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Upper limb overload: tendinopathy

If I had a dollar for every time I heard a patient say “I didn’t realise how much I use my hands”….I would have a lot of dollars! For this reason, one of the most common conditions I see as an upper limb Physiotherapist is tendinopathy (often referred to as overuse injuries, tendinitis or in old terms RSI!).

What is tendinopathy?

Tendinopathy is the generic term to describe all tendon pathology injuries. In the upper limb we tend to see two types:

Tendinosis (degeneration)- It was often thought that all tendon problems were due to inflammation but research has found it is rather due to ‘wear and tear’ of tendons as a result of ageing, microtrauma or repetitive stress (overload).

Tenosynovitis (itis= inflammation)- this occurs in certain tendons that are surrounded by a sheath. The sheath acts like a tunnel for the tendons to pass through to protect them and allow movement without getting stuck. This is especially important at the wrist where many tendons have to pass through such a small space.

It is possible to have both tenosynovitis and tendinosis, especially if the injury has been present for a while.

Common upper limb tendinopathies

  • Tennis elbow
  • Golfers elbow
  • ECU tendinopathy
  • De Quervain’s (tenosynovitis)
  • Trigger finger (tenosynovitis)

What causes Tendinopathy?

Tendinopathy is often caused by overloading the tendon. It often comes on gradually with patients reporting a change in activity levels such as a really busy period at work, more frequent or intense training for athletes or musicians or taking up a new hobby like knitting or gardening. The amount of activity which will cause tendinopathy is different for everyone; a manual worker who uses their hands everyday would take a higher load than a someone with low load demands.

How do we treat Tendinopathy?

Often the first step in treatment of tendinopathy is to ‘offload’ the tendons; a balance between resting them enough to allow your pain to settle but not too much to make them even weaker! In reality this is a very tricky thing to do. It is at this stage that most people realise your hands are used for most day to day activities… using your phone, making breakfast, using your phone, driving, using your phone, opening doors, typing, using your phone, lifting, squeezing, gripping…I’m sure you get the gist!

Splints:
Specific splints can be a helpful way of ‘offloading’ your injured tendons to allow them to settle, whilst allowing you to continue on with your day to day activities as much as possible.

Exercises:
Specific exercises are important to help strengthen and build the load tolerance of your tendons to a point you can get back to doing everything you need to without flare ups. This has to be done gradually as tendons do not like change so we essentially have to ‘trick’ them by increasing load in small increments.

Activity modifications/ergonomic changes:
Your Physio/hand therapist can help you identify any activities that may be contributing to your tendinopathy and work out ways to avoid this. This can include computer set up and posture, addressing sporting equipment, technique and training loads, or simply changing the way you lift items in the kitchen.

Soft tissue release:
Techniques such as massage and dry needling can be helpful to address tight muscles associated with tendinopathy. People with a wrist tendinopathy are often surprised to find the muscles of their forearm to be quite sore! 

Injections and surgery:
In some cases of tenosynovitis, a Cortisone injection may also be prescribed by your doctor to help settle your pain and inflammation. If splinting, exercises and injections fail to resolve the problem, sometimes surgery is required. Shockwave therapy is being used more in the treatment of tendinopathy and further research is being undertaken to prove the clinical effectiveness. This is often considered for patients not responding to load management and exercises.

References

Kaux et al. Current opinions on tendinopathy. J Sports Sci Med. 2011 Jun; 10(2): 238–253.
Sartorio et al. Conservative treatments of tendinopathies of upper limbs in occupational health: A literature review. Med Lav. 2016 Mar 24;107(2):112-28.

Learn more about Sophie Crapper by visiting http://www.opsmc.com.au/person/sophie-crapper/