What are the differences in treatment approaches for tendinosis vs tendinitis?

Treatment Approaches for Tendinosis vs. Tendinitis

The most effective treatment approach for both tendinosis and tendinitis involves relative rest, NSAIDs, and eccentric strengthening exercises as first-line management, with the understanding that tendinosis (degenerative condition) requires longer rehabilitation focused on tissue remodeling while tendinitis (inflammatory condition) may respond better to anti-inflammatory interventions initially. 1

Understanding the Difference

• Tendinitis: Acute inflammatory condition of the tendon
• Tendinosis: Chronic degenerative condition with little to no inflammation

This distinction is crucial because traditional treatments aimed at controlling inflammation (like corticosteroids) may be less effective for tendinosis, which involves degenerative changes rather than active inflammation 2.

First-Line Treatment Approach

For Both Conditions:

1. Relative Rest

   • Reduce activities causing repetitive loading
   • Avoid complete immobilization
   • Continue activities that don't worsen pain 1

2. Pain Management

   • NSAIDs (oral or topical) for pain relief
   • Topical NSAIDs reduce GI side effects while maintaining efficacy
   • Acetaminophen (up to 4g/day) if NSAIDs are inadequate 1

3. Physical Therapy

   • Early initiation alongside medication
   • Focus on gentle, progressive stretching exercises 1

Specific Differences:

For Tendinitis (Inflammatory):

• Cryotherapy: Ice application through wet towel for 10-minute periods to reduce acute inflammation 1
• NSAIDs: May be more effective due to the inflammatory component 2
• Corticosteroid injections: May provide short-term relief but should be limited to 2-3 injections with 4-6 weeks between injections 1

For Tendinosis (Degenerative):

• Eccentric strengthening exercises: Particularly beneficial for tissue remodeling 1, 3
• Longer rehabilitation period: Typically requires 3-6 months for recovery 1
• Tensile loading: To stimulate collagen production and guide normal alignment of newly formed collagen fibers 1

Second-Line Interventions

When first-line treatments fail after 6-8 weeks:

For Both Conditions:

• Diagnostic imaging: MRI without contrast to evaluate for tendon tears or other soft tissue injuries 1
• Extracorporeal shock wave therapy (ESWT): Safe but requires further research 1, 3

For Tendinosis:

• Sclerotherapy: Promising for chronic cases 2, 3
• Nitric oxide patches: Early results are encouraging 2
• Platelet-rich plasma (PRP): Preliminary work is promising but requires further study 2, 3, 4
• High-volume injections: May be beneficial in chronic cases 3, 4

Treatment Duration and Expectations

• Most patients (approximately 80%) fully recover within 3-6 months with appropriate conservative treatment 1
• Even with optimum management, resolution typically requires 3-6 months 1
• Athletes may need more comprehensive rehabilitation before returning to full activity 1

When to Consider Referral

Consider orthopedic referral if:

• Pain persists despite 3-6 months of well-managed conservative treatment
• Significant functional limitations impact quality of life
• Suspicion of more serious pathology 1

Common Pitfalls and Caveats

1. Misdiagnosis: Treating tendinosis as tendinitis can lead to inappropriate use of anti-inflammatory treatments that may not address the underlying degenerative process 2

2. Overuse of corticosteroids: While providing short-term relief, they may inhibit healing and reduce tendon strength long-term 1, 2

3. Inadequate rehabilitation time: Expecting quick recovery, particularly with tendinosis, often leads to treatment failure 1

4. Special populations: Diabetic patients may respond less favorably to conservative measures and may require a modified approach 1

5. Premature return to activity: Can lead to recurrence or worsening of the condition 1