Enthesopathy is a term for painful syndromes caused by inflammation in the tendons.
Skeletal muscles have on each end tendons which are attached to the skeleton. The function of the tendons is to transfer the muscle power on the bone, absorption of a sudden impacts and thus also limiting the muscle damage and overload, and proprioception (the ability to sense stimuli arising within the body regarding position, motion, and equilibrium).
The tendon itself doesn’t contain any muscle fibres, it’s only attached to the muscles. It is made of collagen, which is arranged in fibres. On the surface is ligament. During inflammation the surface ligaments get affected. If the inflammation reaches the collagen fibres as well, it becomes a complication which can have serious results. The basis of the inflammation is destabilisation in consequence to excessive muscle overload.
Enthesis - is a connective tissue between the tendons and bone, attachment to the bone - it is made of 4 layers. Layer with tendon fibres, verging to the zone of uncalcified cartilage zone, further layer of calcified cartilage and bone mass. The gradual transition of the soft cartilage through the calcified cartilage to the bone is securing the needed tension release and pressure during the movement of the certain limb. Irregular transition between the cartilage and the bone mass and involvement of the tendon fibres in this structure increases the mechanical stability and resistance of this connection.
CAUSES FOR TENDON INFLAMMATION
Repeated overload in the area of the tendon attachment, which is not corresponding with regeneration leads to disintegration of the calcified cartilage, formation of necrosis, steatosis (fatty degeneration). It can also lead to formation of increased quantity of the ligament tissue and bone. This new formation of the bone is a manifestation of reparation (replacing the damaged tissue with different tissue - even less valuable, for example ligaments) and regeneration of the damaged attachment is manifested by formation of bone spurs (osteophytes), which are visible on the x-ray images. Main factors which are participating on the formation of enthesopathy are: untreated tendon attachments, small injuries, chronic overload of the transition between tendon-bone and damaged attachment of the tendon.
In childhood age it is based on the initial enthesopathy in certain areas, and it is manifested by damaged epiphyseal plate and formation of avascular necrosis of the bone, for example m. Osgood-Schlatter disease or Sever’s disease. Avascular necrosis of the bone is manifesting by dying bone tissue without the presence of infection and inflammation and other unclear causes. In some cases there can be influence from repeated overload, smaller injuries or blood supply disorders. The bones on the ends are usually affected by this. First thing that happens is the dying out of the bone cells, and consecutive supplementation and formation of a new bone. This responds with the development of the X-ray finding. The disease if manifested by pain, edema, functional limitation according to the position.
Client will clearly describe us the dominating pain in the certain, usually well located area of the tendon attachment and the surrounding area with resulting movement restriction of the muscle group. By touch we can examine edema and swelling of the tendon and its attachment and pain after being touched in the affected area. The pain sensation occurs usually from the beginning during a physical activity of a certain muscle group, later it can transit into chronic condition, the pain occurs even during peaceful regime, and the edemas become more serious and can be followed by skin redness or increased skin temperature.
The base of the therapy is also eliminating further overload of a certain muscle group and in most cases complexive work of the whole body schema, where we usually find continuous dysbalance, which has been manifested on the weakest part of the body. Next to manual techniques, training the post-isometric relaxation and control measures in therapy, we successfully use ESWT (shockwave therapy) - more about it: Tennis and javelin throwers elbow - treatment with shockwave therapy.
Author: FYZIOklinika physiotherapy Ltd., Prague, Czech Republic