Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

shoulder with rotator cuff tendinopathy

1st line – activity modification with physical therapy

Back
ACUTE
|
shoulder with rotator cuff tendinopathy
1st line – 

activity modification with physical therapy

Main treatment is rest, plus evaluating and correcting overtraining errors.[41][44]

Physical therapy starts with stretching to improve range of motion followed by strengthening of the rotator cuff muscles and scapular stabilizers 2 or 3 times per week for 6 weeks. May need multiple courses. Exercise, incorporating loaded exercise (i.e., against gravity or resistance), has been found to be effective in the treatment of rotator cuff tendinopathy with respect to pain and functional disability.[58][104]

May also incorporate home exercise regimen in highly motivated patients.

Modalities are administered by the physical therapist: ultrasound, phonophoresis (ultrasound is used to deliver medication into superficial tissues), and iontophoresis (electric current is applied to deliver medication into superficial tissues). The efficacy of modalities has not been proven with randomized controlled trials. However, the adverse effects (e.g., skin irritation and redness) are minimal so these are often used during therapy sessions.

Consider – ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
shoulder with rotator cuff tendinopathy
Consider – 

ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Treatment recommended for SOME patients in selected patient group

Ice may be applied to the affected area for acute pain relief.

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 physical therapy. 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.[49][50]

Primary options

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) two to three times daily when required, maximum 150 mg/day

OR

celecoxib: 200 mg orally once daily when required

Plus – subacromial corticosteroid injection

Back
ACUTE
|
shoulder with rotator cuff tendinopathy
|
unable to tolerate physical therapy due to severe pain
Plus – 

subacromial corticosteroid injection

Treatment recommended for ALL patients in selected patient group

Subacromial injections with corticosteroid can help control pain, allowing physical therapy to take place.[60][61][105][106]

Corticosteroid is usually mixed with 1% lidocaine.

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.[62]

Adverse effects include hypopigmentation at injection site.

Primary options

triamcinolone acetonide: 40 mg subacromially as a single dose

OR

methylprednisolone acetate: 40 mg subacromially as a single dose

Plus – nitroglycerin patch

Back
ACUTE
|
shoulder with rotator cuff tendinopathy
|
no improvement despite physical therapy and corticosteroids
Plus – 

nitroglycerin patch

Treatment recommended for ALL patients in selected patient group

Topical transdermal nitroglycerin is thought to decrease pain, specifically chronic pain, by improving tendon healing.[70][107]

One systematic review concluded that topical nitroglycerin 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.[71]

Primary options

nitroglycerin transdermal: consult specialist for guidance on dose

Consider – extracorporeal shockwave therapy

Back
ACUTE
|
shoulder with rotator cuff tendinopathy
|
no improvement despite physical therapy and corticosteroids
Consider – 

extracorporeal shockwave therapy

Treatment recommended for SOME patients in selected patient group

A noninvasive treatment in which a device is used to pass acoustic shockwaves to the painful area. Extracorporeal shockwave therapy (ESWT) significantly reduces pain attributable to tendinopathy, although the mechanism by which it works has not yet been elucidated.[73][74][75][76]

High-energy ESWT has been shown to be effective in the treatment of calcific rotator cuff tendinosis, although noncalcific tendinosis did not show benefit from ESWT.[79][80][81][82]

Consider – percutaneous ultrasound-guided tenotomy

Back
ACUTE
|
shoulder with rotator cuff tendinopathy
|
no improvement despite physical therapy and corticosteroids
Consider – 

percutaneous ultrasound-guided tenotomy

Treatment recommended for SOME patients in selected patient group

One systematic review reported good to excellent clinical outcomes following ultrasound-guided needling in patients with chronic calcific rotator cuff tendinopathy.[83] In one randomized controlled trial, 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.[84]

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).[85] There is only low-certainty evidence that dry needling improves pain in patellar tendinopathy.[86]

Consider – surgery

Back
ACUTE
|
shoulder with rotator cuff tendinopathy
|
refractory to other therapies, or tear seen on imaging
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

It is estimated that 70% to 80% of rotator cuff tendinopathies will resolve with conservative treatment.[108] Given the effectiveness of physical therapy when compared with surgical treatment, evidence suggests that patients should pursue conservative treatment for at least 6 to 12 months.[98]

In refractory cases, it is important to obtain an MRI to evaluate for rotator cuff tears or calcifications. If a large tear is found, referral for surgical evaluation is warranted.[41][100][101][102][103]

A randomized controlled trial with 5 years of follow-up demonstrated that primary repair of small- and medium-sized rotator cuff tears (not exceeding 3 cm) may be associated with better outcomes than physical therapy and optional secondary tendon repair.[109] However, the clinical importance of the small differences in outcomes may be equivocal.

shoulder with biceps tendinopathy

1st line – activity modification with physical therapy

Back
ACUTE
|
shoulder with biceps tendinopathy
1st line – 

activity modification with physical therapy

Main treatment is rest, plus evaluating and correcting overtraining errors.[41][44]

Physical therapy starts with stretching to improve range of motion followed by strengthening of the rotator cuff muscles and scapular stabilizers 2 or 3 times per week for 6 weeks. May need multiple courses.

May also incorporate home exercise regimen in highly motivated patients.

Modalities are administered by the physical therapist: ultrasound, phonophoresis (ultrasound is used to deliver medication into superficial tissues), and iontophoresis (electric current is applied to deliver medication into superficial tissues). The efficacy of modalities has not been proven with randomized controlled trials. However, the adverse effects (e.g., skin irritation and redness) are minimal so these are often used during therapy sessions.

Consider – ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
shoulder with biceps tendinopathy
Consider – 

ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Treatment recommended for SOME patients in selected patient group

Ice may be applied to the affected area for acute pain relief.

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 physical therapy. 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.[49][50]

Primary options

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) two to three times daily when required, maximum 150 mg/day

OR

celecoxib: 200 mg orally once daily when required

Consider – extracorporeal shockwave therapy

Back
ACUTE
|
shoulder with biceps tendinopathy
Consider – 

extracorporeal shockwave therapy

Treatment recommended for SOME patients in selected patient group

A noninvasive treatment in which a device is used to pass acoustic shockwaves to the painful area. Extracorporeal shockwave therapy (ESWT) significantly reduces pain attributable to tendinopathy, although the mechanism by which it works has not yet been elucidated.[73][74][75][76]

High-energy ESWT has been shown to be effective in the treatment of calcific rotator cuff tendinosis, although noncalcific tendinosis did not show benefit from ESWT.[79][80][81][82]

Consider – nitroglycerin patch

Back
ACUTE
|
shoulder with biceps tendinopathy
Consider – 

nitroglycerin patch

Treatment recommended for SOME patients in selected patient group

Topical transdermal nitroglycerin is thought to decrease pain, specifically chronic pain, by improving tendon healing.[70][107]

One systematic review concluded that topical nitroglycerin 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.[71]

Primary options

nitroglycerin transdermal: consult specialist for guidance on dose

elbow with lateral epicondylitis

1st line – activity modification with physical therapy

Back
ACUTE
|
elbow with lateral epicondylitis
1st line – 

activity modification with physical therapy

Main treatment for tendinopathy is rest, but pain-free motion should be maintained to avoid development of weakness. Joint mobilizations may improve pain, grip strength, and functional outcomes in the short term (<3 months) for patients with lateral elbow epicondylitis.[51]

Also important to evaluate and correct overtraining errors.

In addition to avoiding repetitive wrist extension, supervised physical therapy is also very important to help reduce pain.

Eccentric strengthening and stretching exercises should be performed 2 or 3 times per week for 6 weeks.[52][53]

May also incorporate home exercise regimen in highly motivated patients who demonstrate clear understanding of the exercises.

It should be noted that there is not sufficient evidence from adequately sized trials to support deep transverse friction massage in lateral epicondylitis.[59]

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

Consider – ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
elbow with lateral epicondylitis
Consider – 

ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Treatment recommended for SOME patients in selected patient group

Ice may be applied to the affected area for acute pain relief.

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 physical therapy. 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.[49][50]

Primary options

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) two to three times daily when required, maximum 150 mg/day

OR

celecoxib: 200 mg orally once daily when required

Consider – low-level laser therapy (LLLT)

Back
ACUTE
|
elbow with lateral epicondylitis
Consider – 

low-level laser therapy (LLLT)

Treatment recommended for SOME patients in selected patient group

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.[95][96]

Consider – percutaneous ultrasound-guided tenotomy

Back
ACUTE
|
elbow with lateral epicondylitis
Consider – 

percutaneous ultrasound-guided tenotomy

Treatment recommended for SOME patients in selected patient group

In the elbow, ultrasound-guided tenotomy has been shown to improve pain and function for both medial and lateral tendinopathy in both short-term (<12 weeks) and long-term (>2 years) follow-up.[85]

Plus – counterforce brace

Back
ACUTE
|
elbow with lateral epicondylitis
Plus – 

counterforce brace

Treatment recommended for ALL patients in selected patient group

A counterforce brace over the proximal lower arm may decrease pain and improve function.[45]

Plus – corticosteroid injection

Back
ACUTE
|
elbow with lateral epicondylitis
|
severe pain
Plus – 

corticosteroid injection

Treatment recommended for ALL patients in selected patient group

In cases where patients have severe pain, corticosteroid injections can help with short-term pain relief.[61][106]

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.[63]

Several systematic reviews have found that corticosteroid injection effectively relieves pain and improves short-term elbow function (<12 weeks) in patients with lateral epicondylitis.[64][65][66] However, symptoms may recur with poor clinical outcome.[65][66][67]

Corticosteroid is usually mixed with an equal volume of 1% lidocaine.

Total injections should be limited to 3 as injections weaken the area and may cause tendon tissue necrosis.

Primary options

triamcinolone acetonide: 20 mg injected into the most tender spot at the lateral epicondyle as a single dose

OR

methylprednisolone acetate: 20 mg injected into the most tender spot at the lateral epicondyle as a single dose

Plus – nitroglycerin patch

Back
ACUTE
|
elbow with lateral epicondylitis
|
no improvement with physical therapy, corticosteroid injection, or counterforce brace
Plus – 

nitroglycerin patch

Treatment recommended for ALL patients in selected patient group

Topical transdermal nitroglycerin is thought to decrease pain, specifically chronic pain, by improving tendon healing.[70][110]

One systematic review concluded that topical transdermal nitroglycerin 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.[71]

Primary options

nitroglycerin transdermal: consult specialist for guidance on dose

Consider – surgery

Back
ACUTE
|
elbow with lateral epicondylitis
|
no improvement despite 6 to 12 months of conservative therapy
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Given the effectiveness of physical therapy when compared with surgical treatment, evidence suggests that patients should pursue conservative treatment for at least 6 to 12 months.[98]

Arthroscopic surgery should be reserved for cases that do not respond to 6 to 12 months of appropriate conservative management.[111] Compared with observation or placebo, pooled data from a meta-analysis indicate a lack of intermediate- to long-term clinical benefit after nonsurgical treatment of lateral epicondylitis.[112]

elbow with medial epicondylitis

1st line – activity modification with physical therapy

Back
ACUTE
|
elbow with medial epicondylitis
1st line – 

activity modification with physical therapy

Avoidance of repetitive wrist pronation and flexion.

Physical therapy including strengthening and stretching exercises, 2 or 3 times per week for 6 weeks.

May also incorporate home exercise regimen in highly motivated patients.

Modalities are administered by the physical therapist: ultrasound, phonophoresis (ultrasound is used to deliver medication into superficial tissues), and iontophoresis (electric current is applied to deliver medication into superficial tissues). The efficacy of modalities has not been proven with randomized controlled trials. However, the adverse effects (e.g., skin irritation and redness) are minimal so these are often used during therapy sessions.

Consider – ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
elbow with medial epicondylitis
Consider – 

ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Treatment recommended for SOME patients in selected patient group

Ice may be applied to the affected area for acute pain relief.

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 physical therapy. 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.[49][50]

Primary options

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) two to three times daily when required, maximum 150 mg/day

OR

celecoxib: 200 mg orally once daily when required

Consider – percutaneous ultrasound-guided tenotomy

Back
ACUTE
|
elbow with medial epicondylitis
Consider – 

percutaneous ultrasound-guided tenotomy

Treatment recommended for SOME patients in selected patient group

In the elbow, ultrasound-guided tenotomy has been shown to improve pain and function for both medial and lateral tendinopathy in both short-term (<12 weeks) and long-term (>2 years) follow-up.[85]

Plus – counterforce brace

Back
ACUTE
|
elbow with medial epicondylitis
Plus – 

counterforce brace

Treatment recommended for ALL patients in selected patient group

A counterforce brace may decrease pain and improve function.[45]

Plus – corticosteroid injection

Back
ACUTE
|
elbow with medial epicondylitis
|
severe pain
Plus – 

corticosteroid injection

Treatment recommended for ALL patients in selected patient group

May be considered in patients with severe pain.

Caution should be exercised when administering the injection anterior to the medial epicondyle because the ulnar nerve runs posterior to the medial epicondyle.[63]

Corticosteroid is usually mixed with an equal volume of 1% lidocaine.

Dose should be limited to 3 times per year.

Primary options

triamcinolone acetonide: 20 mg injected into the most tender spot at the lateral epicondyle as a single dose

OR

methylprednisolone acetate: 20 mg injected into the most tender spot at the lateral epicondyle as a single dose

Consider – nitroglycerin patch

Back
ACUTE
|
elbow with medial epicondylitis
|
no improvement with physical therapy, corticosteroid injection, or counterforce brace
Consider – 

nitroglycerin patch

Treatment recommended for SOME patients in selected patient group

Topical transdermal nitroglycerin is thought to decrease pain, specifically chronic pain, by improving tendon healing.[70][110]

One systematic review concluded that topical transdermal nitroglycerin 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.[71]

Primary options

nitroglycerin transdermal: consult specialist for guidance on dose

Consider – surgery

Back
ACUTE
|
elbow with medial epicondylitis
|
no improvement despite 6 to 12 months of conservative therapy
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Given the effectiveness of physical therapy when compared with surgical treatment, evidence suggests that patients should pursue conservative treatment for at least 6 to 12 months.[98]

Surgery should be reserved for cases that do not improve after 6 to 12 months despite appropriate conservative management and is the final resort.

Recovery time after surgery is long: typically 6 months.

knee with patellar tendinopathy

1st line – activity modification with physical therapy

Back
ACUTE
|
knee with patellar tendinopathy
1st line – 

activity modification with physical therapy

Initial focus on quadriceps strengthening and correction of any predisposing factors such as abnormal patellofemoral tracking or patellar instability.

Gradually, may advance to eccentric strengthening and stretching of the extensor muscles.

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

Eccentric single leg squats have proven benefits in patellar tendinopathy.[5][56][57]

For successful results, these eccentric exercises are best done under supervision.

Modalities are administered by the physical therapist: ultrasound, phonophoresis (ultrasound is used to deliver medication into superficial tissues), and iontophoresis (electric current is applied to deliver medication into superficial tissues). The efficacy of modalities has not been proven with randomized controlled trials. However, the adverse effects (e.g., skin irritation and redness) are minimal so these are often used during therapy sessions.

Consider – ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
knee with patellar tendinopathy
Consider – 

ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Treatment recommended for SOME patients in selected patient group

Ice may be applied to the affected area for acute pain relief.

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 physical therapy. 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.[49][50]

Primary options

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) two to three times daily when required, maximum 150 mg/day

OR

celecoxib: 200 mg orally once daily when required

Consider – patellar tendon straps or patellar brace

Back
ACUTE
|
knee with patellar tendinopathy
Consider – 

patellar tendon straps or patellar brace

Treatment recommended for SOME patients in selected patient group

Patellar tendon straps alter the stresses on the patellar tendon and can decrease pain.

Patellar brace is useful for patients who have abnormal patellofemoral tracking or patellar instability.

Patients should wear these when engaging in aggravating activities.[12]

Consider – extracorporeal shockwave therapy

Back
ACUTE
|
knee with patellar tendinopathy
Consider – 

extracorporeal shockwave therapy

Treatment recommended for SOME patients in selected patient group

A noninvasive treatment in which a device is used to pass acoustic shockwaves to the painful area. Extracorporeal shockwave therapy (ESWT) significantly reduces pain attributable to tendinopathy, although the mechanism by which it works has not yet been elucidated.[73][74][75][76]

One randomized controlled trial found no significant difference between focused shockwave therapy compared with radial shockwave therapy for treating patellar tendinopathy.[78]

Consider – nitroglycerin patch

Back
ACUTE
|
knee with patellar tendinopathy
Consider – 

nitroglycerin patch

Treatment recommended for SOME patients in selected patient group

Topical transdermal nitroglycerin is thought to decrease pain, specifically chronic pain, by improving tendon healing.[70][110]

One systematic review concluded that topical transdermal nitroglycerin 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.[71]

Primary options

nitroglycerin transdermal: consult specialist for guidance on dose

Consider – platelet-rich plasma (PRP) therapy

Back
ACUTE
|
knee with patellar tendinopathy
|
no improvement after 3 to 6 months of conservative therapy
Consider – 

platelet-rich plasma (PRP) therapy

Treatment recommended for SOME patients in selected patient group

PRP injection may benefit patients with patellar tendinopathy, particularly chronic or recalcitrant cases. Some systematic reviews report sustained pain reduction and improved knee function.[92][93] However, randomized controlled trial evidence indicates that, when combined with an exercise-based rehabilitation program, a single injection of leukocyte-rich or leukocyte-poor PRP is not superior to saline for improving outcomes for patellar tendinopathy.[94]

Consider – surgery

Back
ACUTE
|
knee with patellar tendinopathy
|
no improvement after 3 to 6 months of conservative therapy
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Conservative treatment of patellar tendinopathy is successful in >90% of patients.[113]

In cases where patients have not improved after 3 to 6 months of conservative management, surgery may be considered.[114]

Usually, the degenerated tendon tissue is excised arthroscopically.

knee with quadriceps, iliotibial band, or popliteus tendinopathy

1st line – activity modification with physical therapy

Back
ACUTE
|
knee with quadriceps, iliotibial band, or popliteus tendinopathy
1st line – 

activity modification with physical therapy

Quadriceps tendinopathy is much less common than patellar tendinopathy.[115]

Physical therapy should focus on hamstring flexibility and quadriceps strengthening with eccentric exercises.

Modalities are administered by the physical therapist: ultrasound, phonophoresis (ultrasound is used to deliver medication into superficial tissues), and iontophoresis (electric current is applied to deliver medication into superficial tissues). The efficacy of modalities has not been proven with randomized controlled trials. However, the adverse effects (e.g., skin irritation and redness) are minimal so these are often used during therapy sessions.

Consider – ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
knee with quadriceps, iliotibial band, or popliteus tendinopathy
Consider – 

ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Treatment recommended for SOME patients in selected patient group

Ice may be applied to the affected area for acute pain relief.

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 physical therapy. 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.[49][50]

Primary options

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) two to three times daily when required, maximum 150 mg/day

OR

celecoxib: 200 mg orally once daily when required

Consider – nitroglycerin patch

Back
ACUTE
|
knee with quadriceps, iliotibial band, or popliteus tendinopathy
Consider – 

nitroglycerin patch

Treatment recommended for SOME patients in selected patient group

Topical transdermal nitroglycerin is thought to decrease pain, specifically chronic pain, by improving tendon healing.[70][110]

One systematic review concluded that topical transdermal nitroglycerin 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.[71]

Primary options

nitroglycerin transdermal: consult specialist for guidance on dose

Consider – surgery

Back
ACUTE
|
knee with quadriceps, iliotibial band, or popliteus tendinopathy
|
no improvement after 3 to 6 months of conservative therapy
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Conservative treatment of quadriceps tendinopathy is almost universally successful. Given the effectiveness of physical therapy when compared with surgical treatment, evidence suggests that patients should pursue conservative treatment for at least 6 to 12 months.[98]

Usually, the degenerated tendon tissue is excised and the proximal pole of the patella is debrided to stimulate healing.[113]

ankle with Achilles tendinopathy

1st line – activity modification with physical therapy

Back
ACUTE
|
ankle with Achilles tendinopathy
1st line – 

activity modification with physical therapy

If presenting acutely, should begin with immobilization for the first 7 to 10 days using a cast or boot.[47][48]

The most effective component of physical therapy is believed to be eccentric strength training during which the muscle fiber lengthens as the muscle contracts, thus more load is placed on the tendon.[5][56][57][116][Figure caption and citation for the preceding image starts]: Eccentric calf exercise. To start: rise up on bilateral toes over the edge of a stepFrom the personal collection of James Wang, PhD [Citation ends].com.bmj.content.model.Caption@228568d6[Figure caption and citation for the preceding image starts]: Then cross the unaffected ankle behind the affected ankle. Finally, lower the heel down over the stepFrom the personal collection of James Wang, PhD [Citation ends].com.bmj.content.model.Caption@dc4cc07

One randomized controlled trial (RCT), however, demonstrated that heavy slow resistance training for Achilles tendinopathy may be associated with greater early patient satisfaction compared with eccentric training.[117]

Modalities are administered by the physical therapist: ultrasound, phonophoresis (ultrasound is used to deliver medication into superficial tissues), and iontophoresis (electric current is applied to deliver medication into superficial tissues). The efficacy of modalities has not been proven with RCTs. However, the adverse effects (e.g., skin irritation and redness) are minimal so these are often used during therapy sessions.

Consider – ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
ankle with Achilles tendinopathy
Consider – 

ice + nonsteroidal anti-inflammatory drugs (NSAIDs)

Treatment recommended for SOME patients in selected patient group

Ice may be applied to the affected area for acute pain relief.

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 physical therapy. 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.[49][50]

Primary options

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) two to three times daily when required, maximum 150 mg/day

OR

celecoxib: 200 mg orally once daily when required

Consider – low-level laser therapy (LLLT)

Back
ACUTE
|
ankle with Achilles tendinopathy
Consider – 

low-level laser therapy (LLLT)

Treatment recommended for SOME patients in selected patient group

In Achilles tendinopathy, one systematic review showed that LLLT administration in the painful area results in a decrease in short-term pain and disability, with no serious adverse effects.[96] 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.[97]

Plus – one quarter- to three eighths-inch heel lifts

Back
ACUTE
|
ankle with Achilles tendinopathy
Plus – 

one quarter- to three eighths-inch heel lifts

Treatment recommended for ALL patients in selected patient group

Heel lifts help with pain by decreasing the amount of stretch on the Achilles tendon.

Plus – night splints

Back
ACUTE
|
ankle with Achilles tendinopathy
|
diminished dorsiflexion
Plus – 

night splints

Treatment recommended for ALL patients in selected patient group

In cases where dorsiflexion is diminished (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.[46]

Plus – nitroglycerin patch

Back
ACUTE
|
ankle with Achilles tendinopathy
|
no improvement despite other therapies
Plus – 

nitroglycerin patch

Treatment recommended for ALL patients in selected patient group

Thought to decrease pain, specifically chronic pain, by improving tendon healing.[70][118]

One systematic review concluded that topical transdermal nitroglycerin 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.[71]

Primary options

nitroglycerin transdermal: consult specialist for guidance on dose

Consider – extracorporeal shockwave therapy

Back
ACUTE
|
ankle with Achilles tendinopathy
|
no improvement despite other therapies
Consider – 

extracorporeal shockwave therapy

Treatment recommended for SOME patients in selected patient group

A noninvasive treatment in which a device is used to pass acoustic shockwaves to the painful area. Extracorporeal shockwave therapy (ESWT) significantly reduces pain attributable to tendinopathy, although the mechanism by which it works has not yet been elucidated.[73][74][75][76] One systematic review found that low-energy ESWT may be effective for the treatment of chronic Achilles tendinopathy if other conservative treatments fail.[77]

Consider – surgery

Back
ACUTE
|
ankle with Achilles tendinopathy
|
no improvement after several months of conservative therapy
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Approximately 25% of patients with Achilles tendinopathy require surgical treatment.

Patients should be considered for surgery after several months of appropriate conservative management.[8][119]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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