Tendon Problems in Athletic Individuals*†
BY CAROL C. TEITZ, M.D.‡, SEATTLE, WASHINGTON, WILLIAM E. GARRETT, JR., M.D., PH.D.§, DURHAM, NORTH CAROLINA,
ANTHONY MINIACI, M.D.¶, M. H. LEE, M.D.¶, TORONTO, ONTARIO, CANADA,
AND ROGER A. MANN, M.D.#, OAKLAND, CALIFORNIA
An Instructional Course Lecture, The American Academy of Orthopaedic Surgeons
Tendons attach muscle to bone and transmit the
forces generated by muscles across joints to bone in
order to achieve movement or stability of the body in
space. Even when the muscle-tendon unit is not short-
ening, it can be performing a useful function when
activated under conditions of constant length (isomet-
ric) or lengthening (eccentric) contractions. The compli-
ance of tendons varies. Tendons of the digital flexors and
extensors are very stiff, and their length changes very
little when muscle forces are applied through them.
In contrast, the tendons of some muscles, particularly
those involved in locomotion and ballistic performance,
are more elastic. The Achilles tendon, for example, is
stretched in late stance phase as the triceps surae con-
tracts and the ankle dorsiflexes. Near the beginning of
plantar flexion, the muscle activation ceases and energy
stored in the stretched tendon helps to initiate plantar
flexion. Tendons that transmit large loads under eccen-
tric and elastic conditions are more subject to injury73.
A muscle has a much larger cross-sectional area than
does its tendon near its attachment to bone. The tendon
fans out into a much broader and thinner structure as it
joins the muscle. This junctional area is the location
of most injuries caused by tensile forces in a normal
muscle-tendon unit, and it is the site of most common
muscle strains in the active population21.
Histologically, the tendon is seen to be a densely
packed connective-tissue structure, consisting of a ma-
trix of many type-I collagen-fiber bundles that are ori-
ented along the axis of the tendon7. The tightly packed
*Printed with permission of The American Academy of Ortho-
paedic Surgeons. This article will appear in Instructional Course
Lectures, Volume 46, The American Academy of Orthopaedic Sur-
geons, Rosemont, Illinois, March 1997.
†No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study.
‡University of Washington, 300 HEC Edmundson Pavilion, Box
354060, Seattle, Washington 98195-4060.
§Duke University Medical Center, Box 3435, Durham, North
Carolina 27710.
¶Toronto Western Hospital, 399 Bathurst Street, Suite ECW
1-038, Toronto, Ontario M5T 258, Canada.
#3300 Webster Street, Suite 1200, Oakland, California 94609.
138
and highly oriented collagen-fiber matrix makes the
tendon ideal for sustaining tensile load73. Between the
bundles are spindle-shaped fibroblasts that are respon-
sible for creating and maintaining the matrix.
A loose connective-tissue matrix surrounds the bun-
dles of collagen fibrils and is organized within the pri-
mary collagen bundles as well as between the bundles
and surrounding them. A peritendinous connective-
tissue sheath (paratenon) surrounds the entire tendon.
This sheath consists of two layers: an inner (visceral)
layer and an outer (parietal) layer with occasional con-
necting bridges (mesotenon). If there is synovial fluid
between these two layers, the paratenon is called teno-
synovium; if not, it is termed tenovagium.
Pathophysiology
Histological Findings
Painful areas of tendon are traditionally diagnosed
by clinicians as tendinitis. This term implies an in-
flammatory nature of the lesion. However, histologi-
cal studies of operative specimens do not show the
characteristic signs of an inflammatory response as
there are few inflammatory cells such as macrophages
or polymorphonuclear leukocytes. There is little for-
mation of granulation tissue. Rather, the histological
pattern is more characteristic of a degenerative condi-
tion. The matrix is very disorganized without the usual
axial, tightly woven collagen bundles. Fibroblasts are
more numerous, and vascularity is generally increased.
The degenerative pattern can assume fatty, mucoid, or
hyaline features histologically. The better and more
commonly used term for this degenerative condition is
tendinosis7,59.
Necropsy studies have shown that these degenera-
tive changes may also be present in asymptomatic ten-
dons35. The degree of degeneration increases with age
and may represent part of the normal aging process.
The degeneration appears to be activity-related as well.
Operative specimens obtained from younger or middle-
aged patients who put high demands on the involved
muscle-tendon units through recreational or occupa-
tional activities, such as using a strong grip to hold a
THE JOURNAL OF BONE AND JOINT SURGERY
 TENDON PROBLEMS IN ATHLETIC INDIVIDUALS
tennis racquet or a hammer, often show degenerative
changes in the affected tendon34.
Tendon Failure
High forces created by eccentric muscle activation
usually are responsible for tendon failure34,41,59. Bio-
mechanical studies of the effect of loading on normal
bone-tendon-muscle-tendon-bone preparations have
shown that failure rarely occurs in the tendon22. Biopsy
specimens obtained soon after the spontaneous fail-
ure of tendons showed degenerative changes in the
ruptured tendon ends35. Specimens of Achilles tendon
obtained on exploration for operative repair almost al-
ways demonstrate that degenerative changes were pres-
ent within the tendon before it failed. These changes
presumably weakened the tendon to such a degree that
it became the weakest link in the chain.
Research aimed at understanding the pathophysi-
ology and treatment of tendinosis has been limited by
the lack of a good and affordable animal model57. In-
jection of collagenase into the center of an equine ten-
don produces a histological picture similar to that seen
in biopsy specimens of human tendinosis71. However,
this lesion tends to heal and, therefore, may be more of
a model for tendon sprain than for chronic tendinosis.
Perhaps the model most closely resembling tendinosis
occurs in the superficial digital flexor tendon of the
horse. Lesions in this tendon are responsible for poor
performance or lameness, especially in racehorses. The
condition is characterized by fusiform swelling of the
tendon with a degenerative core lesion and more nor-
mal tissue in the tendon peripherally. The tendon un-
dergoes rapid loading and high strains in the galloping
horse. Tendons store energy on stretching and return
most of it when released. However, the energy that is
not returned is dissipated as heat within the tendon, and
the temperature in the central area of the tendon can
reach nearly 45 degrees Celsius. Fibroblast viability is at
risk at this temperature, and death of the central fibro-
blasts may create the central core degeneration that is
seen histologically.
In summary, the pathophysiology of tendinosis has
not been well studied and is not well understood. Sus-
ceptible tendons are those that undergo large loads in
an eccentric or stretching mode in which the tendons
are storing and releasing energy. Susceptibility appears
to be related both to activity and to age. The basic le-
sion can be identified within the tendon core and is
characterized as degenerative rather than inflammatory.
The term tendinitis is, therefore, less applicable than
tendinosis. Possible factors in the etiology include age-
related changes in tendon structure and exercise-related
hyperthermia within the tendon.
Tendinosis of the Rotator Cuff
Disorders of the rotator cuff occur commonly. Over-
use or repetitive stress of the upper extremity in the
VOL. 79-A, NO. 1, JANUARY 1997
139
overhead position may be an important cause of rota-
tor cuff tendinosis11,37,46,48. Poor vascularity and primary
degenerative changes also may contribute to the devel-
opment of the lesion. Codman11 described a so-called
critical zone, located approximately one centimeter me-
dial to the supraspinatus tendon insertion, where tears
usually occur. Rathbun and Macnab60 showed that there
was relative avascularity in this critical zone, and they
hypothesized that this was the reason for the degen-
erative changes. Lohr and Uhthoff42 also found this to
be an area of hypovascularity, but they noted that the
articular side of the tendon was poorly vascularized
whereas the bursal side was well vascularized. Ogata
and Uhthoff56 suggested that primary tendinosis was
also an important etiological factor, especially for the
deep-surface or intratendinous tears that are seen more
often than tears on the bursal side.
Shoulder pain and rotator cuff tendinosis are fre-
quently seen in athletes who are involved in sports, such
as baseball, tennis, and swimming, that require overhead
actions. Jobe et al.33 suggested that subtle glenohumeral
instability was one of the causes of rotator cuff ten-
dinosis in this group. The overhead throwing motion of
baseball pitchers and the service motion of tennis play-
ers require eccentric muscle contractions as the rotator
cuff and shoulder-girdle muscles attempt to maintain
stability of the glenohumeral joint23,33,65. These eccentric
contractions can injure structures such as the biceps-
labrum complex2.
Because the static stabilizers in patients who have
shoulder laxity or multidirectional instability are rela-
tively incompetent, the rotator cuff and other shoulder-
girdle muscles must work harder to limit glenohumeral
translation. This may lead to overuse tendinosis. Fowler
and Webster19 as well as Richardson et al.61 observed a
close relationship between rotator cuff tendinosis and
shoulder laxity in competitive swimmers. Neuromus-
cular imbalance, especially between the internal and
external rotators, also may result in rotator cuff tendino-
sis23. For athletes who use the arms overhead, an imbal-
ance between the internal and external rotators may
compromise the stabilizing function of the rotator cuff,
causing secondary impingement as the humeral head
migrates superiorly. The internal rotators usually are
stronger than the external rotators, causing further mi-
gration of the humeral head anteriorly and superiorly.
Shoulder pain is a common presenting symptom
for many conditions about the shoulder. Although most
patients who have rotator cuff tendinosis report pain,
others may describe clicking, catching, weakness, stiff-
ness, crepitation, or symptoms of instability. In addition,
problems of the neck and the shoulder often have over-
lapping symptoms, and they may exist concomitantly,
complicating diagnosis and management. The age and
occupation of the patient; the duration and location of
the symptoms; and the radiation, timing, quality, and
severity of the pain can be important differentiating
140 C. C. TEITZ ET AL.
factors. The patient should be asked about any alle-
viating or aggravating factors as well as about any
specific traumatic event that precipitated the problem.
Athletes should be questioned about the level and in-
tensity of their participation in sports activities, par-
ticularly those that require overhead use of the upper
extremity, such as baseball, tennis, volleyball, and swim-
ming. They should be questioned about the time that the
pain occurs during each activity and asked to note spe-
cific movements or other factors, such as the position of
the upper limb, that induce the symptoms.
The shoulder examination should be approached
systematically for every patient by following the consec-
utive steps of inspection, palpation, assessment of the
range of motion, strength-testing, neurological assess-
ment, and the performance of special tests. In addition,
the physical examination should include a thorough as-
sessment of the cervical spine and the rest of the upper
extremity.
During inspection, scapular winging may be noted,
which suggests an underlying scapulothoracic dysfunc-
tion that may be associated with shoulder instability,
muscle imbalance, or muscle fatigue. Scapular winging
may become more evident with range-of-motion and
strength-testing. Osseous and soft-tissue structures are
palpated in order to identify specifically any areas of
tenderness. The range of motion, both active and pas-
sive, should then be assessed and documented in all
planes. When there is pain, its severity and the arc of
motion at which it occurs should be noted. An attempt
should be made to determine if any loss of motion is
secondary to pain or to capsular contracture. Loss of
internal rotation may be due to posterior capsular con-
tracture, a condition that is often associated with gleno-
humeral instability43.
Muscles should be isolated and tested specifically
for strength. Special tests may be helpful for differenti-
ating the etiology of the shoulder pain. Impingement
tests such as the Neer49 test and the test of Hawkins and
Kennedy25 may be positive regardless of the cause of the
rotator cuff tendinosis. Pain during crossed-arm adduc-
tion at 90 degrees suggests a lesion in the acromio-
clavicular joint. The tests of Yergason75 and of Speed13
are used to check for a lesion in the biceps. Tests for
instability include the apprehension sign and the reloca-
tion test27. The load and shift test, as described by Haw-
kins et al.26, assesses the degree of translation in all
planes. A sulcus sign may indicate multidirectional in-
stability26. Field and Savoie17 described a test to check
for labral tears involving the anchoring point of the long
head of the biceps.
Radiographic evaluation should consist of an an-
teroposterior, a transscapular lateral, and an axillary ra-
diograph. The supraspinatus outlet radiograph, a lateral
radiograph of the erect scapula with a downward tilt of
10 degrees, can help in the assessment of acromial mor-
phology50. The examiner should note any osseous abnor-
malities, such as a variation in the shape and slope of the
acromion, osteoarthrosis of the acromioclavicular joint,
spurring of the distal aspect of the clavicle, and calcifi-
cation of the rotator cuff tendons. The examiner should
also look for evidence of an osseous Bankart lesion or
a Hill-Sachs lesion. Cystic changes or sclerosis in the
region of the greater tuberosity, proximal migration of
the humeral head, decreased acromiohumeral distance,
or glenohumeral osteoarthrosis may be indicative of a
rotator cuff tear. Arthrography, ultrasonography, and
magnetic resonance imaging can be helpful in the diag-
nosis of full-thickness tears of the rotator cuff, but their
clinical value in the assessment of rotator cuff tendino-
sis remains questionable16,28,47,51. In our experience, shoul-
der arthroscopy has been extremely useful in
demonstrating the exact location and extent of partial-
thickness tears of the rotator cuff and in identifying
other pathological conditions in the shoulder, such as
labral tears or ligamentous laxity.
Regardless of the etiology of the condition, patients
who have rotator cuff tendinosis have similar symptoms
and most can be managed conservatively with an ap-
propriate rehabilitation program. Physiotherapists often
play an important role in this program, using a variety
of modalities such as heat, cold, ultrasound, laser, fric-
tion, and transcutaneous electrical nerve stimulation.
Good communication between the physician, the pa-
tient, and the physiotherapist is essential for a successful
outcome. The role of the patient in the treatment pro-
gram should be clearly defined at the onset, and realistic
goals and expectations of therapy also should be estab-
lished at the start.
The first phase of the rehabilitation process is pain
control, which is achieved by having the patient rest the
shoulder and modify or avoid activities that aggravate
the pain. Anti-inflammatory medications may be help-
ful. Subacromial injections of corticosteroids may be
considered, but they usually are used only in the later
stages of the conservative treatment protocol. We limit
treatment to a maximum of three injections.
The second phase of the rehabilitation protocol
is restoration of the range of motion. Patients are in-
structed in circumduction exercises and in the use of
pulleys to improve motion. Specific stretching exercises
also are taught as a standard part of this program.
The third phase is muscle-strengthening. Emphasis
is placed on the strength of the rotator cuff, the deltoid,
and the scapular stabilizing muscles. Overhead activities
should be avoided, especially during the early phases of
treatment. A progressive resistive program is initiated
with use of Therabands (DePuy, Warsaw, Indiana), elas-
tic tubing, free weights, or a combination of these. Ther-
abands and elastic tubing are easily adapted for use at
home. They create a closed kinetic system, which may
be preferable to the high torque stresses generated at
the shoulder by free weights. Restoration of the power,
endurance, and smooth coordination of the shoulder
THE JOURNAL OF BONE AND JOINT SURGERY
 TENDON PROBLEMS IN ATHLETIC INDIVIDUALS
muscles is emphasized and should be sport-specific. Any
muscle imbalance, especially one between the internal
and external rotators, must be identified and addressed.
Glenohumeral instability should be identified early, and
a proper strengthening program should be directed at
improving the dynamic stabilizers of the shoulder. If
symptomatic glenohumeral instability continues despite
a comprehensive rehabilitation program, operative in-
tervention should be considered to restore stability.
Operative intervention for rotator cuff tendinosis
should be considered only after all attempts at conser-
vative treatment have failed. For patients who demon-
strate primary mechanical impingement, the operative
procedures available are resection of the coracoacromial
ligament25,31,36,58, anterior acromioplasty, resection of the
distal part of the clavicle, and resection of inferior osteo-
phytes from the acromioclavicular joint, depending on
the specific underlying disorder. Glenohumeral insta-
bility that is unresponsive to a program of muscle-
strengthening and balancing should be treated with
operative stabilization.
The use of shoulder arthroscopy has enhanced the
ability to diagnose and evaluate various pathological
conditions in the shoulder, including rotator cuff ten-
dinosis and, in particular, partial-thickness tears. Al-
though we agree with those investigators15,68 who have
advocated repair of sizable or delaminated partial-
thickness tears of the rotator cuff, there is little in the
literature describing the treatment of partial-thickness
tears of the rotator cuff and controversy still exists re-
garding the effectiveness of treatment. Snyder68 de-
scribed an arthroscopic suture-repair technique for
partial-thickness tears as well as for small full-thickness
tears of the rotator cuff.
Tendinosis of the Elbow
The term tennis elbow is widely used to describe a
series of overuse injuries that are characterized by pain
and tenderness in the region of the humeral epicondyles
and that involve the extensors or flexors of the wrist.
The peak prevalence of tennis elbow is in the fourth
decade of life, when it is four times higher than the
prevalence in any other decade12. The lateral epicondyle
is involved seven times more often than is the medial
epicondyle. Although it is termed tennis elbow, the con-
dition occurs very commonly in non-athletes.
Lateral Tendinosis of the Elbow
Although lateral epicondylitis was first described64
in 1873, some controversy still exists regarding the eti-
ology and the pathogenesis of this condition. The basic
underlying lesion seems to be a macroscopic or micro-
scopic tear in the origin of the extensor carpi radialis
brevis tendon that heals with immature reparative tis-
sue52. Gross examination of this region characteristically
shows grayish, gelatinous, friable immature scar tissue
that appears shiny and edematous. Light microscopy
VOL. 79-A, NO. 1, JANUARY 1997
141
reveals a characteristic invasion of fibroblasts and vas-
cular granulation, which has been described as so-called
angiofibroblastic hyperplasia55. Although lateral tendi-
nosis of the elbow most commonly involves the ori-
gin of the extensor carpi radialis brevis, the origins of
the extensor digitorum communis, the extensor carpi
radialis longus, and the supinator can also be involved
in the process. Inflammation of the lateral collateral and
orbicular ligaments also can be observed.
The patient usually is first seen because of the grad-
ual onset of aching pain in the region of the lateral
epicondyle and in the proximal muscles of the fore-
arm. The pain often is related to flexion and extension
of the wrist and to pronation and supination activi-
ties. Other conditions that should be considered in
the differential diagnosis include nerve entrapment (ra-
dial tunnel syndrome) and intra-articular disorders
such as radiocapitellar osteoarthrosis, osteochondritis
dissecans, and an osseous tumor.
Physical examination usually reveals localized ten-
derness directly over the lateral epicondyle in the re-
gion of the origin of the extensor carpi radialis brevis;
however, the area of tenderness often can be quite dif-
fuse. Pain may be increased with resisted wrist or finger
extension, particularly with the forearm in pronation.
Patients may have a positive coffee-cup test, as described
by Coonrad12, in which grasping or pinching with the
wrist in extension reproduces the pain at the point of
maximum tenderness. They also may have a positive
chair test, as described by Gardner20, in which the patient
has pain in the region of the lateral epicondyle while
lifting a chair with one hand with the forearm pronated.
Isokinetic strength deficits also may be observed.
Anteroposterior and lateral radiographs of the el-
bow should be made routinely, as they are helpful
for ruling out other conditions such as radiocapitel-
lar osteoarthrosis or the presence of a loose body or
an osseous tumor. Oblique radiographs occasionally
demonstrate calcifications in the region of the lateral
epicondyle. The findings of electromyography studies
are usually normal, even for patients who have radial
tunnel syndrome. Magnetic resonance imaging may
demonstrate abnormal changes in signal intensity at the
extensor origin on the lateral aspect of the elbow, but a
change in signal intensity does not necessarily correlate
with the histological findings or with the symptoms53.
The pain needs to be brought under control before
the patient can start any extensive rehabilitation. Pain
control can be achieved with the use of non-steroidal
anti-inflammatory medications, rest, and modification of
activity. Physical modalities such as ice or heat, ultra-
sound, and electrical stimulation may help to control the
pain; phonophoresis with 10 per cent hydrocortisone
cream has been found to be useful38. Injections of corti-
costeroids can be tried in resistant cases, with a maxi-
mum of three injections during a period of one year.
Care should be taken to inject the medications directly
142 C. C. TEITZ ET AL.
into the area of maximum tenderness. Counterforce
braces have been shown to be effective in the treatment
of elbow tendinosis as well24. These braces are straps,
approximately five to six centimeters wide, that are ap-
plied just distal to the elbow over the origin of the
common extensor tendon. Biomechanical and electro-
myographic analysis has shown inhibition of maximum
contraction of the wrist and finger extensors by use of a
counterforce brace24. For the tennis player, stroke me-
chanics should be evaluated and modified as necessary
to help control symptoms. When the pain has been con-
trolled, an exercise program that focuses on eccentric
strengthening (as described by Stanish et al.69) and the
restoration of flexibility and endurance can be initiated.
Seven per cent (eighty-eight) of 1213 elbows in one
series55 had resistant lateral tendinosis that needed oper-
ative intervention. Operative treatment should be con-
sidered only after non-operative treatment has failed for
at least one year. The principles of operative treatment
were previously described by Nirschl and Pettrone55. The
origin of the extensor carpi radialis brevis is exposed,
and tears as well as any granulation tissue that is seen
on the underside of the extensor carpi radialis brevis
tendon are excised. A small area of the lateral condyle
can be decorticated or drilled to improve the blood
supply for healing of the detached tendon. Intra-articu-
lar examination usually is not necessary unless an asso-
ciated abnormality was anticipated preoperatively.
Usually, the elbow is splinted in 90 degrees of flexion for
three weeks postoperatively. Then, range-of-motion and
gradual strengthening exercises of the hand and wrist
are performed daily for three additional weeks. From six
to twelve weeks postoperatively, resisted and eccentric
exercises of the wrist are performed. Weights are grad-
ually increased to a maximum of five pounds (2.3 kilo-
grams). After twelve weeks, patients should return
gradually to full activities. They may return to sports
activities at four to six months after the operation or
when strength and endurance are approximately 80 per
cent of normal.
Medial Tendinosis of the Elbow
Medial tendinosis of the elbow occurs much less
commonly than lateral tendinosis of the elbow and re-
sults from overuse of the forearm flexor muscles or from
repetitive valgus stress in throwing athletes. The condi-
tion is seen also in patients who play racquet sports, such
as tennis, squash, and racquetball, in which the fore-
hand stroke creates excessive stress on the medial el-
bow structures. In medial tendinosis of the elbow, the
tendons of the pronator teres, the flexor carpi radialis,
and occasionally the flexor carpi ulnaris are principally
affected.
Patients who have medial tendinosis of the elbow
usually report aching pain that originates from the re-
gion of the medial epicondyle and radiates into the
muscles of the forearm. They may also report decreased
grip strength, but this problem is usually related to pain
rather than to an injury of nerve or muscle. Some of
these patients are seen with an acute disruption of the
common flexor origin or the ulnar collateral ligament,
or both. These conditions, chronic tendinosis and acute
disruption, must be differentiated clinically because
acute rupture of the ulnar collateral ligament is best
treated operatively, especially in an athlete who uses
overhead motion. In medial tendinosis of the elbow, the
pain increases with resisted wrist flexion when the fore-
arm is held in pronation. With a disruption of the ulnar
collateral ligament, a valgus stress test of the elbow
produces pain. Ulnar-nerve entrapment can also cause
medial pain in the elbow, and it should be included in
the differential diagnosis. Nirschl54 reported ulnar-nerve
dysfunction in 60 per cent of patients who had operative
treatment for medial epicondylitis. Entrapment of the
ulnar nerve usually is found in zone 3, distal to the
medial epicondyle.
Non-operative treatment of medial tendinosis of the
elbow should follow the same steps as those described
for lateral tendinosis of the elbow. Operative treatment
involves a medial longitudinal incision with the surgeon
carefully avoiding the medial antebrachial cutaneous
nerve. The tendons of the pronator teres and flexor carpi
radialis are split longitudinally, distal from their origin
on the medial epicondyle. Care should be taken not to
detach the common flexor origin, as this can lead to
posteromedial instability of the elbow. All abnormal,
torn, or degenerative tissue should be sharply excised.
If there is evidence of ulnar neuropathy preoperatively,
a formal ulnar-nerve transposition should be performed
because the results of cubital tunnel decompression
alone have not been satisfactory39.
Tendinosis about the Hip (Snapping Hip)
Two distinct conditions, which have been charac-
terized as internal and external, can cause symptomatic
snapping with motion of the hip. The internal type is due
to the iliopsoas tendon snapping over the femoral head,
over the iliopectineal eminence, or, less commonly, over
a ridge on the lesser trochanter. Internal snapping hip
often is found in athletes who frequently flex and ex-
tend this joint, especially in association with abduction
and external rotation, as occurs commonly in dance and
in the martial arts. The patient is first seen because of
the gradual onset of a reproducible, audible, and palpa-
ble low-pitched clunk in the groin. Typically, the prob-
lem is unilateral. On physical examination, there is no
tenderness and no pain when the rectus femoris works
against resistance. Occasionally, the examiner can elicit
pain with resisted use of the iliopsoas muscle.
Although arthrography or magnetic resonance im-
aging can be considered in order to rule out a loose body
or a labral tear within the hip joint, no workup is nec-
essary when the clinical findings are typical. The diag-
nosis can be made definitively by iliopsoas bursography,
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 TENDON PROBLEMS IN ATHLETIC INDIVIDUALS 143

dition is most common in cyclists and runners, par-

ticularly those who run up and down hills. Anatomical
factors that maintain the iliotibial band in a stretched
position and make it more likely to rub as it passes over
the greater trochanter include genu varum, a true limb-
length discrepancy or a functional short limb (the down-
hill limb while an individual is running on a canted
surface), and a crossover running style. Occasionally, a
causative factor for external snapping hip in cyclists is
the position of the cleat or other shoe-fixation device on
the bicycle.
When these patients are first seen, they report the
gradual onset of pain and a high-pitched snapping over
the greater trochanter. Typically, the problem is uni-
lateral and is sometimes difficult to distinguish from
greater trochanteric bursitis. The patient has tenderness
FIG. 1-A
Figs. 1-A through 1-D: Drawings showing the Ober test for assess-
ing contracture of the iliotibial band. The patient lies on the unaf-
fected side with the unaffected hip and knee flexed enough to
eliminate lumbar lordosis. The examiner holds the extremity to be
tested with the knee flexed. The examiner’s other hand stabilizes the
pelvis. The hip is then flexed, abducted, and hyperextended to catch
the iliotibial band on the greater trochanter. The limb is then ad-
ducted. If the iliotibial band is tight, the limb cannot be adducted
back down to the examining table or to the contralateral limb but
remains passively abducted.
Fig. 1-A: Flexion.

FIG. 1-C
Hyperextension.

FIG. 1-B
Abduction.

which will demonstrate the snapping tendon66.

The internal snapping hip is treated first by en-
couraging the patient to stop intentional snapping. Non-
steroidal anti-inflammatory medications may be helpful
in relieving any inflammation that may have resulted
from repeated snapping. Stretching and strengthening
exercises of the iliopsoas are helpful as is repattern-
ing muscle use during the affected motions. Operative
lengthening of the iliopsoas tendon is rarely necessary1.
The external snapping hip is caused by the iliotibial FIG. 1-D
band snapping over the greater trochanter. This con- Adduction.

VOL. 79-A, NO. 1, JANUARY 1997

144 C. C. TEITZ ET AL.
to palpation over the greater trochanter when tendino-
sis is present and behind it when bursitis is present. In
either case, the patient has pain when the lower ex-
tremity is adducted across the midline. The hip usually
is painful to lie on when the patient has bursitis, but
not when the patient has iliotibial tendinosis. Resisted
abduction is painful when tendinosis is present, but not
when the patient has bursitis alone. An Ober test reveals
tightness of the iliotibial band (Figs. 1-A through 1-D).
The initial treatment of both bursitis and tendino-
sis includes the use of non-steroidal anti-inflammatory
drugs and ice-friction massage. Stretching the iliotibial
band is helpful, but it may aggravate bursitis initially.
The physician should look for and correct any training,
biomechanical, or anatomical factors that may have
contributed to the problem. Differentiation of bursitis
from tendinosis is more important when initial treat-
ment is unsuccessful. When a patient has chronic bursitis
of the greater trochanter, an injection of steroids into
the bursa often relieves symptoms. When the problem is
chronic iliotibial tendinosis, however, injections of ste-
roids are less likely to provide relief, and lengthening
of the iliotibial band should be considered in order to
achieve long-lasting relief4.
Lateral Runner’s Knee (Iliotibial Band Tendinosis)
The condition that is termed lateral runner’s knee is
caused by the iliotibial band rubbing over the lateral
femoral epicondyle. This is most commonly an over-
use condition with the same predisposing biomechani-
cal and anatomical factors as those noted previously for
the iliotibial band snapping over the greater trochan-
ter. In addition, a mild varus position of the heel can
predispose a runner to iliotibial band tendinosis at the
knee because of the varus moment imposed by this de-
formity on the knee during heel-strike and mid-stance10.
FIG. 2
Photograph showing a brace for jumper’s knee. The pad must be positioned directly over the patellar ligament.
The patient is first seen with unilateral pain in the
lateral aspect of the knee, proximal to the joint line, at
the level of the lateral femoral epicondyle. Occasionally,
a patient reports snapping as well. The pain is insidious
in onset, but it is made worse by going up or down stairs,
riding a bicycle, or running. Tenderness to palpation at
the epicondyle and, sometimes, crepitation are noted.
The Ober test is positive for tightness of the iliotibial
band (Figs. 1-A through 1-D). The examiner should also
check the shoes of the runner for abnormal wear along
the lateral part of the midsole and forefoot.
The treatment for this condition is identical to that
for external snapping hip, as described previously. One
way to correct the common biomechanical problems is
to encourage the patient to run in alternate directions
on the track or on alternate sides of the road to avoid
always having the same lower extremity in the downhill
position. In addition, a lateral wedge in the shoe of a
patient who has varus heels or knees can help to de-
crease the varus moment during running. If all else fails,
an injection of steroids into the area of maximum ten-
derness may produce relief, as an inflamed bursa may
have developed deep to the tendon. Lengthening of
the iliotibial band may be performed, but it is rarely
necessary18.
Jumper’s Knee
Jumper’s knee, or so-called patellar tendinosis, re-
sults from microtears of the patellar ligament followed
by a chronic inflammatory response. It is an overuse
injury that is most commonly seen in athletes who par-
ticipate in sports that require a great deal of jumping or
kicking, such as basketball, volleyball, and soccer. Symp-
toms may occur during an adolescent growth spurt, per-
haps because the ligament does not lengthen as fast or
as much as the adjacent bones are growing.
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 TENDON PROBLEMS IN ATHLETIC INDIVIDUALS 145

The patient is first seen with tenderness over the Patients who have tenosynovitis of the posterior
patellar ligament. The area may be red, swollen, or crep- tibial tendon report pain along the posteromedial as-
itant. Resisted use of the quadriceps and full passive pect of the foot and ankle. The pain is minor at first,
flexion of the knee produce pain. Quadriceps tightness but swelling and progressive disability develop as the
is frequently present. condition progresses. The evaluation should begin with
Treatment includes decreasing or stopping the in- careful questioning regarding history, with particular at-
citing activity, use of non-steroidal anti-inflammatory tention paid to the onset of the condition, changes in
drugs, and ice-friction massage. A program of quadri- training habits, the nature and frequency of training, the
ceps stretching is critical, particularly for the adolescent. type of footwear, and the use of orthotic devices. The
Isometric exercises to strengthen the quadriceps can single most important aspect in the assessment of a pa-
be started immediately, but isotonic or isokinetic exer- tient who has suspected dysfunction of the posterior
cises for strengthening the quadriceps should begin only
when the tenderness has subsided. It is very important
that the athlete eventually advance to eccentric quadri-
ceps strengthening in order to train for his or her sport.
Although the precise reason for its clinical effectiveness
is not known, application of a brace that contains a pad
over the patellar ligament is useful when the pain has
resolved and the athlete wishes to return to participa-
tion in sports (Fig. 2).
When patellar tendinosis does not respond to non-
operative intervention, diagnostic ultrasonography may
reveal an area of angiofibroblastic hyperplasia and fi-
brinoid necrosis deep within the ligament (Fig. 3-A).
With use of a local anesthetic, excision of this area can
be carried out by splitting the ligament longitudinally
(Fig. 3-B), and the surgeon should look for gelatinous
material between normal fibers. This material should be
excised, and the remainder of the ligament should be
closed with absorbable sutures. Roels et al. reported that
operative treatment allowed all ten patients in their
series to return to participation in sports62.

Dysfunction of the Posterior Tibial Tendon

The posterior tibial muscle is the main invertor of FIG. 3-A
the subtalar joint. The short fiber length of this muscle Figs. 3-A and 3-B: A patient who had jumper’s knee.
produces a great deal of force on its five insertions into Fig. 3-A: Ultrasonogram showing the hypoechoic area (arrow)
the plantar aspect of the foot. The posterior tibial ten- within the fibers of the patellar ligament. This area corresponds to
the area of angiofibroblastic hyperplasia and fibrinoid necrosis in the
don has an excursion of two centimeters 14. If the hind- ligament.
foot is in an abnormal amount of valgus or the forefoot
is in too much varus, excessive tension is placed on
the posterior tibial tendon, a situation that may lead to
tenosynovitis.
Dysfunction of the posterior tibial tendon can be
acute or chronic. Most commonly, the condition consists
of an acute tenosynovitis secondary to overuse, with-
out any structural change in the hindfoot. In one series,
this condition was reported in fifty-eight (6 per cent)
of 974 runners6. Chronic tenosynovitis, which usually is
found in the non-athletic population, is associated with
tendinosis and structural changes in the hindfoot. An
acute rupture of the posterior tibial tendon before the
age of thirty years has been reported in only four pa-
tients9. Woods and Leach reported one other series of
FIG. 3-B
six patients who had had an acute rupture (complete or
Photograph showing the gross appearance of the patellar ligament.
partial) of the posterior tibial tendon and emphasized Note the discoloration and the loss of fibrous integrity in the dam-
the necessity for early recognition and treatment 74. aged area deep in the ligament (arrow).

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146 C. C. TEITZ ET AL.
tibial tendon is the physical examination. The hindfoot
should be observed with the patient standing. A patient
who has posterior tibial tendon dysfunction may have
an increased valgus posture of the calcaneus and a full-
ness that is seen just distal to the medial malleolus. The
patient should be asked to stand on tiptoe so that the
examiner can assess the degree of active inversion of
the calcaneus that occurs at the subtalar joint. Lack of
heel inversion usually indicates dysfunction or weakness
of the posterior tibial tendon. Next, the patient should
be asked to repeat a toe-rise on one foot approximately
eight to ten times. The examiner should carefully ob-
serve how high the patient is able to rise on the toes as
well as the degree of heel inversion that occurs. Fre-
quently, during an acute episode of tenosynovitis, the
patient is unable to stand on tiptoe at all because of
pain.
The examiner should carefully note the degree of
dorsiflexion and plantar flexion of the ankle (specifi-
cally looking for any lack of dorsiflexion), the range of
subtalar joint motion (looking particularly for dimin-
ished inversion), and the motion of the transverse tarsal
joint. The tendon sheath should be palpated carefully,
with the examiner looking for thickening, increased
warmth, and crepitation. The strength of the tendon
should be evaluated by having the patient both bring the
foot actively from a fully everted position into inversion
and attempt to hold the foot in an inverted position
against resistance.
Weight-bearing anteroposterior, lateral, and oblique
radiographs of the foot should be made. The antero-
posterior radiograph can demonstrate subluxation of
the talonavicular joint and the relationship of the ta-
lus to the calcaneus. The lateral radiograph should be
studied for any sagging of the talonavicular, naviculo-
cuneiform, or first metatarsal-cuneiform joint. No single
specific pattern of radiographic changes is observed in
these patients.
Treatment
Acute tenosynovitis: When acute tenosynovitis is
mild, it can be treated with a decrease in the level of
activities. However, when the symptoms are moderate,
the extremity should be rested and stressful activities
should be stopped. An anti-inflammatory medication or
ice, or both, should be utilized at this stage. If the symp-
toms do not respond within four to six weeks, immo-
bilization in a weight-bearing below-the-knee cast for
four to six weeks is recommended. If the symptoms still
fail to respond, operative treatment should be recom-
mended. The operative procedure consists of explora-
tion of the tendon between the medial malleolus and the
tendon insertion. Most frequently, varying degrees of
synovial proliferation are found. The tendon and sheath
should be carefully debrided of the exuberant synovial
tissue. If necessary, the débridement may be continued
proximal to the medial malleolus, but a one-centimeter
section of sheath should be left in place to act as a
pulley behind the medial malleolus. Occasionally, when
the posterior tibial tendon is explored, the tendon itself
appears to be intact, but the abnormality lies at the
insertion of the tendon into the navicular. Although
excision of the affected portion and advancement of the
posterior tibial tendon into the navicular is preferable
in this situation, often there is not enough excursion of
the musculotendinous unit to allow advancement of the
tendon into the navicular. Therefore, we have found that
it is better to carry out a reconstruction with use of the
flexor digitorum longus tendon as a transfer into the
navicular and then to suture the end of the posterior
tibial tendon into the flexor digitorum longus.
Acute rupture: A patient who sustains an acute rup-
ture of the posterior tibial tendon, a rare injury, demon-
strates no active inversion of the subtalar joint. A defect
in the tendon may be palpable because the rupture usu-
ally occurs between the medial malleolus and the navic-
ular. However, blood in the tendon sheath may mask
this finding. When an acute rupture is present, a recon-
struction with use of the flexor digitorum longus should
be performed as soon as possible in order to avoid the
development of a flatfoot deformity44.
Chronic tenosynovitis: A patient who has had teno-
synovitis of the posterior tibial tendon for more than a
year probably has a mild-to-moderate degree of ten-
dinosis. The foot probably has structural changes (such
as mild flattening of the longitudinal arch secondary to
sagging of the talonavicular joint), although the defor-
mities may be mild and usually are not fixed. These
patients retain fair-to-good strength of the posterior
tibial muscle and can be managed with an orthosis.
The orthosis should include a varus heel-wedge and a
medial forefoot post. When the symptoms persist and
interfere with activities of daily living or athletic activi-
ties, exploration, decompression, and reconstruction of
the tendon with use of the flexor digitorum longus is
indicated.
Chronic rupture: Patients who have chronic rupture
of the posterior tibial tendon note a flatfoot deformity
that has progressed over a period of several years. The
physical examination often demonstrates loss of subta-
lar joint motion, especially inversion, and a fixed varus
deformity of the forefoot that usually exceeds 15 de-
grees. When this is the case, tendon decompression and
transfer is not effective and a double or triple arthrode-
sis is indicated. It should be realized that fusion of this
type can be a substantial impediment to running activi-
ties; however, walking, golf, and doubles tennis are still
feasible.
Dysfunction of the Achilles Tendon
The gastrocnemius-soleus complex spans two joints
and is the largest and strongest muscle in the calf. It is
a stance-phase muscle that undergoes both eccentric
(lengthening) and concentric (shortening) contractions
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 TENDON PROBLEMS IN ATHLETIC INDIVIDUALS 147

during walking and running. Normally, the Achilles ten- motion of the ankle and the subtalar joint should be
don twists as it passes to its insertion, particularly in determined carefully.
the area approximately two to six centimeters proxi- The physical findings in tendinitis consist of inflam-
mal to the insertion. This anatomical configuration re- mation that is limited to the peritenon, as demonstrated
sults in increased internal stress on the tendon30. In by increased warmth and tenderness and, possibly, by
addition, the blood supply to this area has been demon- crepitation. Nodularity is not present with acute Achil-
strated to be tenuous29,40. Problems that commonly occur les tendinitis. During dorsiflexion and plantar flexion,
in the area that is proximal to the insertion of the ten- the fingertips of the examiner feel no nodules in the
don and to the level of the retrocalcaneal bursa are Achilles tendon.
termed non-insertional problems. These include Achil- When tendinosis is present, the tendon is thickened
les tendinitis, which is an inflammation of the tendon
sheath without intrinsic tendinous changes; Achilles ten-
dinosis, which is the occurrence of intrinsic tendinous
changes with or without associated tendinitis; and Achil-
les tendon rupture. Another set of problems occurs in
the area posterior to the retrocalcaneal bursa and at the
insertion of the tendon. These are termed insertional
problems and include calcification within the Achilles
tendon at its insertion into the calcaneus without ten-
dinosis; Achilles tendinosis at its insertion with or with-
out associated calcification; and Achilles dysfunction
associated with a Haglund deformity, which is a promi-
nence of the posterosuperior aspect of the calcaneus.
Such categorization of the various pathological entities
that occur about the Achilles tendon is important for
accurate diagnosis, prognosis, and treatment.
The prevalence of Achilles tendinitis has been esti- FIG. 4-A
mated to be 11 per cent (twenty-five of 232) in run- Figs. 4-A and 4-B: A patient who had insertional tendinosis.
ners32, 9 per cent (thirty-three of 352) in dancers63, 5 per Fig. 4-A: Radiograph demonstrating calcification at the insertion
cent (eight of 147) in gymnasts5, 2 per cent (two of of the Achilles tendon (arrow).
eighty-nine) in tennis players72, and less than 1 per cent
(twenty-three of 2820) in football players76. Tendinitis
is brought about most frequently by training-related
errors, although mechanical factors, such as hyperpro-
nation of the foot, contracture of the gastrocnemius-
soleus complex, or faulty footwear, may be involved as
well. Conversely, Achilles tendinosis represents a de-
generative process of the tendon and probably has
nothing to do with training errors or other mechanical
problems. Achilles tendon ruptures, which are not de-
scribed in the present report, are thought to be due to
underlying tendinosis3,8, although usually the tendinosis
is subclinical.
Evaluation of a patient who has a painful Achilles
tendon begins with careful questioning regarding the
history, including the onset of the condition, the level of
activities, the training techniques, the type of foot-
wear, and the previous treatment. The patient is asked
to place a finger on the area of maximum pain. The
patient should then stand while the examiner notes the
posture of the foot. Next, a toe-rise should be done
three, four, or five times on each foot individually. A
patient who has tendinosis often is unable to do a single
toe-rise, whereas a patient who has tendinitis can per-
form a toe-rise without as much difficulty. The tendon FIG. 4-B
should be palpated for thickening, increased warmth Computerized tomography scan localizing the area of calcification
along the tendon sheath, and crepitation. The range of (arrow).

VOL. 79-A, NO. 1, JANUARY 1997

148
over a length of two to five centimeters. This area may
or may not demonstrate increased warmth, depending
on the extent and duration of the tendinosis. Squeezing
the area of tendinosis often causes substantial pain. Ten-
dinosis may limit the ability of a patient to stand on
tiptoe.
On occasion, an inflamed retrocalcaneal bursa may
be the cause of pain. In this case, most of the pain is
located between the calcaneus and the Achilles tendon
but proximal to the insertion of the tendon. There may
be focal tenderness over the bursal area anterior to
the Achilles tendon, but usually there is no substantial
thickening of the tendon per se. Palpation of the tendon
does not cause pain. Sometimes, the swollen bursa can
be palpated.
Insertional tendinosis includes two basic types. The
first type is characterized by generalized thickening of
the tendon at its insertion, where there is an area of
increased warmth, frequently an osseous prominence,
and marked tenderness to palpation. Performing a sin-
gle toe-rise is often difficult for patients who have this
type of tendinosis, and only rarely can these patients
repeat a toe-rise more than two or three times. The
second type of insertional tendinosis involves a well
localized area that a patient can pinpoint at the inser-
tion of the Achilles tendon. Frequently, the tendon itself
is not particularly thickened except in the localized area
where the pain is located. Patients who have this type
of tendinosis usually can perform a single toe-rise with-
out difficulty. Radiographs often demonstrate calcifica-
FIG. 5-A
Figs. 5-A and 5-B: Magnetic resonance images showing abnormalities within the Achilles tendon.
Fig. 5-A: A defect in the mid-substance of the Achilles tendon, representing the area of tendinosis (arrow).
Fig. 5-B: Insertional tendinosis with probable obliteration of the retrocalcaneal bursa because of adhesion of the tendon to the calcaneus.
C. C. TEITZ ET AL.
tion about the insertion of the tendon (Fig. 4-A). The
radiographs of a patient who has a focal area of pain
usually show a localized area of calcification, as opposed
to a large area, which is frequently seen in a patient
who has generalized tendinosis. Computerized tomog-
raphy scans of a patient who has localized calcifica-
tion frequently demonstrate an area of calcification that
corresponds to the area of the pain (Fig. 4-B). For pa-
tients who have generalized tendinosis, a magnetic res-
onance image may demonstrate cystic areas within the
substance of the tendon, either proximal to or at the
level of the insertion (Figs. 5-A and 5-B). The extent of
the involvement varies greatly among patients.
Treatment of all of these conditions depends on the
severity of the problem. The initial treatment consists
of rest, ice massages, non-steroidal anti-inflammatory
medication, and stretching of the Achilles tendon. Ath-
letes may need to change their training program or foot-
wear. Effective modifications of footwear may include
a softer heel-counter, an orthotic device to correct se-
vere pronation if it is present, or a softer heel-cushion.
If the symptoms fail to respond to these measures,
we have found that immobilization in a weight-bearing
cast, particularly for a patient who has insertional ten-
dinosis, is extremely useful. If the symptoms respond
to the use of a below-the-knee cast and subsequently
recur but the patient is not a good candidate for an
operation, a polypropylene ankle-foot orthosis with no
motion of the ankle joint often provides effective long-
term relief.
FIG. 5-B
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 TENDON PROBLEMS IN ATHLETIC INDIVIDUALS 149

FIG. 6-A FIG. 6-B

Figs. 6-A and 6-B: Drawings showing the reconstruction of the Achilles tendon with use of a flexor digitorum transfer.
Fig. 6-A: The flexor digitorum longus or the flexor hallucis longus is freed from the plantar aspect of the foot and brought posteriorly
through a drill-hole in the calcaneus, after which it is sutured back onto itself. It is important to tension the transplant to approximate the
tension felt with manual dorsiflexion of the contralateral extremity. Usually, this procedure will hold the foot in approximately 10 degrees of
plantar flexion.
Fig. 6-B: A flap of the Achilles tendon is developed either by the turndown method, as demonstrated, or by some type of advancement
somewhat more proximally, depending on the nature of the abnormality. The flap is brought down under tension in order to reconstruct the
Achilles tendon. Sutures are then placed between the transferred tendon and the Achilles tendon.

Operative management should be undertaken only
after conservative treatment has been exhausted. In a
patient who has Achilles tendinitis, chronic inflamma-
tion may create a thickening of the tendon sheath. Re-
lease of the tendon sheath has been reported to be
successful67, but we have not found the procedure to be
necessary for these patients because tendinitis virtually
always responds to non-operative treatment. In patients
who have recalcitrant Achilles tendinosis, we explore
the area of tendinosis but rarely find any substantial
lesion or cyst formation other than an occasional area
of cholesterol deposition. We do not attempt to excise
small lesions of two centimeters or less but rather we
weave the plantaris tendon back and forth through the
area to stimulate an inflammatory healing response.
Postoperatively, the leg is kept in a non-weight-bearing
below-the-knee cast for one month and in a weight-
bearing below-the-knee cast for another month. During
the second month, a removable cast is utilized to allow
the patient to work on range-of-motion exercises and to
use an elastic band to keep some tone in the muscles
during the later healing phase. The enlarged area of
tendinosis usually does not disappear, but it often be-
comes much less painful. We do not permit a patient to
resume unrestricted activities until the enlarged area is
no longer warm or tender to palpation. For some pa-
tients, this may take three to six months. Eight of our
ten patients who were managed with this technique had
a successful result.
When the tendinosis involves the entire segment of
tendon and has failed to respond to conservative treat-
ment, a procedure is used to bypass the involved area,
whether it is in the mid-substance or at the level of the
insertion of the tendon into the calcaneus44. In this pro-
cedure, either the flexor hallucis longus or the flexor
digitorum longus is transplanted from the plantar as-
pect of the foot and is used to bypass the segment of
tendinosis (Fig. 6-A). Depending on the severity and the
length of the segment involved, a portion of the Achil-
les tendon may need to be excised. The tendon of the
flexor hallucis longus or flexor digitorum longus is freed
from the midfoot and tunneled through the calcaneus
to reinforce the reconstructed tendon and to create
one stable musculotendinous unit. The transferred ten-
don acts as a splint for the area of the Achilles tendon
where the segment has been advanced and, in this way,
a sort of scaffolding is created to support the Achilles
tendon until it heals. Next, the central portion of the
Achilles tendon is advanced across the excised area,
either into the calcaneus if the distal portion of the
Achilles tendon was resected or into the substance of
the tendon if a more proximal area was excised (Fig.
6-B). This procedure is technically demanding. Caution
must be used in handling the skin, as it has a marginal
blood supply and a skin slough may occur. Postopera-
tively, the patient is not allowed to bear weight on the
limb for three months. Afterward, progressive weight-
bearing is begun, but full mobilization without a cast is

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150 C. C. TEITZ ET AL.

not permitted until the involved area is no longer warm
or painful to palpation.
When there is a well localized area of calcification
within the tendon, a transverse incision is made in the
skin. Then, a longitudinal incision is made over the area
of calcification, and the calcified area is shelled out.
Postoperatively, a below-the-knee non-weight-bearing
cast is worn for three weeks and then a weight-bearing
cast is worn for an additional three weeks. The result is
usually successful for these patients as the problem is
well localized and extensive tendinosis usually is not
present. This operative approach cannot be used for a
large area of calcification within the substance of the
tendon, as that type of lesion usually is located in the
anterior aspect of the tendon and cannot be reached
from a posterior approach.
A patient who has chronic retrocalcaneal bursitis,
with or without an associated Haglund deformity but
with no tendinosis, often is managed successfully with
simple excision of the posterosuperior aspect of the cal-
caneus in order to decompress the bursa67. Not infre-
quently, it has been observed that the Achilles tendon
actually has become adherent to the posterior aspect of
the calcaneus. Relieving this irritation of the Achilles
tendon usually benefits the patient.
Overview
Tendinitis, although not life-threatening, is an ex-
tremely common problem that interferes with an active
lifestyle. Although it is used often, the term tendinitis is
probably a misnomer. Tendinosis should be used to de-
scribe problems that are predominantly degenerative,
such as those that occur in the rotator cuff and in the
extensor tendons of the wrist. In tendons with a teno-
synovial layer, such as the posterior tibial tendon, the
visceral layer of paratenon can become inflamed in re-
sponse to microtrauma or to degenerative changes in
the tendon proper. The semantic difficulties arise from
a paradox between the histological and the clinical find-
ings. The results of histological examination of chroni-
cally painful tendons are more consistent with tendino-
sis, revealing angiofibroblastic hyperplasia and fibrinoid
necrosis with few or no inflammatory cells. These find-
ings are seen, perhaps, because operative treatment is
rarely undertaken early in the process. Yet, early in
the clinical setting, the symptoms in many patients re-
spond favorably to anti-inflammatory drugs and modal-
ities. One can speculate that the anti-inflammatory
drugs are acting solely as pain relievers, much as they
do in osteoarthrosis. Alternatively, perhaps in some pa-
tients, a microscopic tear in the tendon initiates an in-
flammatory response that, if not treated, is replaced by
tissue that resembles a failed repair or degenerative
process: it is poorly organized, has numerous blood ves-
sels, and contains fibroblasts and areas of hyaline or
mucoid degeneration. Questions remain about the exact
pathophysiology and appropriate terminology for what
are predominantly overuse problems in the tendon.
In the evaluation of a patient who has a tendon
problem, it is important to obtain a detailed history of
the onset of pain and the examiner must look carefully
for contributing anatomical or biomechanical factors.
As we have pointed out, most of these tendon prob-
lems are due to overuse caused by errors in training
by either a younger enthusiastic athlete or an older, un-
conditioned recreational athlete. Most tendon problems
can be treated non-operatively by changing the training
routine and by adjusting or modifying predisposing
anatomical and biomechanical factors. Additional treat-
ment elements include the use of rest, circulatory stim-
ulants, and anti-inflammatory modalities, such as
contrast therapy, ice-friction massage, and non-steroidal
anti-inflammatory drugs. When the initial pain has sub-
sided and while new collagen fibers at the site of injury
are remodeling, the involved musculotendinous unit
should be stretched and strengthened to avoid recur-
rence. For a recalcitrant problem, operative treatment
can be considered.

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