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Classification and external resources
ICD-10 M67.9
MeSH D052256

Tendinosis, sometimes called chronic tendinitis, chronic tendinopathy, or chronic tendon injury, 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 microtears in the connective tissue in and around the tendon, leading to an increase in tendon repair cells. This may lead to reduced tensile strength, thus increasing the chance of tendon rupture. Tendinosis is often misdiagnosed as tendinitis due to the limited understanding of tendinopathies by the medical community.[1]

Classical characteristics of tendinosis include degenerative changes in the collagenous matrix, hypercellularity, hypervascularity, and a lack of inflammatory cells which has challenged the original misnomer tendinitis.[2]


Swelling in a region of micro damage or partial tear may be detected visually or by touch. Increased water content and disorganized collagen matrix in tendon lesions may be detected by ultrasonography or magnetic resonance imaging.

Symptoms can vary from an ache or pain and stiffness to the local area of the tendon, or a burning that surrounds the whole joint around the inflamed tendon. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiffer the following day as swelling impinges on the movement of the tendon. Many patients report stressful situations in their life in correlation with the beginnings of pain, which may contribute to the symptoms.


Tendons are very slow to heal if injured. Partial tears heal by the rapid production of disorganized type-III collagen, which is weaker than normal tendon.[citation needed] Recurrence of injury in the damaged region of tendon is common.

Rehabilitation, rest, and gradual return to the activity in which tendinosis was experienced is a common therapy. There is evidence to suggest that tendinosis is not an inflammatory disorder; anti-inflammatory drugs are not an effective treatment,[3] and inflammation is not the cause of this type of tendon dysfunction.[4] There is a variety of treatment options, but more research is necessary to determine their effectiveness. Initial recovery is usually within 2 to 3 months, and full recovery usually within 3 to 6 months. About 80% of patients will fully recover within 12 months.[5] If the conservative therapy doesn't work, then surgery can be an option. This surgery consists of the excision of abnormal tissue. Time required to recover from surgery is about 4 to 6 months.[6]

On-going research into new treatments[edit]

Both eccentric loading and extracorporeal shockwave therapy are currently being researched as possible treatments for tendinosis. One study found both modalities to be equally effective in treating tendinosis of the Achilles tendon and more effective than a 'wait and see' approach.[7] Other treatments for which research is on-going includes vitamin E, vitamin B6, nitric oxide, and stem cell injections.

Vitamin E[edit]

Vitamin E has been found to increase the activity of fibroblasts, leading to increased collagen fibrils and synthesis, which seems to speed up the regeneration and increase the regenerative capacity of tendons.[8][9]

Nitric oxide[edit]

Nitric oxide (NO) also appears to play a role in tendon healing[10] and inhibition of its synthesis impairs tendon healing.[11] The use of a nitric oxide delivery system (glyceryl trinitrate patches) applied over the area of maximal tenderness was tested in three clinical trials for the treatment of tendinopathies and was found to significantly reduce pain and increase range of motion and strength.[12]

Soft tissue mobilization[edit]

Augmented Soft Tissue Mobilization (ASTM) is a form of manual therapy that has been shown in studies on rats to speed the healing of tendons by increasing fibroblast activity.[13][14] One case study showed ASTM resulting in full recovery in the case of an athlete suffering from chronic ankle pain and fibrosis, after an unsuccessful course of surgery and conventional physical therapy.[15]

Eccentric loading[edit]

A promising line of therapy involves eccentric loading exercises involving lengthening muscular contractions.[16]

Inflatable brace[edit]

The use of an inflatable brace (AirHeel) was shown to be as effective as eccentric loading in the treatment of chronic Achilles tendinopathy. Both modalities produced significant reduction in pain scores, but their combination was no more effective than either treatment alone.[17]

Shock-wave therapy[edit]

Shock-wave therapy (SWT) may be effective in treating calcific tendinosis in both humans[18] and rats.[19] In rat subjects, SWT increased levels of healing hormones and proteins leading to increased cell proliferation and tissue regeneration in tendons. Another study found no evidence that SWT was useful in treating chronic pain in the Achilles tendon.[20]

Tendon bioengineering[edit]

The future of non-surgical care for tendinosis is likely bioengineering. Ligament reconstruction is possible using mesenchymal stem cells and a silk scaffold.[21] These same stem cells were capable of seeding repair of damaged animal tendons.[22] Autologous tenocyte implantation is currently being tested for tendinosis. There is a large randomized, double-blind, placebo controlled trial being conducted in the Netherlands to test the safety and efficacy of tenocyte therapy. Results from the trial are expected by April 2013.

As of November 2013, researchers at the Seoul National University Hospital will be looking to recruit participants into a clinical trial to evaluate the efficacy of allogenic adipose-derived mesenchymal stem cells (ALLO-ASC) in treatment of a tendon injury (symptom duration is over six months). ALLO-ASC will be administrated to the patients with lateral epicondylitis (tennis elbow) by ultrasonographic guided injection.[23]

A paper on using autologous tenocyte injection for the treatment of severe, chronic resistant lateral epicondylitis was published in the American Journal of Sports Medicine on September 2013. A patellar tendon needle biopsy was performed under local anesthetic, and tendon cells were expanded by in vitro culture. Tenocytes used for the injection were characterized by flow cytometry and real-time polymerase chain reaction. Autologous tenocytes were injected into the site of tendinopathy identified at the origin of the extensor carpi radialis brevis tendon under ultrasound guidance on a single occasion. In this study, patients with chronic LE who had previously undergone an unsuccessful full course of nonoperative treatment showed significantly improved clinical function and structural repair at the origin of the common extensor tendon after ATI.[24] The paper cites article including, “Treatment of lateral epicondylitis using skin-derived tenocyte-like cells”, published in the British Journal of Sports Medicine in 2009,[25] and “Skin-Derived Tenocyte-like Cells for the Treatment of Patellar Tendinopathy”, published in the American Journal of Sports Medicine in 2010.[26]

A company has planned a Phase 2 Achilles tendinosis clinical trial using a new source of cells, which are fibroblasts isolated from nonbulbar dermal sheath cells of a hair follicle. This tendon technology will be tested in approximately 90–120 subjects in a Phase 2 trial, and will commence in Q3 2014. The company’s focus on the use of nonbulbar dermal sheath cells is based on the fact that these cells produce significantly more type I collagen than fibroblasts derived from adipose tissue. Type I collagen is the primary collagen in tendons. NBDS cells will be replicated, and then reintroduced into the wounds within the tendon via ultrasound. After injections are performed, subjects will return to the clinic for assessments of safety, function and pain, as well as changes in tendon thickness, echotexture, interstitial tears and neovascularity.[27] The work extends off of papers including, “Skin-Derived Fibroblasts for the Treatment of Refractory Achilles Tendinosis: Preliminary Short-Term Results”, published in the Journal of Bone and Joint Surgery in 2012.[28]

In other animals[edit]

Mesenchymal stem cells, derived from a horse's bone marrow or fat, are currently being used for tendon repair in horses. [29] Bowed tendon is a horseman's term for tendinitis (inflammation) and tendinosis (degeneration), most commonly seen in the superficial digital flexor tendon (SDFT) in the front leg.

See also[edit]


  1. ^ Murrell GA (December 2002). "Understanding tendinopathies". Br J Sports Med 36 (6): 392–3. doi:10.1136/bjsm.36.6.392. PMC 1724561. PMID 12453831. 
  2. ^ Fu SC, Rolf C, Cheuk YC, Lui PP, Chan KM (2010). "Deciphering the pathogenesis of tendinopathy: a three-stages process.". Sports Med Arthrosc Rehabil Ther Technol 2: 30. doi:10.1186/1758-2555-2-30. PMC 3006368. PMID 21144004. 
  3. ^ Khan, K.M.; Cook, J.L.; Kannus, P.; Maffulli, N.; Bonar, S.F. (2002-03-16). "Time to abandon the "tendinitis" myth : Painful, overuse tendon conditions have a non-inflammatory pathology". British Medical Journal 324 (7338): 626–7. doi:10.1136/bmj.324.7338.626. PMC 1122566. PMID 11895810. Retrieved 2007-04-02. 
  4. ^ Marsolais D, Duchesne E, Côté CH, Frenette J. (2007). "Inflammatory cells do not decrease the ultimate tensile strength of intact tendons in vivo and in vitro: protective role of mechanical loading". J Appl Physiol 102 (1): 3–4. doi:10.1152/japplphysiol.00162.2006. PMID 16916923. 
  5. ^ Wilson, J.J.; Best, T.M. (2005). "Common overuse tendon problems: A review and recommendations for treatment" (PDF). American Family Physician (American Academy of Family Physicians.) 72 (5): 811–8. PMID 16156339. Archived from the original on 2007-09-29. Retrieved 2007-04-02. 
  6. ^ David J. Magee, James E. Zachazewski, William S. Quillen Pathology and intervention in musculoskeletal rehabilitation
  7. ^ Rompe JD, Nafe B, Furia JP, Maffulli N (2007). "Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial". Am J Sports Med 3 (35): 374–83. doi:10.1177/0363546506295940. PMID 17244902. 
  8. ^ Gonzalez, Santander R; Plasencia Arriba MA, Martinez Cuadrado G, Gonzalez-Santander Martinez M & Monteagudo de la Rosa M. (1996). "Effects of "in situ" vitamin E on fibroblast differentiation and on collagen fibril development in the regenerating tendon". The International Journal of Developmental Biology (University Of The Basque Country Press) 1 (Supplemental): 181–2. PMID 9087752. 
  9. ^ Plasencia., M.A.; Ortiz C., Vazquez B., San Roman J., Lopez-Bravo A., Lopez-Alonso A. (1999). "Resorbable polyacrylic hydrogels derived from vitamin E and their application in the healing of tendons". Journal of Materials Science: Materials in Medicine (Kluwer Academic Publishers) 10 (10/11): 641–8. doi:10.1023/A:1008991825657. PMID 15347979. 
  10. ^ Xia, W.; Szomor Z., Wang Y. & Murrell G.A. (2006). "Nitric oxide enhances collagen synthesis in cultured human tendon cells". Journal of Orthopaedic Research (Wiley) 24 (2): 159–72. doi:10.1002/jor.20060. PMID 16435353. 
  11. ^ Darmani, H.; Crossan J.C. & Curtis A. (2004). "Single dose of inducible nitric oxide synthase inhibitor induces prolonged inflammatory cell accumulation and fibrosis around injured tendon and synovium". Mediators of Inflammation (Hindawi Pub. Corp.) 13 (3): 157–64. doi:10.1080/09511920410001713556. PMC 1781556. PMID 15223606. 
  12. ^ Murrell GA. (2007). "Using nitric oxide to treat tendinopathy". Br J Sports Med 41 (4): 227–31. doi:10.1136/bjsm.2006.034447. PMC 2658939. PMID 17289859. 
  13. ^ Craig J. Davidson et. al., "Rat tendon morphologic and functional changes resulting from soft tissue mobilization", Medicine & Science in Sports & Exercise, Mar. 1997, Vol. 29, No. 3, pp. 313-319.
  14. ^ Gale M. Gehlsen, "Fibroblast responses to variation in soft tissue mobilization pressure", Medicine & Science in Sports & Exercise, Apr. 1999, Vol. 31, No. 4, pp. 531-535.
  15. ^ Thomas J. Melham et. al., "Chronic ankle pain and fibrosis successfully treated with a new noninvasive augmented soft tissue mobilization technique (ASTM): a case report", Medicine & Science in Sports & Exercise, Jun. 1998, Vol. 30, No. 6, pp. 801-804.
  16. ^ Rowe V, Hemmings S, Barton C, Malliaras P, Maffulli N, Morrissey D (November 2012). "Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning". Sports Med 42 (11): 941–67. doi:10.2165/11635410-000000000-00000. PMID 23006143. 
  17. ^ Petersen W, Welp R, Rosenbaum D (June 14, 2007). "Chronic Achilles Tendinopathy: A Prospective Randomized Study Comparing the Therapeutic Effect of Eccentric Training, the AirHeel Brace, and a Combination of Both". Am J Sports Med 35 (10): 1659–67. doi:10.1177/0363546507303558. PMID 17569792. 
  18. ^ Cacchio A, Paoloni M, Barile A, Don R, de Paulis F, Calvisi V, Ranavolo A, Frascarelli M, Santilli V, Spacca G (2006). "Effectiveness of radial shock-wave therapy for calcific tendinosis of the shoulder: single-blind, randomized clinical study". Phys Ther 5 (86): 672–82. PMID 16649891. 
  19. ^ Chen YJ, Wang CJ, Yang KD, Kuo YR, Huang HC, Huang YT, Sun YC, Wang FS (2004). "Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinosis and increase TGF-beta1 and IGF-I expression". J Orthop Res 22 (4): 854–61. doi:10.1016/j.orthres.2003.10.013. PMID 15183445. 
  20. ^ Costa ML, Shepstone L, Donell ST, Thomas TL (2005). "Shock wave therapy for chronic Achilles tendon pain: a randomized placebo-controlled trial". Clin Orthop Relat Res 440: 199–204. doi:10.1097/01.blo.0000180451.03425.48. PMID 16239807. 
  21. ^ Fan H, Liu H, Wong EJ, Toh SL, Goh JC (August 2008). "In vivo study of anterior cruciate ligament regeneration using mesenchymal stem cells and silk scaffold". Biomaterials 29 (23): 3324–37. doi:10.1016/j.biomaterials.2008.04.012. PMID 18462787. 
  22. ^ Long JH, Qi M, Huang XY, Lei SR, Ren LC (June 2005). "[Repair of rabbit tendon by autologous bone marrow mesenchymal stem cells]". Zhonghua Shao Shang Za Zhi (in Chinese) 21 (3): 210–2. PMID 15996290. 
  23. ^ Seoul National University Hospital. Treatment of Tendon Injury Using Mesenchymal Stem Cells (ALLO-ASC). In: ClinicalTrials.gov [Internet]. Last updated: November 22, 2013. Available from: http://clinicaltrials.gov/show/NCT01856140 NLM Identifier: NCT01856140.
  24. ^ Wang, A.; Breidahl, W.; Mackie, K. E.; Lin, Z.; Qin, A.; Chen, J.; Zheng, M. H. (2013). "Autologous Tenocyte Injection for the Treatment of Severe, Chronic Resistant Lateral Epicondylitis: A Pilot Study". The American Journal of Sports Medicine 41 (12): 2925–2932. doi:10.1177/0363546513504285. ISSN 0363-5465. 
  25. ^ Connell, D; Datir, A; Alyas, F; Curtis, M (2009). "Treatment of lateral epicondylitis using skin-derived tenocyte-like cells". British Journal of Sports Medicine 43 (4): 293–298. doi:10.1136/bjsm.2008.056457. ISSN 0306-3674. 
  26. ^ Clarke, A. W.; Alyas, F.; Morris, T.; Robertson, C. J.; Bell, J.; Connell, D. A. (2010). "Skin-Derived Tenocyte-like Cells for the Treatment of Patellar Tendinopathy". The American Journal of Sports Medicine 39 (3): 614–623. doi:10.1177/0363546510387095. ISSN 0363-5465. 
  27. ^ Ilic, Dusko (2013). "Industry Update: Latest developments in stem cell research and regenerative medicine". Regenerative Medicine 8 (5): 535–542. doi:10.2217/rme.13.56. ISSN 1746-0751. 
  28. ^ Obaid, H.; Clarke, A.; Rosenfeld, P.; Leach, C.; Connell, D. (2012). "Skin-Derived Fibroblasts for the Treatment of Refractory Achilles Tendinosis: Preliminary Short-Term Results". The Journal of Bone & Joint Surgery 94 (3): 193–200. doi:10.2106/JBJS.J.00781. ISSN 0021-9355. 
  29. ^ Koch TG, Berg LC, Betts DH (2009). "Current and future regenerative medicine - principles, concepts, and therapeutic use of stem cell therapy and tissue engineering in equine medicine.". Can Vet J 50 (2): 155–65. PMC 2629419. PMID 19412395. 

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