Pain from Ligaments & Tendons

Tendons, which attach the muscles to the bones, are often also injured and suffer tearing. The most commonly injured tendons are the rotator cuff, patellar, Achilles, and biceps tendons.  The most commonly injured ligaments are the ankle, knee, shoulder and sacroiliac ligaments.

Ligaments connect one bone to another at the joint level and are responsible for stability. Torn ligaments and tendons (whether partial or complete) can cause chronic pain in addition to compromised function. This can result from accidents, falls, or insidiously from prolonged stretching due to poor posture and ergonomics. Acute sprains can heal, though sometimes the ligament may not return to its previous length and strength. Chronic ligament and tendon pathology have significantly reduced ability for self-repair. Particularly in the case of recurrent ligament sprains, the joint affected will be less stable and predisposed to recurrent sprains. In addition, these injuries are capable of generating pain. An injury severe enough to cause a fracture is certainly severe enough to cause damage to a ligament. A very common example is chronic pain and dysfunction after a fractured ankle, invariably associated with chronic ankle sprains. However, this principle applies anywhere in the body; fractures in the pelvis, around the knee, shoulder, elbow and wrist not to mention the spine, are invariably accompanied by pain arising from the surrounding ligaments and muscles, probably due to sprain.

Often patients are not given a correct diagnosis of these problems and may be left untreated for years. A particularly common area of pain occurs in the lower back or sacro-iliac (SI) joints and ligaments.

SI induced pain is often diagnosed with the injection of local anesthetic into the SI joint to see if this eliminates the pain. The pain from the SI joint has thus been estimated to comprise approximately 25% of patients suffering from low back pain. However, this does not take into account those suffering from pain arising from dysfunctional sacroiliac ligaments (see figure 1). Pain and ligament sacroiliac dysfunction may develop after an injury, chronic poor posture, and can develop secondary to other surrounding pathologies such as lumbar spinal stenosis (and certainly after spine fusion) as well as osteoarthritis of the hip joints. If we consider these facts, it is most probable that pain arising from the sacroiliac joints and ligaments plays a significant role of the pain disorder in about 60% of patients suffering from low back pain. This is because the ligaments and joints function as constant shock absorbers with every single step and jump; any pathology in the surrounding structures is going to place a lot more strain on this region. As with the gluteus minimus muscle, the sacroiliac ligaments can cause pain to refer all the way down the leg, even to the heel (see figure 2). The function of these ligaments is very intricately related to that of the buttock muscles; if there is dysfunction of one of these two, then the other is affected.

Common causes of sacroiliac-induced pain are:

  • car accidents and falls
  • secondary to lumbar spinal pathology, spinal stenosis and spine fusion, as well as hip joint pathology
  • poor posture and faulty ergonomics
  • weak buttock and abdominal muscles

If there are positive clinical signs on the physical examination of SI dysfunction, then prolotherapy and platelet-rich plasma injections to these ligaments can lead to lasting relief of severe pain. Patients usually feel that they function better and often note that they are more stable than they used to be. Overall, there are about 12 points at least to be injected over the course of treatment sessions. Not all points are covered in each session, however, they are all covered over a few treatment sessions. At some point in time, the hips and lumbar spine may have to be treated as well to give lasting relief.

Figure 1
Figure 2

The shoulder is the most mobile joint in the body, but this comes at the expense of stability. It is for this reason that dislocations of the shoulder joint and acromioclavicular joint are relatively common, and why the tendons are so vulnerable to degeneration and tearing.

Rotator cuff tears are the most common cause of shoulder pain, though not all tears are symptomatic. Full-thickness tears occur in 25% of individuals in their 60s, and 50% of those in their 80s. Many of these patients suffer from severe pain, especially at night. Pain may also refer all the way down the arm. When pain becomes chronic, the neck muscles often develop trigger points and these also should be treated. In fact, sometimes, it is difficult to discern if the pain arises from the neck or from the shoulder.

One must take into consideration that the shoulder girdle is comprised of 4 joints! These are: the glenohumeral joint (the main shoulder joint), the acromioclavicular joint, the sternoclavicular joint, and even though not a classical joint in the true sense of the word, it functions like one- the scapulothoracic joint. If the latter 3 joints are ignored, posture not assessed, scapular movements not considered as part of the treatment, then one is unlikely to achieve long term benefit with injections or surgical treatments directed just at the main shoulder joint.

Cortisone injections have become the state-of-the-art treatment of shoulder pain including that which arises from rotator cuff tear. Cortisone injections have been found, at best, to bring about short-term relief only. A review in The Lancet has shown that if cortisone injections are repeated over and over, whether in the shoulder or other areas such as the elbow, the condition ends up worse than what it was prior to the beginning of the treatment. It weakens collagen tissue and increases the risk of tear.

In contrast, prolotherapy and platelet-rich plasma can be used to strengthen a weakened shoulder girdle due to tendon tears, and possibly even lead to some healing of partial tears. Even in the case of full-thickness tears, even though the tear is unlikely to be repaired, the supporting ligaments and shoulder capsule can be strengthened in order to improve shoulder function, and prevent further deterioration.

Biologically young patients with full-thickness tears are generally advised to have surgical repair but this depends on several factors. Although surgical repair of partial-thickness tears is becoming more prevalent, it is not recommended to operate on tears smaller than 1cm. One must take into account that surgical repair must be followed by a prolonged rehabilitation period of several months, the arm must be immobilized for some time, and there are serious surgical risks such as damage to the brachial plexus. And after all that, retear is a considerable risk.

The common causes of knee pain are:

  • Osteoarthritis – in the older population
  • Meniscal derangement
  • Ligament injuries- especially from sports activities
  • Patellofemoral knee pain
  • Osgood-Schaletters syndrome- in athletic adolescents
  • Fractures
  • Referred pain from elsewhere


The 3 most common causes of knee pain are osteoarthritis, meniscal tears and ligament tears. As with any other area of the body, not everything found in imaging is the cause of the pain. As one ages, one’s tissues degenerate more and more, and invariably, there are more findings on imaging which may not be relevant. One must remember we are treating patients and not MRIs! So, as I have mentioned time and again, imaging only complements a systematic physical examination.

I can bring a personal example from my own knee pain:

At the age of 62, I have very mild pain in my right knee, and only occurring with very small twisting movements. I am very active, I walk from Hadassah Hospital to Mevaseret Zion (12 km), and do quite challenging hikes. Because I had the pain and off for 5 years, I decided to have an MRI (wrong move) to rule out a meniscal tear. My menisci were found to be perfectly normal, however, I was found to have stage 4 patello-femoral osteoarthritis of the knee, with areas with NO cartilage at all. No damage was found in any of the tendons.

In the end, what actually helped my pain were injections to the pes anserine bursa where a group of 3 tendons insert into the knee! I had one treatment of PRP and one of PRF. This goes to show that what really counts is a very methodical physical examination. Psychologically, it is disheartening to know that you are ageing so much, and I am not doing anything different to treat the findings on the MRI anyway, so there was little point in doing the MRI.

Ligament disruption and sprains may cause persistent pain and dysfunction. It is very common for people who have fractured bones in the ankle or knee to continue suffering pain. In most cases the bones heal, however, if the injury was severe enough to result in a fracture, it was severe enough to sprain or partially tear a ligament supporting the joint. The resulting pain can linger on for months or years if not treated, and lead to compensations in nearby joints leading to further dysfunction. As with any other region in the body, the whole region must be addressed in order to achieve long term results. Prolotherapy, PRP and PRF are all good treatment options for these conditions.

Osteoarthritis becomes exceedingly common with age. Osteoarthritis of the knee is usually associated with some sort of meniscal derangement. Please refer to the section on osteoarthritis.

Whiplash injuries result from excessive forces placed upon the neck muscles and ligaments, typically as a result of involvement in a rear end car collision.

In such cases, the impact of the car from behind crashes into the car in front and causes a fast acceleration of the body to the front. Often the head is “left behind” due to its inertia. The head jolts forward from a reaction force, and then often moves back again.

The high-velocity movements of the head relative to the unprepared body can cause subtle tears in the muscle and ligament fibres of both the front and the back of the neck. Trigger points often develop on these muscles. Both sorts of tears can cause pain to linger on for prolonged periods of time.

The body has tremendous healing powers to repair these damages. However, the most important part of the treatment is to move the neck around and maintain range of motion; failure to do this will lead to more protective muscle spasm, scarring in the muscles, more pain and fear avoidance behaviour. Other treatments are discussed in the section under treatments. McKenzie neck retraction exercises are effective in maintaining range of motion as well as stretching the appropriate muscles.

Dry needling can be used to treat the trigger points within the muscular aspect of the pain, and this may indeed be sufficient, even with longstanding whiplash-associated pain. Prolotherapy is effective in treating the ligaments and the facet joint capsules that may have been sprained. PRP can also be used. All of the above are effective methods in treating this injury and complement each other. Whatever method chosen, care must be taken to avoid faulty posture so as not to stretch already damaged muscles and ligaments and enable healing to occur after the treatment. Avoid at all costs sleeping on the tummy, as this strains excessively the ligaments and muscles on one side which may perpetuate the pain and hinder any progress with the treatment.

Ankle injuries are notorious for suffering from ligament sprains. As with knee injuries, fractures usually heal, however sprained ligaments can remain a source of chronic pain.

The more times one sprains his/her ankle, the more unstable that ankle becomes. The most commonly sprained ligament is the anterior talofibular ligament which connects the bone on the outside of the ankle to the talus bone, just underneath the ankle joint. This leaves the ankle less stable, and if one allows the feet to hang over the bed, the foot tends to hang bent down and inwards (inverted). However, there are so many ligaments in the ankle as there are so many bones, making the ankle and foot very vulnerable to sprains. A severe sprain will probably involve multiple ligaments, possibly affecting both sides of the ankle.

In addition, the ligaments are crucial to giving the feet arch support. There are 3 arches; one on each side along the sides of the feet, and one across the foot. There are various muscles act synergistically with these ligaments, such as the anterior and posterior tibilais. When one develops failure of these supporting structures, one develops severe flat feet which will eventually lead to arthritis of the subtalar (lower ankle) joint.

It is crucial to strengthen these supporting ligaments in order to prevent sprains or arch failure.

One can also treat resulting arthritis, however, if the causes are not treated early enough, results are likely to last only a few months.Patients who are operated on with fixation of fractures often suffer from neuropathic pain. This can result from damage to the surrounding nerves but more commonly from entrapment of these nerves in scar tissue. These entrapments can be released by hydro-dissection nerve blocks performed under ultrasound relieving a lot of the pain.

Often a patient comes into the office and says “I have inflammation”. This is a very non-specific diagnosis and does not add much information. Tendinitis (inflammation of the tendon) is usually a misnomer because, unless in the very acute stage, there is no inflammation but rather a degeneration of the tendon or a tendinosis, either due to an acute injury or due to prolonged wear and tear. Very common conditions are those related to the rotator cuff of the shoulder, tennis elbow, patellar tendinitis of the knee, and Achilles tendinitis at the ankle.

Because there is no true inflammation, there is little point in prescribing anti-inflammatory drugs, or injecting cortisone. Moreover, cortisone is ‘catabolic’ which means that it causes protein breakdown, and therefore will impair the body’s healing potential. Our purpose is quite the opposite- to stimulate a strong repair response. Since, as said above, ligaments and tendons have a reduced ability for self-repair, we inject them with solutions which cause the human body to start the self-repair process – see section on prolotherapy and platelet rich plasma.