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94 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 1 8 indicate pathology of the tendon) are now frequently preferred because they don't emphasize an inflammatory component. It is definitely possible to have true tendinitis where inflammation is a factor, but it is not common. Whether we have collagen degeneration or a true inflammatory process in the tendon makes a significant difference in choosing treatment strategies. For example, if there is a true inflammatory tendon pathology, the administration of anti-inflammatory medications such as corticosteroid injections would make sense. However, steroid injections into tendons also impair collagen synthesis and adversely affect overall tendon strength in the long term. For that reason, treating a collagen degeneration tendinosis complaint with steroid injections could make the condition worse instead of better. One question that frequently comes up with tendon pathologies is what causes pain for these overuse tendon disorders if it isn't an inflammatory condition with tendon fiber tearing. The answer is simply that we aren't sure yet. There are several theories but there is not a definitive model yet for the pain-producing mechanism in tendon disorders. One promising theory is that there are numerous nociceptors in tendons that are sensitive to chemical irritation. The chronic overload on tendons causes a series of biochemical and metabolic challenges in the stressed tendons, which may activate nociceptors and cause tendon pain. 3 Mechanical overload is clearly the most frequent cause for tendon pathology. However, tendinosis can also occur in the absence of significant mechanical overload. Research has shown a strong connection between tendinosis and the fluoroquinolone family of antibiotics. These antibiotics are generally taken for things completely unrelated to tendon or musculoskeletal disorders but they can have an adverse impact on the structural integrity of tendons. Consequently, if a client is complaining of tendon pathology, it would be a good idea to find out in the initial history if the client has been taking any fluoroquinolone antibiotics. If so, mechanically oriented treatment strategies such as increasing load on the tendon may not be the best choice. Tenosynovitis Another relatively common tendon pathology is tenosynovitis. Unlike the common overuse condition frequently called tendinitis, tenosynovitis is an inflammatory condition. Tendons that are contained within a synovial sheath are subjected to significant friction between the tendon and its sheath. As a result of chronic overuse, inflammation and fibrous adhesions can develop between the tendon and surrounding sheath. These fibrous adhesions make it more difficult for the tendon to move smoothly inside the sheath and can produce pain. Because tendon sheaths are only in certain places, tenosynovitis will only occur in those tendons that are housed in a synovial sheath (mostly in the distal extremities). Ligament Injuries Ligament injuries are a bit simpler than the tendon pathologies described above. Ligament injuries occur most frequently when there is a very high-force load that overwhelms the ligament's capability to withstand the force. This is called a sprain and differentiated from a strain, which is an injury to the muscle-tendon unit. Ligament sprains are graded in three different categories: grade 1 (mild), grade 2 (moderate), and grade 3 (severe, including complete rupture). There are various different clinical signs and symptoms associated with each degree of ligament sprain to determine how severe the injury is. Because of the multiple fiber directions and higher elastin content, ligaments can withstand some degree of sudden stretch load. If the force load extends beyond what the ligament can withstand, the ligament may be permanently elongated. Permanent elongation occurs in second- and third- degree sprains, although third-degree sprains may also include a complete rupture of the ligament. When a ligament becomes permanently elongated, also referred to as plastic deformation, there is an increasing degree of mobility at the joint because the ligament is not restricting movement the way it should. The increasing degree of movement at the joint is called hypermobility and can be one factor in early development of osteoarthritis at that joint. Ligamentous laxity and hypermobility can also be a factor in other disorders. For example, laxity in the capsular ligaments of the shoulder has been implicated as one cause for subacromial impingement due to excessive movement of the humeral head. It is not unusual to find massage treatment techniques where the practitioner advocates "releasing" the ligament. We must remember that because ligaments don't contract, they also don't release.