Tendons are tough bands of fibrous connective tissue that attach muscles to bones. They are essential for movement, as they transmit the mechanical force of muscle contraction to the bone, enabling joint motion. When a tendon becomes injured or diseased, it can cause significant pain, mobility issues and disability. Therefore, examining tendons is an important part of many medical assessments. There are several techniques doctors use to visually inspect and assess the condition of tendons.
Visual Inspection
The first thing a doctor will do is visually inspect the tendon. They will look to see if there is any swelling, redness, bruising or deformity of the tendon and surrounding area. Swelling or thickening of the tendon may indicate inflammation, such as from tendinitis. Discoloration like redness or bruising could mean there is some type of trauma or injury to the tendon. Deformities can happen if the tendon has ruptured or been lacerated.
Doctors will also check to see if the tendon appears intact and continuous. A tendon rupture may present as a gap where the ends of the tendon have pulled apart from each other. Tendons also naturally glide under the skin when joints are moved, so doctors will have patients move the associated joint and look to see that the tendon is gliding smoothly underneath the skin. Any catching, snapping or hesitation in the glide may be a sign of problems.
Palpation
After visual inspection, doctors will use palpation, or touching, to further assess the tendon. With light palpation they check for areas of tenderness, nodules, thickening or defects along the length of the tendon. Pain during palpation may indicate tendinosis or tears within the tendon structure. Thickened or nodular areas could represent scarring, calcium deposits or masses within the tendon. Palpation also helps compare the tendons on each side of the body for symmetry.
Testing Range of Motion and Strength
Doctors will also assess range of motion and strength related to the tendon. They may passively move the joint through its range of motion to see if there is pain along the tendon’s path. This helps localize the problem to the tendon. Resistance applied to the muscle may re-create discomfort directly over the tendon if there is an injury. Weakness, instability or restricted joint movement could imply a partial or complete tendon tear. Comparing to the unaffected side helps determine deficits.
Imaging Studies
If a tendon issue is suspected after clinical examination, doctors can utilize various imaging techniques to visualize the tendon. These provide more detailed information about the tendon’s condition.
Ultrasound
Ultrasound uses high-frequency sound waves to create images of the tendon and surrounding structures. It allows dynamic, real-time evaluation of the tendon in motion. Ultrasound is useful for identifying tendon tears, calcium deposits, cysts, scar tissue and swelling. It can also guide needle-based procedures like aspirations or injections. Ultrasound is accessible, non-invasive and does not use radiation.
MRI
Magnetic resonance imaging (MRI) produces highly detailed computerized images using magnetic fields and radio waves. It excels at visualizing soft tissue structures like tendons, ligaments and muscles. MRI depicts the tendon’s internal matrix and can detect subtle changes like inflammation, edema and scarring. It is the gold standard for confirming partial and full thickness tendon tears. MRI requires specialized equipment and is more expensive than ultrasound.
CT Scan
Computed tomography (CT) uses x-rays and computer modeling to generate cross-sectional images of structures. CT can detect bone deformities, calcium deposits and fatty atrophy associated with chronic tendon tears. However, it does not visualize the tendon’s soft tissue as well as MRI. CT may be used in select cases where MRI is contraindicated. As CT uses ionizing radiation, risks versus benefits must be weighed.
X-ray
Plain x-rays are sometimes used as an initial imaging modality for tendons. They show bones well, and can detect fracture, dislocation, arthritis and calcification near the tendon. However, x-rays do not visualize the tendon tissue itself. They are relatively inexpensive and readily available.
Special Tests
There are also some special clinical tests that doctors can perform to detect specific tendon injuries:
Finkelstein Test
This test is used to diagnose De Quervain’s tenosynovitis of the thumb. The examiner grasps the patient’s thumb and sharply deviates the wrist ulnarward while the thumb is flexed into the palm. A positive test causes pain along the abductor pollicis longus and extensor pollicis brevis tendons on the radial side of the wrist.
Thompson’s Test
This assess for a ruptured Achilles tendon. The patient lies face down with feet hanging off the examination table. The examiner squeezes the calf muscles, looking for lack of foot plantarflexion which would indicate an Achilles rupture.
Piano Key Sign
Pressing along the flexor tendons of the palms elicits a piano key-like protrusion of the tendons in patients with tenosynovitis or trigger finger. Pain or locking may also occur.
Surgery
In severe or refractory cases, surgery may be needed to treat damaged tendons. There are various tendon surgeries doctors may perform:
Tenotomy
This involves cutting a tendon to release contracture or realign the tendon. It can improve joint position and reduce pain in conditions like trigger finger.
Tenodesis
Tenodesis grafts a tendon to a new location to restore function lost due to tendon injury. It is used for certain tendon tears and ruptures.
Tendon Repair
Tendon repair, or tendorrhaphy, is used to suture together ends of ruptured or lacerated tendons. This may be done using traditional open surgery or newer arthroscopic techniques.
Tendon Release
In this procedure, the tendon sheath is longitudinally opened to free up adhesions and scar tissue that may be restricting tendon gliding and causing symptoms.
Debridement
Debridement removes degenerated, thickened or necrotic tissue from chronic tendinopathies to promote healing. It is commonly done for conditions like tennis elbow.
Augmentation
Tendon augmentation uses grafts to reinforce a torn or weakened tendon. This encourages regeneration and protects the repair during healing.
Tenosynovectomy
This removes inflamed synovial sheath tissue from around a tendon. It can reduce pain and swelling in tenosynovitis.
Conclusion
Doctors utilize a variety of techniques to assess and treat problematic tendons. Initial visual inspection and palpation provide important clinical information. Range of motion and strength testing localize issues to specific tendons. Advanced imaging like ultrasound and MRI give detailed internal views of tendon structure and pathology. Special tests aid in diagnosing particular tendon injuries. Finally, surgical options like tenotomy, tendon repair or debridement can help remedy severe tendon damage when conservative measures fail. With a thorough multi-modal approach, doctors can accurately evaluate tendon issues and provide appropriate management tailored to each patient.