Chronic Tendinopathies

Meg Greene, Laura Mister, & Katie Meade, ATS

Melissa Davis, LAT, ATC, Beth Funkhouser, LAT ATC,
Matt Harris, PT, LAT, & Joseph Vess, Advisor

11/30/2018
 Table of Contents
CLINICAL SCENARIO 1
FOCUSED CLINICAL QUESTION 2
KEYWORDS 2
SUMMARY OF SEARCH METHODOLOGY 3
SEARCH STRATEGY 3
SOURCES OF EVIDENCE SEARCHED 3
BEST EVIDENCE REVIEWED 3
CLINICAL BOTTOM LINE 4
IMPLICATIONS FOR CLINICAL PRACTICE 4
RECOMMENDATIONS FOR FUTURE RESEARCH 5
REFERENCES 5

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CLINICAL SCENARIO
When a person hears the word tendinitis, they will often immediately starting thinking of
an overuse injury and talk about how much stress the athlete may be putting on the
tendon. While overuse is most often the case in an active population, researchers have
brought forward a case of tendinitis being caused by underuse injuries. However, this
research is not new. We must ask the question; why are underuse injuries going unnoticed?
This question is more prevalent than ever considering how social norms are leading to a
more inactive population. This being said, we can still see underuse injuries in active and
athletic people caused by muscular imbalances. Our question has been created to make
underuse injuries more known and relevant in a clinical setting.

Development of Clinical Question:

In advanced strength & conditioning class while discussing NATA articles, a new study was
brought up about the possibility of tendinitis being an underuse injury. This was shocking
to us as students because all we have ever truly talked about is tendinitis being an overuse
injury. With this exciting conversation we decided to do more research of our own and
make it our clinical question.

Development of Investigation Committee:

The investigation committee was formed based off of expertise and knowledge on the topic
of chronic tendinopathies. Melissa, a certified Athletic Trainer, and Matt, a Physical
Therapist, were selected because our group felt that they would balance each other out and
provide useful information about both underuse injuries and overuse injuries. We felt
specifically that Matt would be able to provide more on the underuse injuries because he
typically has an older population which we felt would be more indicative of underuse
injuries. For a similar reason, we chose Melissa because she has an active population of
men’s soccer players. We felt the active population would tend to have more overuse
injuries. Beth was chosen because she is the muse of this project and already had insight
and sources on our topic. Finally, we have Joseph as our ampersand represetative because
he has the most enthusiasm in the ampersand center. We also felt if we wanted to push this
research further he would be very beneficial to have on our committee.

Focused Clinical Question:

Is the change in collagen in chronic tendinitis in physically active people due to an overuse
or underuse injury?

Keywords:
Injury
Overuse
Tendons
Underuse

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SUMMARY OF SEARCH METHODOLOGY
To answer our clinical question we decided that academic articles would help us support
our answer. The articles we decided to review contained the keywords above.

Search Strategy:
Patient: Physically Active People
Intervention: Change in collagen
Comparison: Overuse or Underuse Injury
Outcome: Chronic Tendinitis

Sources of Evidence Searched:

EBSCOhost
PubMed

Best Evidence Reviewed:

“Are we facing a new paradigm of inactivity physiology?”
In the article, “Are we facing a new paradigm of inactivity physiology?”, the authors explore
the possibility that instead of the issue of needing to exercise more, there is a new issue of a
complete absence of exercise in a whole. Inactivity is being a lifestyle, not a season in one’s
life. The inactivity physiology is based upon four statutes:

1) Sitting and limiting non-exercise activity may independently increase the disease
risk. 2)Sedentary behaviour is a distinct class of behaviour with specific
determinants and effects on disease risk, separate from the behaviour of leisure
time exercise. 3). The molecular and physiological responses in the human body of
too much sitting are not always the same as the responses that follow a bout of
additional physical exercise. 4) People already insufficiently physically active will
increase their risk even further by prolonged sitting time (Paragraph 3).

According to the article, recent studies have shown that one hour of watching television
can increase “the prevalence of the metabolic syndrome in women by 26%” (Paragraph 4).
Simply watching one hour without an equivalent activity counterpart could significantly
negatively affect one’s health. Moreover, muscular inactivity is becoming increasingly more
prevalent due to the nature of the culture in society today, and inactivity/underactivity
carries exponential health effects on our bodies.

“Tendinopathy: Update on Pathophysiology”

The authors, Alex Scott, Ludvig J. Backman, and Cathy Speed, go into depth about many
aspects of tendinous injuries and their nature. To begin, the article supplies the readers
with definitions of tendinopathy, tendinitis, tendinosis, and tenosynovitis. Tendinopathy is
defined as an umbrella term for a non-rupture injury of a tendon that is a result of
mechanical loading (833). Tendinitis is defined as a tendon injury due to inflammation, and
tendinosis is a tendon pathology that is not accompanied by inflammation (833). Lastly,
tenosynovitis is defined as a “pathology of a fully developed synovial sheath, which
typically presents with acute swelling with or without crepitus and triggering” (833). Their

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research that is particularly relevant to the question of overuse or underuse injuries can be
found in the “Mechanisms of Injury” section. The article mentions the possible mechanisms
of “stress shielding” and de-adaptation (836). De-adaptation is the “use it or lose it”
concept, and stress shielding is the idea that particularly structures or parts of the tissue do
not receive as much stress as other areas of the tissue because of “microinjury” to the
collagen fibers or the uneven distribution of forces” (836). Regardless of how the tissues
receive less stress, the reduction in usage can lead to significant and rapid loss in
“structural organization and mechanical properties” (837). The article sums up the idea
behind underuse of tissues by stating, “a period of inactivity followed by a sudden increase
in loading may precipitate a tendon injury” (837).

“Underuse” as a cause for musculoskeletal injuries: is it time that we

started reframing our message?
This article poses statements and questions worth contemplating more in a clinical setting.
The authors state that currently patients report injuries after a movement. For example, “ I
jogged three miles, and now my knees hurt.” They question if it is overuse or if it is truly an
underuse injury followed by movements of the body in an unfamiliar manner. Therefore,
the lack of previous movement is more likely the source of their pain and injuries. The
article also questions the treatment of chronic tendinitis asking, “why do we treat overuse
injuries with eccentric muscle-tendon exercise?” If the injury is truly overuse, then what is
the purpose to having the patient do more use?

The main point the authors try to make is that sports medicine clinicians need to be leaders
in the field of physical activity promotion. Some may argue that sports medicine is the care
of active individuals, and that athletes who overtrain get injured more often. This level of
activity leads people to assume the phrase “overuse injury.” They argue that sports
medicine clinicians need to be more aware of the inactive population which will include
changing the language used to describe underuse activities making it more well know and
relevant in society.

CLINICAL BOTTOM LINE

Overall, it is best to say that tendinopathy is caused by both overuse and underuse
mechanisms depending on the athlete’s situation. Overuse injuries are definitely extremely
prevalent in regards to tendinopathy, but it appears that underuse injuries are often
overlooked and the true mechanism of the injury is missed. Additionally, we discovered
that there was not much research conducted on the idea of tendinopathy as an underuse
injury. This is due to the neglect of recognizing underuse in active populations of people.

Implications for Clinical Practice

The evidence that we found regarding the possibility of tendinopathy being an underuse
instead of an overuse injury was significant in favor of the underuse mechanism. This
concept can potentially help reduce the amount of tendinopathy injuries by educating
athletes on the importance of proper mechanics to avoid stress shielding and ensuring that
they understand the importance of active rest. Injury prevention can be improved when all

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the athletes’ coaches and care team are involved (athletic trainers, sport coaches, strength
coaches, etc.). Each part of the team could be able to specify parts of training and
strengthening to ensure that all tissues are being stressed equivalently and the correct
interventions are being taken to make sure that the athlete will not have to experience a
tendinous injury due to underuse. Additionally, this research will help clinicians when
planning rehabs because when the mechanism of the injury can be pinpointed, then the
rehabilitation process is able to be more specific.

Recommendations for Future Research

In the future, it would be beneficial to be able to isolate the exact cause of tendinopathy in
relation to an underuse injury. Currently, it can be narrowed down to a few different
possibilities; however, treatment options and preventative measures could be specifically
tailored to the athlete if an exact cause could be known. Being able to differentiate the
stresses placed on a tendon would be especially useful. Additionally, some lines between
overuse and underuse tendinous injuries are still blurred. It is hard to know if the athlete is
truly placing too much stress on a tendon or if an increased load after a prolonged rest is
causing the issue because an athlete cannot be monitored around the clock. Therefore, if
research could open the door to a specific way to find a more direct cause of the injury,
leaps and bonds in recovery and management could take place.

REFERENCES:
Ekblom-Bak E, Hellenius M-L, Ekblom B. Are we facing a new paradigm of inactivity
physiology? British Journal of Sports Medicine. 2010;44(12):834-835.
doi:10.1136/bjsm.2009.067702.

Scott A, Backman LJ, Speed C. Tendinopathy: update on pathophysiology. Journal of

Orthopaedic & Sports Physical Therapy. 2015;45(11):833-841.
doi:10.2519/jospt.2015.5884.

Stovitz SD. "Underuse" as a cause for musculoskeletal injuries: is it time that we started
reframing our message? British Journal of Sports Medicine. 2006;40(9):738-739.
doi:10.1136/bjsm.2006.029975.