Differential Diagnosis of Tendinopathy: Difference between revisions
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== Introduction == | == Introduction == | ||
Tendinopathies can be notoriously difficult to treat, they are also challenging to diagnose and good clinical reasoning skills can be key to effective management. | Tendinopathies can be notoriously difficult to treat, they are also challenging to diagnose, and good clinical reasoning skills can be key to effective management. While there is significant interest in the research on tendinopathy, a precise definition for the term 'tendinopathy' remains unclear.<blockquote>"Tendinopathy is currently diagnosed as a clinical hypothesis based on the patient symptoms and physical context."<ref>Canosa-Carro L, Bravo-Aguilar M, Abuín-Porras V, Almazán-Polo J, García-Pérez-de-Sevilla G, Rodríguez-Costa I, et al. [https://www.sciencedirect.com/science/article/pii/S0011502921001905 Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice]. Dis Mon. 2022 Oct;68(10):101314.</ref></blockquote>In general, tendinopathy is a complex, multifaceted condition that is associated with pain, decreased function and exercise tolerance.<ref>Millar NL, Silbernagel KG, Thorborg K, Kirwan PD, Galatz LM, Abrams GD et al. Tendinopathy. Nat Rev Dis Primers. 2021 Jan 7;7(1):1. </ref> However, tendons that present as pathological on imaging may be entirely asymptomatic.<ref>Lieberthal K, Paterson KL, Cook J, Kiss Z, Girdwood M, Bradshaw EJ. Prevalence and factors associated with asymptomatic Achilles tendon pathology in male distance runners. Phys Ther Sport. 2019;39:64-8. </ref><ref>Rio EK, Ellis RF, Henry JM, Falconer VR, Kiss ZS, Girdwood MA et al. Don't Assume the Control Group Is Normal-People with Asymptomatic Tendon Pathology Have Higher Pressure Pain Thresholds. Pain Med. 2018;19(11):2267-73.</ref> When considering the diagnosis of tendinopathy, the aim is not to determine if the tendon has pathology, but instead to determine whether or not the tendon is the ''source'' of pain.<ref name=":0">Cook J. Jill Cooks latest tendon nuggets clinical pearls Slides. Accessed 8 August 2019 <nowiki>https://sportsphysiotherapy.org.nz/sportsphysiotherapy.org.nz/documents/jill.pdf</nowiki></ref> Many structures can be implicated in a patient's pain when only one structure is viewed in isolation. For example, anterior knee pain is a clinical finding in patella tendinopathy, but it is also a key symptom in patellofemoral pain. By looking at the patient's entire clinical picture, the correct diagnosis can be made. | ||
This page explores specific factors that should be considered when in a differential diagnosis for tendinopathy. | |||
== Tendon Load and Capacity == | == Tendon Load and Capacity == | ||
When tendons act as springs (e.g. the patella tendon during jumping), tendon pain can be related to overload. It is important to understand the different loads (e.g. tensile, compressive, combination and shear and friction loads) that play a role in the development of tendon pathology. Diagnosing which type of load caused the dysfunction can guide the differential diagnosis and subsequent treatment. | |||
For more information on types of load, please see: [[Tendon Load and Capacity]]. | |||
== Dose Dependent Load == | == Dose-Dependent Load == | ||
Tendinopathies usually | Tendinopathies are usually associated with dose-dependent load - i.e. pain increases as the load applied to a tendon increases. For example, in Achilles tendinopathy, discomfort will usually progressively increase as you increase the load - i.e. from double leg heel raises to a small jump to a hop.<ref name=":2">Rio E. [https://members.physio-pedia.com/clinical-reasoning-in-tendons-course/ Clinical Reasoning in Tendinopathy Course]. Plus, 2019.</ref> | ||
== Palpation of Tendons == | == Palpation of Tendons == | ||
Palpating a tendon for localised pain is often considered an important part of the assessment for tendinopathy. However, while pain on palpation can be an indicator of pathology within a tendon,<ref>de Vos RJ, van der Vlist AC, Winters M, van der Giesen F, Weir A. [https://bjsm.bmj.com/content/55/5/247 Diagnosing Achilles tendinopathy is like delicious spaghetti carbonara: it is all about key ingredients, but not all chefs use the same recipe]. Br J Sports Med. 2021 Mar;55(5):247-48. </ref><ref>Matthews W, Ellis R, Furness J, Hing WA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8485842/ The clinical diagnosis of Achilles tendinopathy: a scoping review]. PeerJ. 2021 Sep 28;9:e12166. </ref> it cannot be used in isolation. A tendon might be painful on palpation, but this pain might not be relevant to the patient's condition (e.g. the patella tendon is one of the most sensitive structures in knee osteoarthritis<ref name=":2" />). Rather, the absence of pain on palpation may be helpful to rule out tendinopathy.<ref name=":2" /><blockquote>"It's really important that you don't do palpation in isolation. There's been some fantastic suggestions that palpation might help if it's negative, if it's not painful. So it might be good at ruling, it might help you rule it out, but it actually doesn't help you rule it in." -- Ebonie Rio<ref name=":2" /></blockquote> | |||
== Imaging Tendons == | == Imaging Tendons == | ||
The | <blockquote>The presence of tendon pathology on imaging does NOT implicate the tendon as the source of a patient's symptoms.<ref name=":3">Kaux JF, Forthomme B, Le Goff C, Crielaard JM, Croisier JL. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3761855/ Current opinions on tendinopathy.] Journal of sports science & medicine. 2011 Jun;10(2):238.</ref> However, the absence of tendon pathology can be helpful to rule OUT tendon pathology.<ref name=":2" /></blockquote>Ultrasound and MRI can be used in the diagnosis of tendinopathy. Imaging should be done with care and should be matched with a patient's clinical presentation. Tendons can be viewed successfully on ultrasound, and this method of imaging is significantly cheaper than MRI. | ||
MRI results should also be interpreted with care. An MRI provides a very detailed view and can show pathology that has no relation to the patient's symptoms.<ref name=":3" /> Imaging results should, therefore, be interpreted with caution. For example, a tendon might appear like it is affected on MRI, but the patient might have experienced significant improvements in pain and function. Communicating this to a patient may be helpful to decrease the threat value of findings on imaging. | |||
== Helpful Clues to Diagnose Tendon Related Pain == | == Helpful Clues to Diagnose Tendon-Related Pain == | ||
* Pain is related to overload | * Pain is related to overload | ||
* Pain increases with loading and immediately lessens when the load is removed<ref name=":1">Malliaras P, Cook J, Purdam C, Rio E. [https://www.jospt.org/doi/pdfplus/10.2519/jospt.2015.5987 Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations]. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):887-98.</ref> | * Pain increases with loading and immediately lessens when the load is removed<ref name=":1">Malliaras P, Cook J, Purdam C, Rio E. [https://www.jospt.org/doi/pdfplus/10.2519/jospt.2015.5987 Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations]. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):887-98.</ref> | ||
* Pain is very localised to the tendon<ref name=":0" /><ref name=":2" /> | * Pain is very localised to the tendon<ref name=":0" /><ref name=":2" /> | ||
* Pain should increase when the load applied to the tendon increases (dose-dependent loading)<ref name=":1" />, | * Pain should increase when the load applied to the tendon increases (dose-dependent loading)<ref name=":1" /> | ||
* Pain should | ** For example, a shallow squat should be less painful than a deep squat in patella tendinopathy | ||
* Pain tends to improve during activity (warm-up phenomenon) but may be worse the day after high loading activities<ref name=":1" /> | * Pain should be localised during loading activities<ref name=":0" /> | ||
* Isometric exercises often decrease pain originating from a tendon (if isometrics aggravate the pain possibly consider a different diagnosis)<ref name=":0" /> | ** Please note, this may not be true in all tendinopathies - for example, gluteal tendinopathy can refer down the leg<ref name=":2" /> | ||
* | * Pain tends to improve during activity (warm-up phenomenon) but may be worse the day after high-loading activities<ref name=":1" /> | ||
* Isometric exercises often decrease pain originating from a tendon (if isometrics aggravate the pain, possibly consider a different diagnosis)<ref name=":0" /> | |||
* There are area-specific signs in tendon-related pain, such as morning stiffness for Achilles tendinopathy<ref>Knapik JJ, Pope R. Achilles Tendinopathy: Pathophysiology, Epidemiology, Diagnosis, Treatment, Prevention, and Screening. J Spec Oper Med. 2020;20(1):125-40.</ref> and sitting pain for hamstring tendons<ref name=":0" /> | |||
== References == | == References == | ||
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[[Category:Tendinopathy]] | [[Category:Tendinopathy]] | ||
[[Category:Course Pages]] | [[Category:Course Pages]] | ||
[[Category: | [[Category:Plus Content]] | ||
Latest revision as of 02:38, 2 November 2023
Original Editor - Mandy Roscher Top Contributors - Mandy Roscher, Kim Jackson, Jess Bell, Rachael Lowe and Simisola Ajeyalemi
Introduction[edit | edit source]
Tendinopathies can be notoriously difficult to treat, they are also challenging to diagnose, and good clinical reasoning skills can be key to effective management. While there is significant interest in the research on tendinopathy, a precise definition for the term 'tendinopathy' remains unclear.
"Tendinopathy is currently diagnosed as a clinical hypothesis based on the patient symptoms and physical context."[1]
In general, tendinopathy is a complex, multifaceted condition that is associated with pain, decreased function and exercise tolerance.[2] However, tendons that present as pathological on imaging may be entirely asymptomatic.[3][4] When considering the diagnosis of tendinopathy, the aim is not to determine if the tendon has pathology, but instead to determine whether or not the tendon is the source of pain.[5] Many structures can be implicated in a patient's pain when only one structure is viewed in isolation. For example, anterior knee pain is a clinical finding in patella tendinopathy, but it is also a key symptom in patellofemoral pain. By looking at the patient's entire clinical picture, the correct diagnosis can be made.
This page explores specific factors that should be considered when in a differential diagnosis for tendinopathy.
Tendon Load and Capacity[edit | edit source]
When tendons act as springs (e.g. the patella tendon during jumping), tendon pain can be related to overload. It is important to understand the different loads (e.g. tensile, compressive, combination and shear and friction loads) that play a role in the development of tendon pathology. Diagnosing which type of load caused the dysfunction can guide the differential diagnosis and subsequent treatment.
For more information on types of load, please see: Tendon Load and Capacity.
Dose-Dependent Load[edit | edit source]
Tendinopathies are usually associated with dose-dependent load - i.e. pain increases as the load applied to a tendon increases. For example, in Achilles tendinopathy, discomfort will usually progressively increase as you increase the load - i.e. from double leg heel raises to a small jump to a hop.[6]
Palpation of Tendons[edit | edit source]
Palpating a tendon for localised pain is often considered an important part of the assessment for tendinopathy. However, while pain on palpation can be an indicator of pathology within a tendon,[7][8] it cannot be used in isolation. A tendon might be painful on palpation, but this pain might not be relevant to the patient's condition (e.g. the patella tendon is one of the most sensitive structures in knee osteoarthritis[6]). Rather, the absence of pain on palpation may be helpful to rule out tendinopathy.[6]
"It's really important that you don't do palpation in isolation. There's been some fantastic suggestions that palpation might help if it's negative, if it's not painful. So it might be good at ruling, it might help you rule it out, but it actually doesn't help you rule it in." -- Ebonie Rio[6]
Imaging Tendons[edit | edit source]
The presence of tendon pathology on imaging does NOT implicate the tendon as the source of a patient's symptoms.[9] However, the absence of tendon pathology can be helpful to rule OUT tendon pathology.[6]
Ultrasound and MRI can be used in the diagnosis of tendinopathy. Imaging should be done with care and should be matched with a patient's clinical presentation. Tendons can be viewed successfully on ultrasound, and this method of imaging is significantly cheaper than MRI.
MRI results should also be interpreted with care. An MRI provides a very detailed view and can show pathology that has no relation to the patient's symptoms.[9] Imaging results should, therefore, be interpreted with caution. For example, a tendon might appear like it is affected on MRI, but the patient might have experienced significant improvements in pain and function. Communicating this to a patient may be helpful to decrease the threat value of findings on imaging.
Helpful Clues to Diagnose Tendon-Related Pain[edit | edit source]
- Pain is related to overload
- Pain increases with loading and immediately lessens when the load is removed[10]
- Pain is very localised to the tendon[5][6]
- Pain should increase when the load applied to the tendon increases (dose-dependent loading)[10]
- For example, a shallow squat should be less painful than a deep squat in patella tendinopathy
- Pain should be localised during loading activities[5]
- Please note, this may not be true in all tendinopathies - for example, gluteal tendinopathy can refer down the leg[6]
- Pain tends to improve during activity (warm-up phenomenon) but may be worse the day after high-loading activities[10]
- Isometric exercises often decrease pain originating from a tendon (if isometrics aggravate the pain, possibly consider a different diagnosis)[5]
- There are area-specific signs in tendon-related pain, such as morning stiffness for Achilles tendinopathy[11] and sitting pain for hamstring tendons[5]
References[edit | edit source]
- ↑ Canosa-Carro L, Bravo-Aguilar M, Abuín-Porras V, Almazán-Polo J, García-Pérez-de-Sevilla G, Rodríguez-Costa I, et al. Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice. Dis Mon. 2022 Oct;68(10):101314.
- ↑ Millar NL, Silbernagel KG, Thorborg K, Kirwan PD, Galatz LM, Abrams GD et al. Tendinopathy. Nat Rev Dis Primers. 2021 Jan 7;7(1):1.
- ↑ Lieberthal K, Paterson KL, Cook J, Kiss Z, Girdwood M, Bradshaw EJ. Prevalence and factors associated with asymptomatic Achilles tendon pathology in male distance runners. Phys Ther Sport. 2019;39:64-8.
- ↑ Rio EK, Ellis RF, Henry JM, Falconer VR, Kiss ZS, Girdwood MA et al. Don't Assume the Control Group Is Normal-People with Asymptomatic Tendon Pathology Have Higher Pressure Pain Thresholds. Pain Med. 2018;19(11):2267-73.
- ↑ 5.0 5.1 5.2 5.3 5.4 Cook J. Jill Cooks latest tendon nuggets clinical pearls Slides. Accessed 8 August 2019 https://sportsphysiotherapy.org.nz/sportsphysiotherapy.org.nz/documents/jill.pdf
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Rio E. Clinical Reasoning in Tendinopathy Course. Plus, 2019.
- ↑ de Vos RJ, van der Vlist AC, Winters M, van der Giesen F, Weir A. Diagnosing Achilles tendinopathy is like delicious spaghetti carbonara: it is all about key ingredients, but not all chefs use the same recipe. Br J Sports Med. 2021 Mar;55(5):247-48.
- ↑ Matthews W, Ellis R, Furness J, Hing WA. The clinical diagnosis of Achilles tendinopathy: a scoping review. PeerJ. 2021 Sep 28;9:e12166.
- ↑ 9.0 9.1 Kaux JF, Forthomme B, Le Goff C, Crielaard JM, Croisier JL. Current opinions on tendinopathy. Journal of sports science & medicine. 2011 Jun;10(2):238.
- ↑ 10.0 10.1 10.2 Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):887-98.
- ↑ Knapik JJ, Pope R. Achilles Tendinopathy: Pathophysiology, Epidemiology, Diagnosis, Treatment, Prevention, and Screening. J Spec Oper Med. 2020;20(1):125-40.
