What Are Some Important Myth-Conceptions of
Inflammation and Pain in Chronic Tendonitis?
Myths of Why Inflammation and Pain In Chronic Tendonitis Are NOT Correlated in Most Cases
And Why “Tendinitis” Is Usually The Wrong Word
We must look at a big blind spot around “tendinitis” existing in health & medicine right now. A blind spot causing large numbers of people to receive partially or totally inappropriate treatment for their problems, such as strength building exercises (very often contra-indicated), anti-inflammatory drugs, and surgery.
It turns out that, according to a number of medical researchers, the term and diagnosis of tendinitis and its alleged preferred treatment is totally off the mark for the vast majority of people with chronic pain.
Yet it is interesting how many people seem to use the word inflammation as synonymous with pain, as in, “My low back is inflamed right now.” [~DSL]
The major problem with this is the very common tendency to prescribe anti-inflammatory drugs for inflammation and pain in chronic tendonitis. It’s true that these drugs often provide some relief. But if they are providing relief for something that is NOT happening, what is really going on? And so what? … Here’s what …
Anti-inflammatory medications (NSAIDs) and/or corticosteroid injections can actually accelerate the degenerative process and make the tendon more susceptible to further injury, longer recovery time and may increase likelihood of rupture.” [emphasis added ~DSL]
Quotes from ‘Tendonosis vs. Tendonitis’ by Dr. Murray Heber, DC, BSc(Kin), CSCS, CCSS(C), Head Chiropractor for Canada’s Bobsleigh / Skeleton Team.
What’s Wrong with the Focus on “Tendin-Itis”
(Inflammation of the Tendon)?
Technically, inflammation refers to the production of specialized cells delivered via the blood stream to an acutely injured area to facilitate repair and healing of tissues damaged in some way. When inflammation is present in tissues of the body, the assumption is there’s an aggressive healing response going on.
That’s what inflammation is supposed to be. It is a healing activity for specifically, damaged tissues, as in an actual tear, laceration, rupture, or lesion to the local tissues.
There is also inflammation, for example, of the inner linings of the blood vessels. When metabolic processes, such as too much sugar ingested, triggering the production of homocysteine. As Wikipedia states:
A high level of homocysteine in the blood (hyperhomocysteinemia) makes a person more prone to endothelial cell [linings of various organ tissues] injury, which leads to inflammation in the blood vessels, which in turn may lead to atherogenesis [formation of fatty plaques in the arteries], which can result in ischemic [reduced blood supply] injury. Hyperhomocysteinemia is therefore a possible risk factor for coronary artery disease. Coronary artery disease occurs when an atherosclerotic plaque blocks blood flow to the coronary arteries, which supply the heart with oxygenated blood.
So naturally, if there is indeed a metabolic healing response involving inflammation, there was some damage to the local tissues requiring healing.
So Far, So Good. But …
Where the Medical Profession, and Chiropractors, Go Wrong Regarding Inflammation and Pain In Chronic Tendonitis
Many doctors and patients, and lots of other people, too, also assume pain is a reliable indicator of inflammation. Well, sometimes … but not always, and maybe not even usually. There are other causes of pain that do not (necessarily) entail inflammation.
So pain and inflammation are not the same thing. They might come at the same time, but are not always correlated. And much of the time, you can have a LOT of pain, yet NO real inflammation.
Inflammation also implies (usually) swelling and redness of local tissues, as more inflammatory cells and accompanying fluids accumulate in an area. Yet, in many cases, there is no real overt evidence the tissue has actually swelled as in an inflammatory swelling. Sometimes, a stressed muscle contracts, flexes, and expands or bulges, giving the appearance of swelling.
There is also fluid retention, which can swell an area, but is not necessarily brought on by inflammation. Excess fluids can get trapped in an area, often from chronic, excess muscle tension. Yet as soon as the muscle relaxes, the bulging, or swelling, goes away. Sometimes it needs some “encouragement” manual therapy can help with.
But, as in so many other cases in other kinds of diagnoses, such as back and neck pain, inflammation is almost immediately stated or diagnosed as the problem. It has come to the point that when many people have pain, they automatically think the area is inflamed. A lot of doctors seem to think that, as well. Thus the vast quantity of “anti-inflammatory” drugs being prescribed.
But as Dr. John Sarno, in his books on back pain states, there has never really been any substantive, scientific proof that most of what many physicians call inflammation is, in fact, inflammation.
Quoting from Dr. Sarno in his book Healing Back Pain (page 118-119), 1991:
Inflammation must be discussed for it is the explanation presented for many cases of upper and lower back pain [and lots of other pain ~DSL] and is the basis for the prescription of both steroidal (cortisone) and non-steroidal (such as ibuprofen) anti-infammatory drugs. Because of the magnitude of the back pain problem, these medications are widely used.
Experience with the diagnosis and treatment of TMS [Sarno’s diagnosis of Tension Myoneural Syndrome] makes it clear that the source of the pain is neither spinal structures nor inflammation. An inflammatory process is an automatic reaction to disease or injury; it is basically a protective, healing process. The response to an invading bacteria or virus is an inflammation.
[Also, a direct injury where tissue is actually damaged — tearing, sprains, lacerations, ruptures — triggers a healing, inflammatory response. ~DSL]
If that’s what an inflammatory process is, what is going on in the back? Is it an infection, a response to a back injury — or what? No satisfactory, scientifically supported answer has ever been given. It has been suggested in this book that the source of pain is oxygen deprivation [hypoxia] and not inflammation. This idea has at least a modicum of support from the rheumatological studies on fibromyalgia. [emphasis added]
So Sarno states in two of his books there is no credible evidence of inflammation being involved in such chronic pain patterns as he deals with, or in longer term, chronic pain.
In a more definitive vein, actual, targeted research over the last couple of decades has repeatedly shown that, except possibly in the first few days or weeks after an actual tissue damaging event, there are NO inflammatory cells in a tendon area. Let me repeat that.
The most well known researcher on this topic (that I could find) seems to be Dr. Karim M. Kahn, who has published quite a bit on the issue.
They have discovered, via medical biopsy, that in most chronic situations, there are NO inflammatory cells in the neighborhood, even though there are definite physical signs of a degenerative process.
They found this out first by doing biopsies (where they surgically open up and explore an area) in animals such as rats. (Sorry, animal lovers, I’m not advocating it, I’m just telling you what happened.) Later, they examined the local tissues in human beings who were undergoing surgery for tendon related problems. They seldom found inflammatory cells in the area.
They did find degeneration, discoloration, and breakdown (fraying) of the fibers of the tendon, but usually did not find inflammatory cells. This can be confirmed, if you would like, by going to the web sites of various entities such as the British Medical Journal that carry this article:
“Time to abandon the “tendinitis” myth” in BMJ, Mar 2002; 324: 626 – 627.
“Painful, overuse tendon conditions have a non-inflammatory pathology”
“…physicians should acknowledge that painful overuse tendon conditions have a non-inflammatory pathology.”
ARTICLE: Time to Abandon “Tendinitis” Myth
(Abstract available here, rest of text by subscription.)
What Dr. Kahn and others are saying is there’s very little evidence that most people are suffering from true inflammation of the tendons. But there IS, in advanced cases, a breakdown — a fraying and visible discoloration — of the sheath of the tendon, and in advanced cases the whole tendon, including the deeper fibers, is in breakdown.
There might have been inflammatory cells at the outset of injury if there was direct damage to the tissues. But many long term, chronic pain situations, such as RSI (repetitive strain injury), there was never actual tissue damage. It was only long term strain and irritation.
What results is what Dr. Sarno calls Tension Myoneural Syndrome (TMS) or what I call C.E.M.&.N.T. or Chronic, Excess Muscle & Nerve Tension & Stress.
These physicians and researchers prefer to call the problem tendinosis or tendinopathy.
- -osis means a pathological state
- -opathy means disease of
- -itis means inflammation
Since the very word tendinitis (tendin – itis) explicitly means that the problem is “inflammation of the tendon,” we cannot in most cases honestly use that term except in the case of a particular individual with a particular condition who has been clearly diagnosed as having a truly inflammatory condition; a situation that’s quite rare, according to modern, up-to-date research. Or rather, a damage to the tissue, such as a tear or laceration, must have occurred and the tissue is not healed and still being repaired by the natural processes, which includes inflammation.
Plus, clear diagnosis is a tall order. It was not until they actually looked inside while doing surgery, and tested by biopsy, the local fluids during surgery, to see if inflammatory cells were indeed present, which there usually were not. Remember, pain by itself is not an inherently nor necessarily an inflammatory sign. And the fact that there are people who got pain relief from taking anti-inflammatories does not mean they had inflammation.
This only means the drug is working, at least in many cases, based on unknown factors. And it is often these unknown factors leading to the many negative side effects of many drugs.
Dr. Sarno believes that when anti-inflammatory drugs do “work,” it is probably a placebo effect. Or, the drug is having another, unknown physiological effect other than reducing inflammation. Which means that one should NOT prescribe anti-inflammatory drugs, which are, like many other drugs, quite toxic to the system.
At this point, we need to move from using the word tendinitis (inflammation of tendons) to other, more appropriate terms.
In the medical field, the terms tendinopathy and tendinosis are now more commonly used, and are technically more accurate, given what has been, and is being, discovered about the lack of inflammation in these problems.
- Tendinosis — pathology of the tendon
- Tendinopathy — disease of the tendon
However, we still have the problem that the focus is on the tendon itself, rather than those pesky “mechanical forces” that are “not well understood” by orthodox medical research. Not that we should not consider the tendon, but to recognize that unless there is evidence of direct damage or trauma to it, it is difficult to find a way to blame the tendon all by itself for its problems and pain.
Since the main focus of this book is on the “mechanical forces” generated by the muscles, the name of the problem should most probably include the muscle.
The prefix myo- literally means muscle. So we can use a term like myotendinopathy:
Disease of the musculo-tendinis unit.
Please see my e-book on Myth-Conceptions of Tendinitis & RSI:
For an excellent overview of this topic, please check out this article:
Here is a short quote from the well detailed article:
People; if your doctor is still treating you for tendinitis and not tendinosis, he / she is caught in a time warp. According to what the American Academy of Orthopedic Surgeons said over 20 years ago, tendinosis is not an inflammatory condition (itis)! It is a degenerative condition (osis)! Not only is there some debate over whether or not tendinitis actually exists at all, but as you will see in a moment, the anti-inflammation medications and Corticosteroid Injections that your doctor has been prescribing you are actually creating more degeneration. … [emphasis added]
Thank You for your interest in our views on inflammation and pain in chronic tendonitis and chronic tendinosis.
Thank You for Reading,
David Scott Lynn (DSL*)
* DSL: Your Hi-Touch Up-Link to the Inner-Net*
* Inner-Net: Your Psycho-Neuro-Musculo-Fascial & Joint System