Approach

The main goal in the treatment of tendinopathy is to reduce pain and allow return to activity.

Tendinopathies are not complicated injuries, but can be difficult to manage. Patients need to be monitored by the physician on a regular basis for response to therapy. General principles of therapy are shared among all tendinopathy sites, but details within each treatment modality vary by anatomical site.

Treatment begins with relative rest and activity modification, with ice and non-steroidal anti-inflammatory drugs (NSAIDs) for acute pain relief.[39] [ Cochrane Clinical Answers logo ] Physiotherapy may be enhanced by corticosteroid injections, topical glyceryl trinitrate, and/or specialised modalities, depending on the anatomical site and response to initial therapy.[40]

Relative rest and activity modification

Because tendinopathy is an over-use injury, the main initial treatment is relative rest and activity modification.[41][42]

  • Goal is to decrease the mechanical over-load to promote tendon healing and pain relief.

  • Important to evaluate and correct athletic over-training errors.

  • For some anatomical sites, a brace, cast, boot, splint, or heel lift may be useful.[12][43][44][45][46]

    • Epicondylitis: a counterforce brace over the proximal lower arm may decrease pain and improve function.

    • Achilles' tendinopathy: heel lifts help with pain by decreasing the amount of stretch on the Achilles' tendon. If Achilles' tendinopathy presents acutely, treatment should begin with immobilisation for the first 7 to 10 days using a cast or boot.

    • Tight gastrocnemius-soleus complex: a night splint may be used to hold the foot in neutral to dorsiflexion for 6 to 8 weeks to maintain passive dorsiflexion.

    • Patellar tendon strap: alters the stresses on the patellar tendon and can decrease pain. Useful for patients who have abnormal patellofemoral tracking or patellar instability. Patients should wear these when engaging in aggravating activities.

Ice plus NSAIDs

Ice provides acute pain relief, and its use is widely accepted.

NSAIDS provide good short-term pain relief, but have no effect on long-term outcomes. NSAIDs may be used for a few days to help break the pain cycle in preparation for physiotherapy. Because tendinopathy is mainly a degenerative (not inflammatory) condition, NSAID use in the chronic setting may be more harmful than beneficial, given the adverse-effect profile of long-term NSAID use.[47][48]

Physiotherapy

Combined with relative rest and activity modification, physiotherapy is the main component of conservative treatment.

Patients need to strengthen and stretch the affected body part. One course of physiotherapy is generally considered to be 2 or 3 sessions per week for 6 weeks. Some evidence suggests that joint mobilisation may improve pain and functional outcomes in the short term (<3 months) for patients with lateral elbow epicondylitis.[49]

Gradually, patients can advance to eccentric strengthening and stretching of the extensor muscles.[50][51] Eccentric exercises are best done under the guidance of an experienced physiotherapist.[52][53]

  • In eccentric contraction, the muscle fibre lengthens as the muscle contracts, thus more load is placed on the tendon.

  • Eccentric single leg squats have proven benefits in patellar tendinopathy when the correct technique is used.[5][54][55]

  • Physiotherapy for knees with quadriceps, iliotibial band, or popliteus tendinopathy should focus on hamstring flexibility and quadriceps strengthening with eccentric exercises.

  • One systematic review of exercise, incorporating loaded exercise (i.e., against gravity or resistance), for rotator cuff tendinopathy supported its use with respect to pain and functional disability.[56]

Modalities administered by the physiotherapist include ultrasound, phonophoresis (ultrasound to deliver medication into superficial tissues), and iontophoresis (electric current to deliver medication into superficial tissues). The efficacy of modalities has not been proven with randomised controlled trials (RCTs). However, the risks are minimal (i.e., skin irritation, redness), so these are often used during therapy sessions.

There is not sufficient evidence from adequately sized trials to support deep transverse friction massage in lateral epicondylitis.[57]

Corticosteroid injections

Commonly used to help treat acute pain, although efficacy is debated.[58][59][60] Corticosteroid is usually mixed with an equal volume of 1% lidocaine.

Ultrasound-guided corticosteroid injection identifies vascular structures and neural tissue in the needle path and facilitates injection of the drug at the appropriate location.

Lateral epicondylitis

When considering administration of the corticosteroid injection anterior to the medial epicondyle, caution should be exercised as the ulnar nerve runs posterior to the medial epicondyle.[61]

Several systematic reviews have found that corticosteroid injection effectively relieves pain and improves short-term elbow function (<12 weeks) in patients with lateral epicondylitis.[62][63][64] However, symptoms may recur with poor clinical outcome.[63][64][65]

Rotator cuff tendinopathy

One systematic review and network meta-analysis reported that the beneficial effects of corticosteroid injections (improvements in pain and function) may not persist beyond the short term (3-6 weeks) in patients with rotator cuff tendinopathy.[60]

Patellar tendinopathy

Systematic reviews have found no benefit of corticosteroid injection in the treatment of patellar tendinopathy.[66][67]

Topical glyceryl trinitrate

Transdermal glyceryl trinitrate is thought to decrease pain, specifically chronic pain, by improving tendon healing.[68]

One systematic review concluded that topical glyceryl trinitrate for up to 6 months significantly improves pain for all types of tendinopathy in the short term (2-8 weeks) compared with placebo. Mid-term results (12-24 weeks) reported improvements in range of movement, quality of life, strength, and local tenderness.[69] A subsequent systematic review and meta-analysis found that, compared with placebo, topical glyceryl trinitrate was associated with a borderline significant reduction of pain-associated rotator cuff tendinopathy, Achilles' tendinopathy, patellar tendinopathy, and lateral epicondylitis.[70]

Extracorporeal shockwave therapy (ESWT)

A non-invasive treatment in which a device is used to pass acoustic shockwaves to the painful area. ESWT significantly reduces pain attributable to tendinopathy, although the mechanism by which it works has not yet been elucidated.[71][72][73][74] One systematic review found that low-energy ESWT may be effective for the treatment of chronic Achilles' tendinopathy if other conservative treatments fail.[75]

One RCT found no significant difference between focused shockwave therapy compared with radial shockwave therapy for the treatment of patellar tendinopathy.[76]

High-energy ESWT has been shown to be effective in the treatment of calcific rotator cuff tendinosis, although non-calcific tendinosis did not show benefit from ESWT.[77][78][79][80]

Percutaneous ultrasound-guided tenotomy

One systematic review reported good to excellent clinical outcomes following ultrasound-guided needling in patients with chronic calcific rotator cuff tendinopathy.[81] In one RCT, ultrasound-guided needling plus corticosteroid injection improved clinical and radiographic outcomes in patients with calcific tendinitis of the rotator cuff compared with corticosteroid injection alone.[82]

In the elbow, ultrasound-guided tenotomy has been shown to improve pain and function for both medial and lateral tendinopathy in both the short term (<12 weeks) and the long term (>2 years).[83] There is only low-certainty evidence that dry needling improves pain in patellar tendinopathy.[84]

Platelet-rich plasma (PRP) injection

PRP is prepared from autologous blood. The patient's whole blood is centrifuged to achieve a high concentration of platelets within a small volume of plasma. PRP is then injected at the site of injury, or implanted as a gel during surgery. PRP has become a popular option in orthopaedics and sports medicine for the treatment of tendinopathy.

Systematic reviews and meta-analyses do not consistently demonstrate benefit.[85][86][87][88] Significant improvements have been reported, but these may not equate to minimal clinically important differences.[88] Efficacy may vary with the specific indication; heterogeneity in preparations, injection technique, dosing, and frequency of PRP injection preclude uniform recommendations regarding the use of PRP.[85][89]

PRP injection may benefit patients with patellar tendinopathy, particularly chronic or recalcitrant cases. Some systematic reviews report sustained pain reduction and improved knee function.[90][91] However, RCT evidence indicates that, when combined with an exercise-based rehabilitation programme, a single injection of leukocyte-rich or leukocyte-poor PRP is not superior to saline for improving outcomes for patellar tendinopathy.[92]

Low-level laser therapy (LLLT)

In lateral epicondylitis, LLLT administered directly to the lateral elbow extensor tendon insertions results in a decrease in short-term pain and disability, with no serious adverse effects.[93][94]

In Achilles' tendinopathy, one systematic review showed that administration of LLLT in the painful area results in a decrease in short-term pain and disability, with no serious adverse effects.[94] A subsequent systematic review found that the pain of Achilles' tendinopathy may be reduced by LLLT plus eccentric exercises at 2 months (vs. sham plus eccentric exercises), but this effect was no longer significant at 3 months and 13 months.[95]

Surgery

Given the effectiveness of physiotherapy when compared with surgical treatment, evidence suggests that patients should pursue conservative treatment for at least 6 to 12 months.[96]

Low-certainty evidence suggests that surgery for patellar tendinopathy may not provide clinically meaningful benefit compared with eccentric exercise with respect to pain, function, or participant-reported treatment success.[97]

Persistent pain after a trial of appropriate conservative treatment, or in cases with evidence of complete tendon tears, warrants a surgical evaluation.[39][96][98][99][100][101]

Currently, arthroscopic surgery is more common than open surgery.

Use of this content is subject to our disclaimer