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Tendonitis / tendinosis / tendinitis

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Background

Musculoskeletal pain that cannot be located in the back or joints usually relates to tendons and muscle attachment points and is known under the popular names of tennis elbow, golfer’s arm, shoulder-arm syndrome or the feared fibromyalgia. A strictly medical distinction should be made between tendopathy and tendinitis, since the probability of success of PEMF treatment is certainly related. However, this is where the problem begins, since there are now conflicting opinions as to whether tendinitis is not a misinterpreted tendinosis.

Definition of tendopathy (acute or chronic)

Tendopathy is a tendon that is extremely sensitive to stress and which, in the case of acute tendopathy, is caused by a blow or kick (“Achilles tendon”) or a sudden increase in stress and is typical for young patients (15 to 25 years). The tendon cells react with an increased formation of proteins (proteoglycans), which are normally only found in cartilage. The proteins store significantly more water, so that the entire tendons swell – which serves to quickly adjust the tendon resilience [1] .

Chronic tendopathy (patients> 30 years old), which can occur spontaneously, is based on a minimal but permanent tendon overload. Acute stress increases can cause severe pain (VAS 7 – 8/10). It manifests itself in a spindle-like or knot-shaped thickening of the tendon, whereby it should be noted that other tendon sections are completely normal in their structure. What is important: There are neither inflammatory cells nor inflammatory messengers in an affected tendon.

Scientific dispute

However, more recent findings seem to contradict this [2] , [3] . For example, in the case of epicondylitis, for example a tennis elbow, which often arises spontaneously and without any apparent cause of origin or also as a result of prolonged one-sided stress, no signs of inflammation were found in histopathological examinations – which suggests the presence of tendonosis [4] . Immature type III collagen fibers (healthy tendons contain type I) and a confused increase in new blood vessels (vascularization) can be found under the microscope – but these obviously do not fulfill any blood vessel function and are also not an indication of increased healing [5] .

However, since some tendinitis (tendinitis) sometimes reacts to anti-inflammatories such as ibuprofen or cortisone, an inflammatory genesis can never be ruled out. How difficult it is to pinpoint the root cause of chronic tendopathy can be seen from the fact that, for example, psychological triggers such as changing jobs, double exposure also play a role. Or just the condition of the floor at the workplace, the ergonomics of the devices to be operated or just a new shoe.

Possible consequences:

Tendinoses on the forearm and or near the wrist pose a risk of carpal tunnel syndrome. The thickening of the tendons and the swelling of the surrounding tissue can lead to compression of the median nerve.

Spectrum of tendinosis / tendinitis

In addition to the tennis elbow (epiconylitis humeri lateralis), golfer’s arm (epicondylitis humeri ulnaris), shoulder-arm syndrome (synonym: impingement syndrome / supraspinatus syndrome / rotator-cuff syndrome), there is also the patellar tip syndrome (i.e. irritation of the patellar tendon in the area of ​​the lower tip of the patella) and, for example, Achilles tendon “inflammation”. Repetitive-strain syndrome (RSI) also refers to epicondylitis (constant rapid movements of the fingers / rapid rotating movements of the forearm without great force development). The RSI primarily affects musicians and people who work a lot on the PC or at a till. It is not for nothing that the elbow is also called the bones of the musicians – or “funny bone” in English – but here because of the exposed nerve path, which leads to a kind of “electric shock” under local pressure. The peritrochanteric pain syndrome (“irritation near the bone protrusion at the upper region of the thigh bone”), which includes myofascial pain syndrome or trochanteric bursitis (bursitis there), is discussed in the document Osteoarthritis.

A prevalence of 1 to 3% is given for the tennis elbow [6] . For the golfer arm it is 1 to 2% [7] . Impingement syndrome is one of the most common shoulder diseases, with the prevalence increasing with age (1.47 to 2.32%) [8] .

Classic therapy for tendopathy

In addition to the advice that the tendon should be loaded in a dosed manner, there is no therapeutic pause or absolute immobilization, and there is no really “healing” therapy arsenal. The not infrequent use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, diclofenac, Voltaren etc. and cortisone must be viewed very critically in any case, since NSAIDs prevent collagen repair [9] . The same can be expected with cortisone [10] .

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Definition of fibromyalgia

The pain syndrome of fibromyalgia (generalized tendomyopathy) has a completely different background. Above all, there are spontaneous pains in the course of tendons and tendon attachment points, which occur alternately in different regions of the muscular apparatus and can be triggered increasingly at so-called tender points [11] . At the same time, it is characterized by a multitude of accompanying symptoms such as fatigue, sleep disorders, morning stiffness, poor concentration and drive. The cause of fibromyalgia and its mechanisms of origin are largely unknown. Emotional and psychosocial conflicts can be explored in 40 to 70% of patients (strangely, fibromyalgia affects almost exclusively women) [12] , [13] .

The frequency (prevalence) of chronic pain in several body regions or of fibromyalgia syndrome is between 7 to 11% and 1 to 5% in population-based studies [14] . According to the revised ACR criteria, the prevalence is 2.1 [15] . Others speak of 1 million fibromyalgia patients in Germany [16] .

Therapy of fibromyalgia

Since the cause of fibromyalgia is in the dark, there are no sustainable treatment options. The standardized recommendations include aerobic endurance training [17] , psychotherapy [18] and multimodal pain therapy [19] . However, the treatment is often perceived as disappointing by both those affected and the practitioners [20] . Although medication with tricyclic antidepressants and benzodiazepines leads to improvements in 30 to 50% of cases [21] , it is not particularly attractive for patients due to the high side effect rate of up to 98% [22] .

PEMF in tendopathies

After a large part of the therapeutic effects of PEMF, for example in arthritis or wound treatment, is linked to an anti-inflammatory effect and the inflammatory genesis of tendopathy remains open, the question arises as to the relevance of PEMF therapy in this regard.

Study location

The unpredictability of PEMF treatment in tendopathies is discussed in a more historically oriented review and at least seven studies with a positive treatment result were identified [23] .

In a further systematic review [24] , which analyzed and evaluated two reviews and 20 RCT studies with regard to the use of ultrasound, extracorporeal shock wave therapy (ESWT), TENS, laser and PEMF, the result was that only ultrasound and laser in the medial and lateral epicondylitis were effective. However, the authors point out that it is necessary to carry out further examinations with regard to the intensities used and a longer follow-up.

Study 1 – PEMF cell culture studies

In an in-vitro study, human tendon cells (HTCs) from the M. semitendinosus and gracilis area were exposed to various PEMF parameters (1.5 or 3 mT for 8 or 12 hours, single or repeated treatments). Result: None of the treatments led to apoptosis. Cell growth (proliferation) improved under all applications. Only the 3 mT PEMF increased the viability of the cells. However, only single treatment with 1.5 mT led to the highest up-regulation of SCX, VEGF-A and COL1A1 expression and significantly reduced the COL3A1 synthesis compared to untreated cells. All treated cells resulted in significantly more IL-1ss, IL-6, IL-10 and TGF-ss. Only 1.5 mT-PEMF also increased IL-10 production. The 1.5 mT application showed the best result [25] .

Explanation:

The SCX protein (scleraxis) is one of the transcription factors (“ensure that the activity of the genes is synchronized with the cell cycle and the respective metabolic situation”) and leads to a synthesis of tendon cells.

COL1A1 is a protein that is encoded by the COL1A1 gene and leads to the production of type I collagen. COL3A1 leads to type III collagen. Collagen I is fiber-forming in the collagen fibers of tendons and the skin – collagen III is mainly fiber-forming in the skin, the skeletal muscles and the blood vessels. IL-1ß, IL-6, IL-10 and TGF-ß are anti-inflammatory and pro-inflammatory cytokines. For example, IL-10 has an anti-inflammatory effect.

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Study 2 – PEMF epicondylitis study

In one study, 60 patients with lateral epicondylitis (tennis elbow) were randomly divided into three groups: Group I received PEMF (6 mT, 4.6 + 25 Hz / 30 minutes daily / 15 sessions within 3 weeks). Group II was treated with a placebo PEMF. Group III received cortisone (40 mg) as well as a local anesthetic (20 mg) in the area of ​​the most severe pain. Results: After three weeks, the pain score (VAS) in group III for dorsiflexion of the hand against resistance was significantly lower than in group I. However, after 3 months, group I had less pain at rest, in normal activity and at night than group III , Placebo was ineffective. A PEMF application works better than a placebo treatment. Cortisone and local anesthetics seem beneficial for quick short-term success. PEMF is recommended for patients who are interested in a lasting improvement in their symptoms – or who are critical of invasive therapy (injection) [26] .

In another study (no placebo control) for lateral epicondylitis (LE), 22 patients received PEMF treatment within 6 weeks (6 mT, 25 Hz / 4.6 Hz, 5 sessions a week of 30 minutes each). The LE symptoms had lasted on average for 16 months. The results: After 6 weeks of PEMF, the VAS score dropped from 7.82 to 3.11. The pressure pain threshold (PPT) increased from 2.95 kg / cm 2 to 4.84 kg / cm 2 and the pain-free grip strength (PFGS) improved from 18.6 kg to 22.1 kg [27] .

Study 3 – PEMF in Achilles tendopathy

Animal study with 180 male rats (prospectively randomized) with experimentally caused irritation of the Achilles tendon (inflammation). It was either with PEMF I (5.1 mT, 15 Hz or 46 Hz, 15 minutes daily, 5 times a week over 4 weeks) – or with PEMF II (4.95 mT, 17 or 50 Hz). At each of the 6 rats, the Achilles tendons were removed under anesthesia and then sacrificed: 2 hours after the operation, after 1 day, after 3 days, after 7 days, after 14 days or after 28 days. Results: The different treatments had a significant influence on the water content of the tendons. This was significantly higher on the 3rd day under 46 Hz than in the other groups. Overall, however, the most convincing reaction to the collagen remodeling at the end of the applications was below 17 Hz. 17 Hz also led to a greater decrease in inflammation and better tendon restitution.

A feasibility study with 53 patients suffering from chronic Achilles tendinopathy of the middle tendon area is also interesting. The active PEMF group with 28 participants (25 placebo) received a total of 8 treatments (80 mT) within 4 weeks (at home as an outpatient), whereby they also wore an insole (heel cushion) because they were supposed to move and were not subject to local anesthesia. The placebo group only wore the heel pillow. Result: After 12 weeks, the VAS score in both groups had decreased, although the score in the active group was significantly better [28] .

Study 4 – PEMF in Patella Irritation

Patella-femoral pain syndrome (PFPS) is a common cause of recurrent knee pain in young adults who exercise. It is usually located retropatellar (i.e. behind the patella). A randomized, controlled trial was designed to determine whether a home exercise program (HEP) together with PEMF was more effective than HEP ​​alone. 31 patients were admitted. The results were checked with VISA (Victorian Institute of Sport Assessment Score), VAS and Feller’s Patella Score at the beginning, after 2, 6 and a 12-month follow-up. Results: The increase in the VISA score after 2 and 6 months in the PEMF / HEP group was significantly higher than in the control group with HEP alone, as was the increase in the Feller’s Patella Score after 12 months. Accordingly, the VAS score in the PEMF group was significantly lower after a 6-month follow-up. As a result of the reduced pain, PEMF led to better rehabilitation overall, which is important for young adults who want to quickly return to their sporting activities [29] .

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Explanation:

VISA (Victorian Institute of Sport Assessment Score) [30] is a questionnaire to determine the severity and the follow-up of patellar tendopathy (front knee pain), existing restrictions in everyday life and sport, especially in sports with high jump loads such as basketball or volleyball (“Jumpers Knee “). However, it is now also used for inflammation of the Achilles tendon. The areas of symptoms, simple function tests and the ability to exercise are recorded on an analog scale from 0-10. The maximum score that can be achieved is 100 and represents a symptom-free patient. A patient experiences a clinically meaningful change from a change of more than 13 points.

Feller’s Patella Score: Since customary knee scores, including the Knee Society Score, do not take into account special symptoms of the femoropatellar joint, a special patella score was developed [31] . The maximum possible score is 30.

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Study 5 – PEMF in shoulder-arm syndrome

Controlled double-blind study in 29 patients with persistent rotator cuff tendinitis that did not respond to cortisone injections and other conventional conservative measures. Results: During the first 4 weeks, the PEMF group (15 patients) experienced significant pain relief compared to the placebo group. There was no difference in the second 4 weeks during which all patients were treated with PEMF. This continued in the third phase, in which all patients received no treatment for a further 8 weeks. At the end of the study, 19 patients (65%) of the 29 patients had no symptoms and the symptoms had improved in a further 5 patients [32] .

Randomized, double-blind and controlled study in 46 patients with subacromial impingement syndrome. All participants received a treatment program consisting of Codmans’ pendulum exercises and a subsequent cold-gel pad 5 times a day on the aching shoulder, limited to daily activities that require the hands to be held above the head. They also received 15 mg of meloxidim tablets (non-steroidal anti-inflammatory drug) daily. Group I also received PEMF (25 min, 5 times a week for 3 weeks). Group II was treated with a placebo device. Result: Compared to the baseline, both groups improved significantly in terms of pain (VAS) and shoulder function. However, no difference between the two groups [33] .

Comment: Problematic study design, since it is possible that the conservative therapeutic measures were sufficient for therapy success or for anti-inflammatory.

Study 6 – Impingement Syndrome

In another randomized, double-blind study with 56 impingement syndrome patients (SIS), group I was treated with PEMF (26 patients) or placebo (30 patients). After three weeks, both groups carried out a defined exercise program to strengthen their shoulders. Results: PEMF patients showed a better functional level and less pain compared to the baseline at all follow-up times (up to 3 months). However, the placebo group had better function and less pain in week 9 and after 3 months. In the shoulder dynamometry test, the PEMFs had an increased force in the lateral rotation after 9 weeks and an increased force in the medial rotation in the 9th week and after 3 months – each compared to the baseline. There were no significant differences in shoulder strength compared to the placebo group. Conclusion: The combination of active shoulder exercises and PEMF improves shoulder function and muscle strength and alleviates pain in SIS. However, the results should be interpreted cautiously since there were actually no differences between the groups [34] .

Study 7 – PEMF in fibromyalgia

In a randomized, double-blind and placebo-controlled study, 56 fibromyalgia patients were either (28 people) with a PEMF (MRS2000 system, 40 µT, 0.1 to 64 Hz, 30 minutes per session, twice a day for 3 weeks) or a placebo device ( 28 people). Result: The PEMF group showed significant improvements in FIQ and VAS as well as the “subjective” survey with the BDI (Beck Depression Inventory) and the SF-36 Health Survey – 4 and 12 weeks after the start of therapy. Similar improvements were also observed in the placebo group after 4 weeks – but not in the FIQ. After 12 weeks, improvements in the placebo group were only reported in the BDI and SF-36 [35] .

Explanations

The FIQ (Fibromyalgia Impact Questionnaire) [36] was first published in 1991 and is one of the questionnaires with the best detectable clinical improvements in fibromyalgia syndrome. The BDI records the severity of depressive symptoms and consists of 21 questions. The SF-36 Health Survey or health questionnaire is a disease-unspecific measuring instrument for ascertaining the health-related quality of life.

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Conclusion

Despite the scientific discussion of whether the pain syndromes of the shoulder, elbow, Achilles or patella tendon are inflammation (tendinitis) or pathological changes in tendons and muscle attachment points (tendonosis), PEMF treatment seems to be the case Epicondylitis, impingement syndrome and other tendon irritation – the course of studies on the Achilles tendon and patellar syndrome is of course too small to make an assessment. Fibromyalgia syndrome, whose probably psychopathological background makes it difficult to intervene in the somatic reaction typology of changing muscle tension, does not belong to the actual form of the above tendonoses. This should also be the reason why so far only one study on the use of PEMF in this area exists.

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Swell:

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