What are tendons and tendon sheaths?
A tendon is a strong tissue that attaches a muscle to a bone. For example, the tendons that you can see on the back of your hand come from muscles in your forearm and allow you to move the bones of your fingers.
Some (but not all) tendons are covered by a sheath called the synovium. The synovium makes a tiny amount of oily fluid which lies between the tendon and its overlying sheath. The fluid helps the tendon to move freely and smoothly when it pulls on the bone it is attached to.
What are tendonitis and tenosynovitis and what causes them?
Tendonitis and tenosynovitis are types of tendon injury. They can often occur together. Strictly speaking:
- Tendonitis means inflammation of a tendon. (It is sometimes spelt tendinitis.)
- Tenosynovitis means inflammation of the sheath that surrounds a tendon. (The sheath is called the synovium.)
However, more recently, it is thought that inflammation of the tendon and the tendon sheath is not the whole picture in all cases. It is thought that most of the time there is an injury, or several repeated small injuries or tears, to the tendon. This may initially cause some inflammation of the tendon. But, in the longer term, if these injuries continue, it can lead to tendon damage (degeneration).
These injuries typically occur when tendons are overused. For example, this may be after playing a lot of sport, or overuse in the course of your work. (Tenosynovitis commonly occurs around the wrist. Overuse by lots of writing, typing, assembly line work, etc, can trigger inflammation. This type of overuse tendon injury is also known as repetitive strain injury (RSI).
However, in some cases, there is no history of overuse of the tendon, and tendonitis or tenosynovitis seem to occur for no apparent reason. There are also some other causes of tendonitis and tenosynovitis:
- Arthritis – some types of arthritis such as rheumatoid arthritis can sometimes cause inflammation of tendon sheaths as well as joints. You would normally have joint pains and swelling in addition to tendon problems.
- Infection – this is a rare cause. The infection may occur because a cut or puncture wound to the skin over a tendon may allow bacteria to get in to infect the tendon and/or tendon sheath. However, infection sometimes spreads from other parts of the body via the bloodstream to infect a tendon sheath. For example, a small number of people who have gonorrhoea (a sexually transmitted infection) develop tenosynovitis as a complication.
Some doctors feel that tendonitis and tenosynovitis should actually be called tendinosus or tendinopathy.
Who gets tendonitis and tenosynovitis?
These problems are more common in middle-aged adults, and particularly in people who are quite sporty. They may be more common if your work involves repetitive movements such as writing, typing or use of a computer mouse.
What are the symptoms of tendonitis and tenosynovitis?
Tendonitis usually occurs at the part of the tendon that attaches to the bone. The main symptoms are pain, tenderness and sometimes swelling of the affected part of the tendon. The pain is typically when you move the affected area. The overlying skin in that area may also feel warm. You may have reduced movement or weakness of the part of the body that is pulled by the affected tendon. The area may feel stiff. In some cases the condition lasts just a few days and then goes away on its own. In other cases it can last weeks or months if not treated.
Any tendon of your body may be affected. However, some areas of your body are more prone to these problems. For example, tendons around your wrist and hand are the most commonly affected. Some types of tendonitis and tenosynovitis cause very characteristic symptoms and have their own name. For example:
- De Quervain’s tenosynovitis. This is a common condition that affects the tendons that are used to straighten (extend) your thumb. The typical symptom is pain over your wrist at the base of your thumb that is made worse by activity and eased by rest.
- Trigger finger. This most commonly affects your ring finger. The condition prevents your finger from straightening fully. (See separate leaflet called ‘Trigger Finger’ for more details.)
- Tennis elbow (lateral epicondylitis). In this condition, you have pain on the outer side of your elbow. It is usually due to overuse of your forearm muscles. (See separate leaflet called ‘Tennis Elbow’ for more details.)
- Golfer’s elbow (medial epicondylitis). This is similar to tennis elbow but the pain is experienced on the inner side of your elbow.
- Achilles tendonitis. This affects the large tendon just behind and above the heel. See separate leaflet called ‘Achilles Tendinopathy’.
- Rotator cuff tendonitis. Your rotator cuff is a group of four muscles that help to lift and rotate your shoulder. The tendons from these muscles can sometimes become irritated due to overuse. (See separate leaflet called ‘Rotator Cuff Injury and Inflammation’ for more details.)
Do I need any tests?
Usually not. The diagnosis of tenosynovitis and tendonitis can usually be made when your doctor talks to you and examines the affected area. If an infection is the suspected cause (uncommon) then blood tests and other tests may be done to find the cause of the infection. Sometimes, if the diagnosis is uncertain, your doctor may suggest an X-ray, an ultrasound scan or an MRI scan of the affected area.
What is the treatment?
The best treatment for tendonitis or tenosynovitis is uncertain. However, one or more of the following treatments may be used:
- Rest. It is important to rest to allow the condition to settle. Sometimes a splint, firm bandage or brace is put on a wrist if this is the area affected. This enforces your hand and wrist to stay in the same position for a time to allow rest of the affected tendon.
- Ice packs over the affected area may ease swelling and pain. A simple ice pack can be made by wrapping a pack of frozen peas in a tea towel. Apply it to the affected area for 10 minutes twice a day.
- Anti-inflammatory painkillers are often prescribed (for example, ibuprofen). These ease pain and reduce inflammation. However, as discussed above, inflammation may not be the main problem in tendonitis and tenosynovitis. However, they will provide pain relief. Some anti-inflammatory painkillers also come as creams or gels which you can rub over the painful area. These tend to produce fewer side-effects than those taken by mouth. There are various brands which you can buy, or get on prescription. Ask your doctor or pharmacist for advice.
- Other painkillers. If you cannot take anti-inflammatory painkillers, other painkillers such as paracetamol, with or without codeine added, may be helpful.
- Physiotherapy may be advised, especially if the condition is not settling with the above measures.
- A steroid injection into the affected area may be given if the above measures do not work. Steroid injections may be helpful in easing pain in the short-term but pain tends to come back in many people.
- Surgical release of a tendon is rarely needed.
- Antibiotics are needed in the uncommon situation where infection is the cause.
Other treatments are also being used to treat tendonitis and tenosynovitis. These include:
- Shockwave therapy. This uses high-energy sound waves to treat the condition. A special device allows the shockwaves to be passed through your skin to the affected area. A local anaesthetic may also be given, as sometimes the shockwaves can be painful. One or more treatment sessions may be needed. The procedure appears to be safe but it is not clear yet exactly how well it works, and more research is needed.
- Autologous blood injection. Blood is taken from you and then injected into the area around the damaged tendons. It is thought that the blood helps to heal the tendons. A local anaesthetic is often given as a pain relief during the procedure. Several treatment sessions may be needed. This procedure is generally only considered if other treatments have failed. Again, it is not clear yet how effective this treatment is, and more research is needed.
Can tenosynovitis or tendonitis be prevented?
There is no proof that anything can prevent a bout of tenosynovitis or tendonitis. However, the following are sensible suggestions that may help to prevent a recurrence:
- Avoid repetitive movements and overuse of the affected area. This may be very difficult if your job involves repetitive movements. If it is a recurring problem then you should discuss this with your employer. A change of duties may help.
- Exercises to strengthen the muscles around the affected tendon may help. It may be best to seek advice from a physiotherapist to find the best exercises to use.
- Remember to warm up, warm down and stretch properly when you exercise.
References and Disclaimer | Provide feedback
- Steele M, Norvell JG; eMedicine. Tendonitis. Updated: Mar 31, 2008.
- van Tulder M, Malmivaara A, Koes B; Repetitive strain injury. Lancet. 2007 May 26;369(9575):1815-22. [abstract]
- Xu Y, Murrell GA; The basic science of tendinopathy. Clin Orthop Relat Res. 2008 Jul;466(7):1528-38. Epub 2008 May 14. [abstract]
- Andres BM, Murrell GA; Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008 Jul;466(7):1539-54. Epub 2008 Apr 30. [abstract]
- Rees JD, Wilson AM, Wolman RL; Current concepts in the management of tendon disorders. Rheumatology (Oxford). 2006 May;45(5):508-21. Epub 2006 Feb 20. [abstract]
- Autologous blood injection for tendinopathy, NICE Interventional Procedure Guideline (January 2009)
- Extracorporeal shockwave therapy for refractory tennis elbow, NICE Interventional Procedure Guideline (August 2009)
- Wilson JJ, Best TM; Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician. 2005 Sep 1;72(5):811-8. [abstract]