RSI: Tendinitis vs. Tendinosis
So recently, while doing research on my various health problems, I discovered something very interesting. It turns out that in fact, I do not have tendinitis. "Chronic tendinitis" is something of a myth. There is a term to accurately describe my RSI, though - it's called tendinosis.
What is the difference between tendinitis and tendinosis? The -itis ending indicates an inflammatory condition. If you're playing sports and you overstretch or twist or otherwise injure yourself, that injury causes an inflammatory response from the immune system which increases circulation to the area. This results in redness, heat in the area, and swelling. When that happens to a tendon, it's called tendinitis. The tendon itself is swollen and inflamed, and usually you can tell this just from looking at someone's arm/other injured place.
Treatment for tendinitis is RICE - rest, ice, compression, and elevation. NSAIDs and corticosteroids are used as well, as they both reduce inflammation. The patient may be told to wear a splint to help make sure the tendon is getting enough rest. Surgery may be indicated when an inflamed tendon can't heal because it is being squeezed through a narrow space - usually the surgery involves opening up the narrow space so there is more room for the tendon while it heals.
Tendinosis, on the other hand, indicates an actual structural change in the tendon. When you have a repetitive stress injury, basically you have an accumulation of mini-injuries. You have a teeny tear in your tendon, and before the body can heal it, you get another one, and so on until you have enough of an injury that you feel pain. There is little to no inflammation in this condition. This explains why most people with RSI don't have big puffy red wrists, hands, or elbows! Tendinitis is an acute injury, but tendinosis is a chronic injury, thus my claim that "chronic tendinitis" doesn't exist.
In a healthy tendon, there are collagen fibers that run parallel to each other along the length of the tendon. With tendinosis, essentially the collagen fibers become tangled up and the body produces abnormal collagen which prevents healing (on order to heal, you'd need to add more normal collagen to the tendon). You can read that tendinosis link I posted if you're more interested in details. If you just want the gist of it, here it is: if a healthy tendon is a spaghetti noodle, then tendinosis is a pretzel stick with salt. Some of you might remember when I posted some RSI treatment techniques a while back and I mentioned soft tissue massage using a straight edge. I think I said something about how you'll feel smooth areas and "crunchy" areas, and that you should focus on the crunchy parts. This is exactly what that means!
Soft tissue massage focusing on the crunchy parts is basically an attempt to increase blood flow to the injured area, break down the bad collagen, and stimulate a healing response to grow normal collagen to replace the bad collagen. That's why it seemed to help me so much! My OT theorized that in conditions like this, blood flow is actually decreased to the area, putting one more obstacle in the path to healing. Essentially the body gives up on trying to heal your tendon.
The treatment of tendinosis is basically doing things that will put just enough stress on the tendon to provoke a new healing response. This might include things like soft tissue massage, stretching, and strengthening. Some people also recommend ice massage. In ice massage, you freeze water in a paper cup, then tear off enough of the cup to expose some ice, and massage your injured area with the ice. It actually feels pretty good.
The important thing though is that NSAIDs and corticosteroids will not cause the screwed up collagen to heal. They are designed for reducing inflammation, and if there's no inflammation to reduce, they might as well be useless. I have also read that in fact they may do more damage than good in cases of tendinosis. It is theorized that they might provide a measure of pain relief because they act on some other substances in the blood/cells, but they do not treat the source of the pain, so the pain will just keep coming back. Also, splinting is definitely NOT indicated for tendinosis. The tendon needs to continue being gently stressed in order to heal. Splinting it just weakens the tendon further and prevents healing.
Okay, so now we know about tendinosis. We're ready for the rant about the failure of the healthcare system. It turns out that most doctors apparently don't know what tendinosis is, or that it is different from tendinitis and requires different treatment. This includes many orthopedic surgeons, like the ones I have been to. Physical and occupational therapists are more likely to know about it than doctors, but they don't know it all the time either. The doctors who are likeliest to understand this condition are sports medicine doctors who treat overuse injuries in athletes on a regular basis.
RSI is so incredibly prevalent in the world today because of all the computers, so WHY do people not know about this? RSI is not an acute injury, kind of by definition. And yet, when someone goes to their doctor about achy pain they have from too much typing, which they've had for months, and which doesn't show any obvious signs of inflammation, they still usually follow this pattern of treatment: (1) Prescribe NSAIDs, ice, rest, told to come back in 3-6 weeks if it doesn't go away. (2) Refer to specialist, usually orthopedic surgeon, who takes x-rays to make sure there are no broken bones and there's no arthritis. (3) Sent to therapy for treatment, likely involving splints, ice, ultrasound with steroid cream, maybe iontophoresis, and possibly massage. (4) If it doesn't get better, sent back to orthopedic surgeon. (5) Given cortisone injections. (6) If it still isn't better, considered for surgery, maybe have surgery. (7) If that didn't help, sent to rheumatologist to test for joint pain diseases, most of which are incurable.
Personally, after hitting the point of going to a rheumatologist and being tested for stuff like rheumatoid arthritis (which is completely ridiculous because I never had any redness or swelling, which are characteristic of RA), I basically hit the end of the rope. If the rheumatologist doesn't know what to do, who will? There's no hope, and you're basically told "tough luck, get a new job." Doctors start to think you're crazy, you start to feel hopeless, you feel like your career is coming to an end before it even began, and you sure wasted a lot of money on those college degrees for computer work.
That really sucks.
I just keep thinking, if the first doctor I went to knew enough to recognize what was wrong with me, they could have given me the correct treatment right away, instead of spending years giving me treatments that probably just exacerbated the problem. The longer the problem goes on, the longer it takes to heal.
In my case this is complicated by the thyroid problem, because it turns out that hypothyroidism can cause decreased synthesis of new collagen and decreased breakdown of old collagen, in addition to causing calcification and generally just weakening the structure of the tendons. Basically, even if I'd had the correct treatment, I still might not have gotten better because of the untreated hypothyroidism. IMO, women with RSI should be screened for hypothyroidism since women have a higher rate of hypothyroidism and a higher rate of RSI, and there is a link between the two. It's a simple blood test. Why isn't this the standard?