Tendinopathy - July 5, 2019
The Tyranny of Tendon Terminology
“…the person down the street is going to come at you and ask you ‘why are you still playing footy with knee tendinitis?’ when their son’s got it and they’ve been told they’re not allowed to play footy for six weeks.” Joel Selwood, AFL 360, Fox Footy Channel

I love alliteration. Language, and how we perceive and use it, fascinates me. So, I could not resist putting together a blog post that allows me to talk about terminology in tendons and create an amazing alliterative appellation (I had to Google the definition of appellation – it’s a fancy word for title).

Before we delve into terminology, it is worth noting that La Trobe is running a Tendinopathy Symposium on August 30 and 31. World-class speakers, such as Professor Jill Cook, Dr Anthony Schache, Dr Ebonie Rio, Dr Tania Pizzari, and Dr Adam Castricum will cover the latest research and clinical evidence in both upper and lower limb tendinopathy. This is a fantastic opportunity to participate in clinical workshops that will share simple tools to assist in diagnosis and treatment of tendinopathy, which can be directly implemented when you go back to the clinic. You can register for the event here.

Now back to some word play. One of the biggest debates in tendon research for the past 30 years has been ‘what do we call the clinical condition of pain and dysfunction associated with tendons?’ While it seems like a debate that is only important to researchers, it’s also an important discussion for clinicians and patients. Tendinitis, tear, tendinopathy, rupture, and tendinosis are all terms that are used in the literature. None of these terms are completely incorrect or inappropriate, but their clinical appropriateness is where the debate lies. There are two aspects in selecting an appropriate term. Firstly, does the term accurately reflect the clinical condition? And secondly, what impact do the terms have on patient’s perception of tendon pain?

At the recent International Scientific Tendinopathy Symposium in Groningen, Professor Hans Zwerver, Professor Bill Vicenzino, Professor Alex Scott, and Dr Ebonie Rio convened a consensus meeting to discuss how terminologies reflect clinical conditions. They discovered that while inflammation is a feature of tendon pathology, it is certainly not the sole feature. However, the suffix ‘-itis’ in tendinitis implies that we need to direct treatment at the inflammatory cascade, which has had limited effectiveness to date. Tear is a term that is based on imaging findings and our accuracy in differentiating a tear from an area of disorganisation is limited. Therefore, the agreement at the consensus meeting was that tendinopathy should be used as the preferred term to describe the clinical condition.

The second aspect we need to consider is the impact terms can have on patient’s perception of tendon pain. Through the fantastic work of Lorimer Moseley and David Butler, we have a greater appreciation of the fact that language and words can have a nocebo effect. With pain being a response to perceived threat/danger to our bodies, language that can enhance or ameliorate these perceived dangers may influence pain.

A systematic review by Nickel and colleagues looked at how different terms influenced management preferences in the same clinical condition. Unsurprisingly, patients tend to prefer more invasive treatment options when medical terminology is used. Only one paper looked at a musculoskeletal condition, yet I think these findings are also relevant to tendons. How fearful of a complete rupture will a patient be if their ultrasound scan reports ‘torn tendon’ compared to an ‘abnormal tendon’? What treatment is a patient likely to choose if they are diagnosed with ‘tendinitis’ compared to ‘tendon pain’?

There is an asymmetry of information between clinician and patient that can have a considerable effect on a patient’s choice, or perceived effectiveness, of various treatments. Patients can have their own preconceptions of injuries and certain terminology.

Being selective with our language and explaining the condition may aid self-efficacy, a phenomenon that has have a significant impact on patient outcomes following physiotherapy.

There is a lot more work to do in this space, from developing standardised reporting terminology for clinical imaging that is reliable to ascertaining patients understanding of tendinopathy and its implications. The La Trobe Tendinopathy Symposium is a fantastic opportunity to learn more about this topic, and others, that will improve your clinical practice.

Hear from Professor Jill Cook on the upcoming Symposium here.

Blog by Dr Sean Docking