Insertion tendopathies are pain conditions caused by irritation of the tendon insertions at the transition from tendon to bone. Athletes in particular are affected by insertional tendopathies.
What is insertional tendopathy?
Insertion tendopathies are collectively referred to as inflammation or irritation in the tendon attachment area, i.e., the transition zone from tendon to bone. Depending on the clinical symptoms, a distinction is made between chronic and acute insertion tendopathies. While acute insertion tendopathies focus on pain symptoms as a result of trauma, chronic irritations of the tendon insertions often result in structural-degenerative changes such as calcification, bone spur formation or ossification in the affected areas. Pronounced pain in the area of the tendon insertion, which increases with passive stretching as well as active tension under resistance, are characteristic symptoms of insertion tendopathy. In general, insertional tendopathy can manifest at all tendon insertions; predisposed sites include the Achilles tendon (achillodynia), the patellar tendon (patellar tendinopathy), the supraspinatus tendon (supraspinatus tendinopathy), and the tendon insertions of the elbow (tennis elbow).
Causes
In general, a distinction is made between primary insertion tendopathy, which is directly caused by sports-specific overloads, and secondary insertion tendopathy, which may occur in association with muscular tension due to osteoarthritis or vertebragen-related (spine-originating) disorders. Particularly in athletes and untrained individuals, tendon insertions are severely strained during peak loads. Unilateral loads, incorrect movement patterns as well as external factors (including very hard flooring, exposure to cold) can cause incorrect loading of the insertion areas, which on the one hand ensure the transmission of force from the tendon to the bone and on the other cushion excessive loads. In addition, malpositions affecting the joints or bone axes can lead to permanent mechanical irritation of the tendons (microtraumas). As a result of pain-induced permanent relief of the affected area, the adjacent muscles may additionally atrophy. Inflammatory (including rheumatoid arthritis, ankylosing spondylitis) or metabolic diseases may also favor the development of insertional tendopathy.
Symptoms, complaints, and signs
Insertional tendopathy is primarily manifested by increasing pain in the affected body part. The discomfort occurs primarily during physical activity and causes tension and muscle stiffness as it progresses. As a result of the pain, permanent muscle weakness may also develop. Atrophy may also occur. Externally, insertional tendopathy can be recognized by the noticeable swelling or thickening of the tendon. The affected body region may be reddened and overheated. The symptoms occur mainly at the tendon insertions of the elbow and in the area of the Achilles tendon and patellar tendon. After a sports injury, painful inflammation or irritation may also occur in the pelvic region. The pain itself can occur with exertion and at rest. Typically, the inflammation is most noticeable at night. This is when severe pain occurs, leading to sleep disturbances, depression and other complications in sufferers. As a result, sufferers are often irritable and occasionally suffer from depressive moods. As a result of the relieving posture, joint wear and tear, permanent deformities, circulatory disorders and a number of other symptoms and complaints can occur. In children, developmental disorders or permanent muscle weakness may even occur under certain circumstances.
Diagnosis and course
In many cases, the suspicion of insertional tendopathy results from the clinical symptoms as well as the sport-specific stresses described by the affected person in the course of the anamnesis. Radiographic examination can reveal the loosened areas in the bony region of the insertion sites that are characteristic of chronic insertion tendopathy, as well as the structural changes; in some cases, a comparative evaluation with the opposite side may be useful.Magnetic resonance imaging (MRI) can be used to assess osseous changes and the typical thickening and swelling of the tendons in the insertion area (edematous and fatty degeneration). In addition, the end points of the tendons usually show fibrous roughening. Although the prognosis and course of insertional tendopathies depend to a great extent on the specific tendon insertion affected and the compliance (cooperation with regard to therapy) of the affected person, they can generally be rated as good.
Complications
In most cases, insertional tendopathy occurs primarily in athletes. This results in pain and inflammation of the tendons, and there is usually also severe limitation of movement. The patient’s quality of life is reduced by this disease. It is not uncommon for pain to occur in the muscles, which leads to a reduced ability of the affected person to bear weight. Similarly, the movement restrictions can be so severe that the affected person is dependent on the help of other people in everyday life. Without treatment, insertional tendopathy results in muscle weakness. The affected person’s everyday life is significantly restricted by this disease. It is not uncommon for the affected regions to swell as well. Should rest pain occur, this rest pain can also lead to sleep problems or to depression. Treatment is carried out with the help of medications or therapies. No particular complications occur during this process. However, it may not be possible to relieve the pain and discomfort completely. Life expectancy is not usually reduced or affected by insertional tendopathy. As a rule, certain sports can no longer be performed without further ado.
When should you see a doctor?
If pressure pain, muscle tension, or strain pain is noticed at the tendon insertion, a physician or sports medicine specialist should be consulted promptly. Medical evaluation is necessary if the discomfort persists for more than a few days or rapidly increases in intensity. If the complaints occur in connection with an injury, a doctor should be consulted immediately. Medical advice is required in particular in the case of externally visible symptoms, for example redness or even bleeding. If hardening of the muscles is noticed, the disease may already be more advanced. A doctor must diagnose insertional tendopathy before thickening of the tendon or other serious secondary symptoms develop. Athletes and people whose jobs expose their feet to great stress are particularly susceptible to the disease and should see a doctor if they experience any of the symptoms mentioned above. The right contact person is the family doctor, a sports physician or an orthopedist. If the affected foot can no longer be moved at all, it is best to go to the nearest hospital. Ideally, insertional tendopathy is treated in a specialized clinic. Children should be taken to a pediatrician if they show signs of tendinopathy.
Treatment and therapy
Therapeutic measures depend significantly on the severity of pain symptoms and whether acute or chronic inflammation of the tendon insertion is present. In the case of acute insertion tendopathy, for example, the treatment measures are initially aimed at immobilizing the affected area. Cryotherapeutic measures (including CO2 or ice) as well as orally or locally applied anti-inflammatory drugs can be used to support the treatment. After the acute pain symptoms have subsided, electrotherapeutic and physical measures (including TENS, ultrasound therapy, iontophoresis) are usually indicated. In chronic insertion tendopathies, isometric contraction exercises are usually recommended initially to strengthen the musculature, which are substituted by dynamic exercises below the pain threshold in the later course of therapy. Additively, corticosteroid infiltrates, local heat applications, and extracorporeal shock wave therapy (ESWT) may be used as appropriate to relieve pain and ensure elasticity. In addition, the underlying cause of the insertional tendopathy should be treated or corrected. For example, if the Achilles tendon insertion (Achillodynia) is affected, footwear with slightly elevated heels may already provide relief in some cases.Furthermore, in chronic insertion tendopathies, particularly at the Achilles tendon, elbow or shoulder, therapy with ACP (autologous conditioned plasma) may be considered to stimulate regenerative growth and accelerate healing. Surgical removal of the affected portion of the tendon is considered ultima ratio in insertional tendopathies and, because of the risk for functional impairment, is considered only if conservative measures fail to achieve therapeutic success.
Outlook and prognosis
As a rule, insertional tendopathy must always be treated by a physician. If the condition is not treated, the pain will not go away on its own and in most cases there will be a significant worsening of symptoms. As a rule, the severe pain of insertional tendopathy can be treated well with the help of painkillers. This does not lead to further complications or other discomfort. Furthermore, the pain can be alleviated with the help of various therapies and exercises. This also alleviates the further course of the disease and limits the discomfort. Proper treatment of insertional tendopathy also results in a positive course of the disease in most cases, although a complete cure cannot always be achieved. If insertional tendopathy is not treated, it leads to considerable complications and restrictions in the daily life of the affected person. The patient suffers from severe restrictions in movement and is usually no longer able to cope with everyday life on his own. He is dependent on the help of other people and suffers from a significantly reduced quality of life. Life expectancy is usually not negatively affected by insertional tendopathy.
Prevention
Sport-specific overuse and, therefore, insertional tendopathies can be avoided by adequate training programs adapted to individual needs. Untrained individuals should also avoid overloading during sports activities. In addition, well-built muscles protect against tendon overuse and reduce the risk of insertional tendopathies.
Aftercare
There are usually very few, if any, special aftercare measures available to the patient with insertional tendopathy. In this disease, the affected person is primarily dependent on a rapid diagnosis and also on a rapid and, above all, early treatment of the disease so that further complications can be prevented. Self-healing cannot occur with insertional tendopathy, so that affected persons are always dependent on treatment by a physician. As a rule, treatment is carried out by taking medication. Patients should always ensure that they take their medication regularly and in the correct dosage in order to permanently alleviate their symptoms. In many cases, concentration exercises are also necessary to control the symptoms of insertion tendopathy. Many of the exercises can be done in the patient’s own home, which may speed up the healing process. Most patients also depend on the help and support of their own family and friends for this disease, and loving and intense conversations may also be necessary, especially to prevent psychological upset or depression.
This is what you can do yourself
As a rule, the treatment of insertional tendopathy always depends on the exact cause. However, in any case, the affected person must immobilize the affected region and take it easy and not move it. Athletes in particular should no longer pursue their sport if they suffer from insertion tendopathy. To strengthen the musculature, patients have a variety of exercises at their disposal that can be performed in physiotherapy or at home. Contraction exercises in particular have a positive effect on the course of the disease. This can also restore mobility to the region so that there are no restrictions in everyday life. Heat applications are also very helpful in insertional tendopathy. This includes hot baths or a visit to a sauna. If the complaints occur at the Achilles tendon, special shoes can be helpful here.These should have a slight heel and be slightly wider than ordinary footwear to support the leg while walking. The affected person should also regularly apply the prescribed medication to the respective area to relieve pain, as this will also prevent further inflammation and treat the current ones.
