• Clinical science

Insertional tendinopathy

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

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Overuse or overload injury (repetitive, excessive strain), degeneration
  • 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

References:[1]

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 trauma → improper healing → disorientation of the tendon's collagen fiberstendinopathy
  • Hypovascularity → predisposition to hypoxic tendon degeneration

Unlike in cases of tendinitis or tenosynovitis, inflammation plays a negligible role in the development of tendinopathy!References:[1][2]

Overview of insertional tendinopathies

Upper limbs

Lower limbs

References:[3][4][5][6][7][8]

Diagnostics

  • Clinical diagnosis: further workup rarely needed
  • Imaging
    • X-ray: usually normal; possible detection of fractures or periostitis at the site of tendon insertion
    • Ultrasound: tendon thickening; hypoechoic areas within the tendon
    • MRI: increased signal in abnormal tendons ; simultaneous assessment of bone, cartilage, and ligaments
  • Complete blood count: to rule out infection in patients with osteitis pubis

References:[1][8][7]

Treatment

  • Conservative treatment
    • Rest ; cooling/ice for the first 24–48 hours; topical/oral NSAIDs
    • Physiotherapy: stretching and strength training once the pain has subsided
    • Orthotic braces and bands [2]
  • Corticosteroid and lidocaine injections
    • Only considered if conservative treatment has failed
    • Short-term relief; has no long-term benefit .
    • Injection into surrounding tissue, not directly into tendons
  • Surgery
    • Indicated in patients with persistent symptoms despite 6 months of conservative treatment
    • Excision of abnormal tendon tissue; longitudinal incisions (tenotomies) in scarred and fibrotic areas to promote healing

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

References:[8][2][9]