in the short term, non-corticosteroid injections might be of benefit for long-term treatment."
Here is what is almost comical about these conclusions. Some of these "non-corticosteroid injections, that according to the authors, "might be of benefit for long-term treatment," include things like BOTULISM TOXIN (Botox), Prolotherapy (sugar water injections), Apropitn (The drug was temporarily withdrawn worldwide in 2007 after studies suggested that its use increased the risk of complications or death, and was entirely and permanently withdrawn in 2008, when follow up studies confirmed the original result), PLATELET RICH THERAPY INJECTIONS (which I have never one single time seen work), and even saline (salt) solution --- or nothing at all (HERE).
What did the researchers actually have to say about these "wonderful" non-steroidal injection therapies that they are at least on some level, promoting via their mere mention? "Lauromacrogol (polidocanol), aprotinin, and platelet-rich plasma were not more efficacious than was placebo for Achilles tendinopathy, while prolotherapy was not more effective than was exercise." Unfortunately, none of this even begins delving into the fact that the study also stated (not surprisingly) that, "Adverse events were also reported". Or should I say, "UNDER-REPORTED"?
The reviewers determined that, for most of those who suffered from tendinopathies, cortisone injections did bring fast and significant pain relief. However, when the patients were re-examined at 6 and 12 months, the results were substantially different. Over all, people who received cortisone shots had a much lower rate of full recovery than those who did nothing or who underwent therapy. They also had a 63 percent higher risk of relapse than people who adopted the time-honored wait-and-see approach. Great stuff, that cortisone! It doesn't work, but has ugly side effects. Just what we all wanted! Just like the good ole days in 1954!
Why cortisone shots would even be imagined to be of benefit in the healing process of tendon problems in light of current medical knowledge is beyond me. But this question was essentially answered in a Lancet-published response to the study. For decades it was widely believed that tendon-overuse injuries were caused by inflammation, said Dr. Karim Khan, a professor at the School of Human Kinetics at the University of British Columbia and the co-author of a response to the above response. The injuries were, as a group, given the name tendinitis, since the suffix “-itis” means inflammation. Cortisone is an anti-inflammatory medication. Using it against an inflammation injury was logical.
But in the decades since, numerous studies have shown, persuasively, that these overuse injuries do not involve inflammation. When animal or human tissues from these types of injuries are examined histologically, they do not contain the usual biochemical markers of INFLAMMATION. Instead, the injury seems to be degenerative. The fibers within the tendons fray. Today the injuries should be referred to as tendinopathies, or "TENDINOSIS". Although you will see this reflected in the ICD-10 codes found on the HCFA forms doctors use to submit to insurance companies, it has certainly not filtered down to EVERYDAY DOCTORS treating patients with shoulder, knee, elbow, wrist, or other joint / tendon problems.
Why then does a cortisone shot (an anti-inflammatory drug) seemingly work in the short term in regards to non-inflammatory injuries? The injections seem to have "an effect on the neural receptors" involved in creating the pain in the sore tendon, Dr. Khan said. “They change the pain biology in the short term,” but, he said, cortisone shots do “not heal the structural damage” causing the pain. Instead, they actually “impede the structural healing.”
So the question of whether cortisone shots still make sense as a treatment for tendinosis, depends, as Dr. Khan said, on how you choose “to balance short-term pain relief versus the likelihood” of longer-term negative outcomes. In other words, is reducing soreness now worth a significantly increased risk of delayed healing and possible relapse within the year?
To many patients and their all-too-ready-to-inject doctors, that answer frequently remains yes. There has always been and always will be the desire for a magic bullet --- that elusive cure-all that will take care of anything and everything (HERE'S MINE). My goal for all of my patients is to GIVE THEM A GOLD BRICK, hopefully leaving them much better off than when they came in. I feel like I am accomplishing this as well as anyone out there. Because I believe in a different kind of "EVIDENCE", you can view some of our PATIENT TESTIMONIALS, by just clicking the link.
TENDINITIS OR TENDINOSIS?
WHY IT MATTERS
So, if “itis” (inflammation) is not the primary cause of most of what we today refer to as 'tendinitis', what is? Medical Research has shown us that the primary culprit is something called “osis”. Thus the name, “tendon – osis” (tendinosis). But this begs the question, what is osis? The suffix “osis” indicates that there is a derangement and subsequent deterioration of the collagen fibers that make up the tendon. The truth is, even though doctors still use the term “tendinitis” with their patients, look on your EOB and you'll see that their AMA-mandated Diagnosis Codes almost always indicate that the problem is “tendinosis” or “tendinopathy” (tendinopathy indicates an unspecified tendon problem).
Is the differentiation between “tendinits” and “tendinosis” really that important, or am I simply “splitting hairs” and making a big deal out of nothing? Instead of answering that question myself, I will let one of the world’s preeminent orthopedic surgeons and tendon researchers answer it for me.
“Tendinosis, sometimes called tendinitis, or tendinopathy, is damage to a tendon at a cellular level (the suffix “osis” implies a pathology of chronic degeneration without inflammation). It is thought to be caused by micro-tears in the connective tissue in and around the tendon, leading to an increased number of tendon repair cells. This may lead to reduced tensile strength, thus increasing the chance of repetitive injury or even tendon rupture. Tendinosis is often misdiagnosed as tendinitis due to the limited understanding of tendinopathies by the medical community.” Tendon researcher and orthopedic surgeon, Dr. GA Murrell from an article called, “Understanding Tendinopathies” in the December 2002 issue of The British Journal of Sports Medicine.
Unfortunately, if you are dealing with a chronic tendinopathy, you are probably being treated using a model that is at least 25-30 years behind the times as far as the medical research is concerned (HERE)! You think not? Read what Dr. Warren Hammer, board certified Chiropractic Orthopedist (in practice since the late 1950′s), had to say about the subject in a 1992 column from Dynamic Chiropractic:
The American Academy of Orthopedic Surgeons has provided a new classification of tendon injuries…. In the microtraumatic tendon injury the main histologic features represent a degenerative tendinopathy thought to be due to an hypoxic [diminished oxygen] degenerative process. The similarity to the histology [study of the cells] of an acute wound repair with inflammatory cell infiltration as in macrotrauma seems to be absent. A new classification of tendon injury called “tendinosis” is now accepted.
“Tendinosis” is a term referring to tendinous degeneration due to atrophy (aging, microtrauma, vascular compromise). Histologically there is a non-inflammatory tendinous degeneration due to atrophy (aging, microtrauma, vascular compromise), as well as a non-inflammatory intratendinous collagen degeneration with fiber disorientation, hypocelluarity, scattered vascular ingrowth, and occasional local necrosis or calcification.
If your doctor is still treating you for tendinitis and not tendinosis (using NSAID medications and CORTICOSTEROIDS), he / she is caught in a time warp. Anti-inflammatory drugs are known to deteriorate collagen-based tissues (this is why they are --- or should be --- rationed by your doctor). Plainly stated, the vast majority of tendinopathies are not inflammatory conditions (itis)! They are tissue derangements that wind up causing degeneration of the collagen fibers (osis)! For information about effectively treating tendonosis, visit our page specifically dedicated to helping people with all sorts of TENDINOSIS.
Dr. Schierling completed four years of Kansas State University's five-year Nutrition / Exercise Physiology Program before deciding on a career in Chiropractic. He graduated from Logan Chiropractic College in 1991, and has run a busy clinic in Mountain View, Missouri ever since. He and his wife Amy have four children (three daughters and a son).
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