Statins And Their Effects On Tendons

Patella tendon pain

An article in today's Sunday Times (pictured below) mentioned that 50,000 people (or 1 out of 140) are at a very high risk of a heart attack due to an inherited gene mutation unless they take statins.

Sunday Times 200823

Statins (pictured below) are medications that reduce the levels of bad cholesterol or low level lipoprotein (LDL) in your blood and protect the insides of your arteries. When cholesterol is reduced, it lowers the risk of developing heart and circulatory diseases including stroke and heart attacks.

A study of 594,130 participants found that statin medications regardless of statin types were associated with a  significantly greater risk of all types of tendinopathy development compared with no statin treatment. This is inclusive of tennis elbow, trigger finger, rotator cuff tendinopathy, Achilles tendinopathy and De Quervain's (or radial styloid) tenosynovitis. There were 84,102 statin users and 168,204 non users (control) in that study (Kwak et al, 2023).

Tendinopathy is the term used now when there is pain and dysfunction in our tendons instead of tendinitis. It is associated with overuse in and around tendons and characterised by pain, reduced function and reduced exercise tolerance. There is seldom inflammation found in the tendons, it is more of a failed healing response of the tendon leading to disruption of collagen fibers in the tendon.

The oxygen consumption of tendons and ligaments during exercise is 7.5 times lower than skeletal muscles (Radak et al, 2013). This low metabolic rate and well developed anaerobic energy generation capacity are needed to carry loads and maintain tension for long periods when we are standing, moving and exercising. 

When blood flow (carrying oxygen) is restricted or reduced in tendons, it can lead to necrosis (or death) of the cells in the tendons. A low metabolic rate also results in slow healing after injury.

What we know about tendinopathy is that it does not improve with rest. The pain may ease but returning to activity/ sports is often painful again since rest does not increase the tolerance of the tendon to load. There is usually very little inflammation invloved in tendinopathy, hence it is not considered a classic inflammatory response. Anti inflammatory medication may help if you have very high pain levels, but it is still unclear what effect they have on the cells.

Tendinopathy can be caused by many different factors, the main factor being a sudden change in certain activities like running and jumping where the tendon is required to store energy. Some people are predisposed beacause of biomechanics (poor endurance or poor muscle capacity) or systemic factors (age, menopuase, elevated cholesterol and other metabolic factors). Predisposed people may develop tendon pain even with little changes in their activities.

Modifying load is very important in settling tendon pain. Reducing tendon load (at least in the short term) always helps.

Pathology on scans does NOT equal to pain. MRI scans often show tendon 'damage' (or abnormality) in people without pain. Even if you have 'tears' or 'severe' pathology DOES NOT mean you will have a better or poorer outcome. The pathology may not improve even with the best intentioned treatment (not on scans anyway), so treatment should be targeted at improving pain and function.

Tendinopathy rarely improves with passive treatments like massages, therapeutic ultrasound, injections and extracoporeal shock wave therapy (ESWT). Note that not all ESWT machines are the same. Most if not all physiotherapy clinics use hand held ESWT devices that do not require licenses. The doctor operated devices (with ultrasound imaging requiring a license to operate) usually cost over $250,000 versus the less than $40,000 cheaper versions that do not require licenses.

Eccentric (or lengthening) exercises seems to be the most evidenced based treatment for tendinopathy. This allows the tendons to be loaded progressively so they can develop greater tolerance that one needs for day-to-day activities or sports. I'm not a fan at all about getting our patients to do exercises, but even I had to do some eccentric strengthening exercise. The hands on fascia treatment I received definitely helped, but the individualised ecccentric exercise was the final part of the puzzle.

Tendinopathy responds very slowly to exercise, so patience is definitely needed while doing the correct eccentric exercises and it also needs to be progressed appropriately. Resist the temptation to accept 'short cuts' like injections and surgery.

References

Andres BM and Murrell GA (2008). Treatment Of Tendinopathy: What Works, What Does Not, And What Is On The Horizon. Clin Orth Relat Res. 466(7): 1539-1554. DOI: 10.1007/s11999-008-0260-1

Kwak D, Moon SJ, ParkJW et al (2023). Effects Of Statin Treatment On The Development Of Tendinopathy: A Nationwide Population-Based Cohort Study. Orth J Sp Med. 1197): 23259671231167851. DOI: 10.1177/23259671231167851

Radak Z, Zhao Z, Koltai E et al (2013). Oxygen Consumption And Usage During Physical Exercise: The Balance Between Oxidative Stress And ROS- Dependent Adaptive Signaling. Antioxi Redox Signal. 18(10): 1208-1246. DOI: 10.1089/ars2011.4498

Patient With "Shoulder Tendinitis" Not Better After Medication

Can you guess what's wrong with my patient's shoulder?

Just by looking at the picture above, can you guess which shoulder was giving my patient problems? I also showed the picture to some of my staff and asked them "what can you see from this picture?"

Alright, for those who can't tell, here are some more clues. My patient came in with some neck pain and a very uncomfortable shoulder. He had seen his family doctor who told him he had tendinitis in his shoulder and gave him some NSAIDS (non steroidal anti inflammatory drugs).

However he did not get much better with the medication. He still had some neck discomfort and couldn't raise his arm above shoulder height. Lying on his affected side made his shoulder worse and he could only sleep supine.

At first I too thought the shoulder pain was referred from his neck. He mentioned that there was slight tingling sensation in his fingers occasionally too (which was why I thought the problem was coming from his neck). However I changed my mind after seeing he had trouble even lifting his arm sideways above shoulder height.

I told him that he probably had a tear in his L Supraspinatus muscle. If you look at the picture above carefully, you will see a hollowing above his left shoulder blade. There is also wasting in the muscle (or muscle atrophy) around the part where his neck on the left connects to his shoulder.

I was told later after an ultrasound scan that he had a full thickness tear in his left Supraspinatus muscle with retraction of the tendon! The doctor referred him for an MRI and said he may need surgery to repair the retracted tendon.

By the way, scientists have assessed biopsies from both people and animals with supposed tendinitis and found very few signs of inflammation in the tendons.

NSAIDs are commonly prescribed to reduce pain and inflammation of tendinitis. So if there is no inflammation, the medication is not going to help.

So the word tendinitis with the suffix "itis" means inflammation is misnamed since the condition has little or no inflammation. Researchers prefer the term "tendinopathy" meaning damaged or degenerating tendon.


Reference

Warden SJ (2009). Prophylactic Misuse And Recommended Use Of Non-steroidal Anti-inflammatory Drugs By Athletes. BJSM. 43(8): 548-549. DOI: 10.1136/bjsm.2008.056697.