Tendinitis

One of the most common injuries suffered by performers of all types is tendinitis. But what exactly is it? Quite simply, the suffix “-itis” means “inflammation of,” so tendinitis is an inflammation of the tendon. To be more precise, tendinitis is an overuse injury affecting a muscle’s tendon and the musculotendinous junction (the part where the muscle fibers join with the tendon fibers). [A side note: tendinitis and tendonitis are both correct spellings.]

Causes

Like all overuse injuries, tendinitis is caused by what’s referred to in the physiology world as “repetitive microtrauma.” This is a fancy way of saying that the tendon’s tissues are subjected to damage on the cellular and tissue fiber level over and over and over. Repetitive microtrauma is actually the first step in building muscle and bone, but it can become an injurious process (as in the case with tendinitis) when the body doesn’t have enough time to heal and recover from the microtrauma.

Activity-specific causes of tendinitis will vary based on the particular tendon being injured (you’re not going to get hamstring tendinitis from the same motion that causes biceps tendinitis). However, the generic causes of tendinitis are:

• Repetitively using the muscle, especially when the muscle contractions are in rapid succession
• Repeatedly placing the muscle and tendon on a stretch while using it, especially when the muscle or tendon is rubbed over other tissues like bone (This is what can happen when you do a bunch of arabesques and it causes iliopsoas tendinitis)
• Using the muscle or tendon excessively (through all of the activities you do throughout your day)

Signs and Symptoms

As an overuse injury, tendinitis symptoms frequently start to show up a few weeks into a new season (especially if you sat on the couch or the beach all summer!), new choreography, or shortly after a sudden increase in physical activity (rehearsing and/or exercising).

The signs and symptoms of tendinitis are:

• Pain with use of the tendon or associated muscle
• Pain with stretching of the tendon
• Limited range of motion, due to pain and/or a decrease in force transmission
• Tenderness over the tendon
• Increased pain with eccentric muscle activity (lowering a load or weight in a controlled manner – this can include going down the stairs, sitting down, or squatting)
• Some tendons, due to their positioning within the body will be able to be felt through the skin (like the hamstring tendons by your knee, the tendons in your wrist). When these tendons are inflamed, they take on a very thick and hard texture, sometimes feeling like a steel cable, especially when compared to the way the other side feels (assuming the other side is not injured, too)
• Mild swelling may also be noticeable, depending on the location of the tendon

Common Injury Sites

The most common places that dancers get tendinitis are:

• Achilles tendon
• Patellar tendon
• Iliopsoas tendon: this tendon is actually a combination of two muscles that work to flex your trunk over your pelvis and (more importantly for dancers) flex your hip. This tendon runs right in front of your actual hip joint (and is the tendon that makes the snapping sound in the front of your hip).
• Flexor Hallucis Longus (FHL) tendon: this is the tendon of the muscle that curls your big toe and helps to stabilize the big toe joint during demi-pointe and pointe work. FHL tendinitis is so common among dancers, especially ballet dancers, that it has been referred to as “dancer’s tendinitis”
• Hamstrings tendons: any of them, both proximally (by the hip/pelvis) and distally (by the knee)
• Extensor Hallucis Longus (EHL) tendon: the muscle associated with this tendon extends (bends back) your big toe and helps to stabilize your big toe joint during demi-pointe and pointe work
• Peroneal tendons: located on the “outside” of your lower leg, ankle, and foot, the peroneal muscle group pulls the foot into eversion at the ankle. This motion is referred to as “winging the foot” in dance

Instrumentalists often get tendinitis in the wrist flexor tendons and biceps tendon (most commonly at the elbow versus the tendon that crosses the shoulder). Instrumentalists who walk around while playing (marching band and strolling strings performers) are prone to Achilles tendinitis, patellar tendinitis, and peroneal tendinitis, too.

Common Treatments

Tendinitis can be managed easily if it is caught early enough in the injury process. However, this injury can very quickly become a nagging or incapacitating injury that simply does not go away until you take several weeks or months off from activity. If you correctly treat tendinitis shortly after the symptoms begin and listen to your body, treatments can be very effective.

The most common and effective treatments for tendinitis include:

• Rest.  Most of the time, relative rest (resting your injured body part without becoming a complete couch potato) is all that is needed, but if treatment is not started early enough in the inflammatory process, then absolute rest is necessary.
• Gentle stretching.  You won’t be taking the muscle into as intense of a stretch as you would to increase your flexibility, but you still need to follow the rules of stretching.
• Ice with the tendon/muscle on a slight stretch.  If you’ve ever used ice before, you may recall that it has some interesting effects on your body, including making your injured area feel stiff after the ice application is over. By placing your tendon and muscle on a slight stretch, you can slightly counteract this effect by preventing the muscle fibers from shortening as much due to the cold. The slight stretch does not have to feel like an actual stretch, it just needs to prevent the injured muscle/tendon from being in a shortened position. One example of this is to sit on the floor with your leg out straight in front of you and your foot flat on the wall while icing your Achilles tendon.
• Ice massage, depending on which tendon is injured (only tendons that are close to the surface of the skin will be effectively treated with ice massage)
• Cross-friction massage

When returning to activity

• Use heat before beginning your warm-up and stretching.
• A good warm-up before starting activity is critical for continuing to reduce your symptoms

Remember, using a heating pad is not the same thing as warming up! You need to do both for the best results, especially while returning to activity after tendinitis.

Some other treatment techniques, like using ultrasound before activity or instrument-assisted soft-tissue mobilization in the later stages of treatment/rehabilitation, can also be helpful if you are working with a medical professional who has access to the tools needed to perform these techniques.

When to Seek Medical Attention

If you have taken steps to protect against further injury and facilitate the healing process but your pain and other symptoms stay the same or get worse after 3 days, see a doctor because you may have something other than tendinitis.