What is the treatment for tendonitis?

Treatment of Tendonitis

The most effective first-line treatment for tendonitis includes relative rest, NSAIDs, and eccentric strengthening exercises, which should be implemented for 3-6 months before considering more invasive interventions. 1

First-Line Management

Non-Pharmacological Interventions

• Relative rest: Reduce activities that cause repetitive loading of the damaged tendon while avoiding complete immobilization 1

  • Continue activities that don't worsen pain
  • Avoid activities that aggravate symptoms

• Physical therapy: Should be initiated early alongside medication 1

  • Eccentric strengthening exercises (proven highly beneficial for Achilles and patellar tendinopathy)
  • Gentle, progressive stretching exercises
  • Tensile loading to stimulate collagen production and guide normal alignment

• Cryotherapy: Apply ice through a wet towel for 10-minute periods for short-term pain relief and reducing swelling in acute inflammatory tendinopathies 1

Pharmacological Interventions

• NSAIDs: First-line drug treatment for pain relief 1, 2

  • Oral naproxen: Starting dose of 500 mg, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as required 2
  • Initial total daily dose should not exceed 1250 mg, thereafter not exceeding 1000 mg daily 2
  • Topical NSAIDs may reduce gastrointestinal side effects while maintaining efficacy 1
  • Use the lowest effective dose for the shortest duration consistent with treatment goals 2

• Acetaminophen: Alternative first-line analgesic if NSAIDs are inadequate or contraindicated 1

  • Up to 4g/day as needed for pain and stiffness

Supportive Measures

• Orthotics and braces: Can reinforce, unload, and protect tendons 1

  • Tennis elbow bands for lateral epicondylitis
  • Shoe orthotics for correcting biomechanical problems like excessive foot pronation
  • Elbow sleeves/braces to unload and protect affected areas

• Technique modification: Essential for athletes and manual laborers to minimize repetitive tendon stress 1

Second-Line Interventions

• Corticosteroid injections: May be more effective than oral NSAIDs for acute pain relief 1

  • Should be limited to 2-3 injections with 4-6 weeks between injections
  • Use with caution as they may inhibit healing and reduce tendon strength
  • Approximately 90% of De Quervain's tenosynovitis cases can be effectively managed with corticosteroid injections 3

• Other modalities:

  • Therapeutic ultrasound: May decrease pain and increase collagen synthesis (weak evidence) 1
  • Extracorporeal shock wave therapy (ESWT): Appears safe and effective but requires further research 1
  • High-volume injections: Can reduce pain and improve function in Achilles or patellar tendinopathy 4

Prognosis and Referral

• Most patients (approximately 80%) fully recover within 3-6 months with appropriate conservative treatment 1
• Over 90% of cases have good outcomes with appropriate conservative management 1
• 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

Special Considerations

• Elderly patients: May require dosage adjustment for NSAIDs due to increased unbound plasma fraction of the drug 2

  • Use the lowest effective dose in elderly patients

• Patients with renal impairment: Naproxen-containing products are not recommended for patients with moderate to severe renal impairment (creatinine clearance < 30 mL/min) 2

• Athletes: May need more comprehensive rehabilitation before returning to full activity 1

• Diabetic patients: May respond less favorably to conservative measures and may require a modified approach 1

Common Pitfalls and Caveats

• Despite the common term "tendonitis," pathoanatomic studies have not clearly demonstrated actual inflammation of tendon tissue 5
• Many treatments lack strong evidence from controlled studies, particularly physical therapy interventions aimed at flexibility and strengthening 5
• Conservative management should be given adequate time (3-6 months) before considering more invasive options 1
• De Quervain's tenosynovitis specifically responds well to conservative management with a multimodal approach, with surgical intervention usually unnecessary 6
• Eccentric training has shown promising results for De Quervain's tendinopathy when added to standard conservative treatment 7