What is the difference in treatment approach for tendinosis vs tendinitis?

Treatment Approach for Tendinosis vs Tendinitis

The primary difference in treatment approach between tendinosis and tendinitis is that tendinitis should be treated with anti-inflammatory interventions initially, while tendinosis requires tissue remodeling through eccentric strengthening exercises as the cornerstone of treatment. 1, 2

Understanding the Difference

• Tendinitis: Acute inflammatory condition of the tendon

  • Characterized by inflammation
  • Often responds to anti-inflammatory treatments
  • Short-term condition (days to weeks)

• Tendinosis: Chronic degenerative condition of the tendon

  • Characterized by tissue degeneration with little or no inflammation
  • Requires tissue remodeling approaches
  • Long-term condition (months)

Treatment Approach for Tendinitis

1. Initial Management:

   • NSAIDs as first-line medication for pain and inflammation
   • Relative rest and activity modification
   • Ice application to reduce acute inflammation

2. Medication Options:

   • Oral NSAIDs (ibuprofen, naproxen)
   • Topical NSAIDs for localized pain
   • Acetaminophen (up to 4g/day) if NSAIDs are contraindicated 1

3. Physical Interventions:

   • Gentle stretching
   • Protection from aggravating activities
   • Corticosteroid injections may provide short-term relief but should be used cautiously 1

Treatment Approach for Tendinosis

1. Primary Intervention:

   • Eccentric strengthening exercises are the cornerstone of treatment 2, 3, 4
   • Progressive loading protocol over 8-12 weeks
   • Performed multiple times daily

2. Medication Considerations:

   • NSAIDs and corticosteroids may provide short-term pain relief but do not address the underlying degeneration
   • May potentially inhibit healing and reduce tensile strength 1, 2
   • Nitric oxide patches show promising results 1

3. Adjunctive Therapies:

   • Sclerotherapy may be beneficial 1
   • Ultrasound therapy to potentially increase collagen synthesis
   • Shock wave therapy (inconsistent results) 1

Treatment Duration and Progression

• Tendinitis: Usually resolves within 2-4 weeks with proper management
• Tendinosis: Requires 8-12 weeks (minimum) of consistent therapy 3, 4
• Treatment should be reassessed every 4-6 weeks with adjustments as needed

Common Pitfalls and Caveats

1. Misdiagnosis: Treating tendinosis as tendinitis can lead to prolonged symptoms and delayed recovery

   • Chronic tendon pain (>6 weeks) is more likely tendinosis than tendinitis

2. Overreliance on Anti-inflammatories:

   • NSAIDs and corticosteroids may provide temporary relief but can potentially impair long-term healing in tendinosis 1, 2

3. Inadequate Loading Protocol:

   • Insufficient intensity or duration of eccentric exercises
   • Premature return to full activity before adequate tissue remodeling

4. Surgical Considerations:

   • Surgery should be considered only after 3-6 months of failed conservative management
   • Outcomes are inconsistent and recovery involves significant morbidity 1, 5

Emerging Treatments

• Growth factors and stem cell treatments show promise but require further research 1
• These approaches aim to promote tissue regeneration rather than simply managing symptoms

Algorithmic Approach to Treatment

1. Determine duration of symptoms:

   • <6 weeks: Likely tendinitis → Anti-inflammatory approach

   • 6 weeks: Likely tendinosis → Tissue remodeling approach

2. For tendinitis:

   • NSAIDs + relative rest + ice → reassess in 2 weeks
   • If improving: gradually return to activity
   • If not improving: consider corticosteroid injection and reassess diagnosis

3. For tendinosis:

   • Implement eccentric exercise protocol for 8-12 weeks
   • Adjunctive therapies as needed for pain control
   • Gradual return to activity as symptoms improve
   • Consider advanced interventions if no improvement after 12 weeks