What is the recommended treatment for tendinitis using steroids, such as prednisone (corticosteroid)?

Steroid Treatment for Tendinitis

For tendinitis, corticosteroids should be used with caution as they provide short-term pain relief but may lead to long-term deterioration of tendon tissue and increased risk of recurrence.

Corticosteroid Treatment Options

Local Corticosteroid Injections

• For localized tendinitis affecting 1-2 joints:
  • Intra-articular or peritendinous corticosteroid injections can be considered 1
  • Dosing should be based on the size of the involved joint(s) 1
  • Limited to 2-3 injections with 4-6 weeks between injections 2
  • Provides effective short-term pain relief but has poorer long-term outcomes compared to other treatments 3

Oral Corticosteroids

• For more widespread tendinitis:
  • Prednisone or prednisolone at 0.5-1 mg/kg per day (typically 60-80 mg/day) 1
  • Taper after 2-4 weeks depending on response:
    • Reduce by 10 mg every 2 weeks until reaching 30 mg/day
    • Then reduce by 5 mg every 2 weeks until reaching 20 mg/day
    • Then reduce by 2.5 mg every 2 weeks until completed
    • At 10 mg/day, may slow to 1 mg every 2-4 weeks 1

First-Line Treatment Recommendations

1. NSAIDs are strongly recommended as first-line treatment 2:

   • Ibuprofen 1.2g daily (safest option)
   • Can increase to 2.4g daily if inadequate relief
   • Can combine with acetaminophen (up to 4g daily) for additional pain relief

2. RICE Protocol for acute tendinitis 2:

   • Rest
   • Ice
   • Compression
   • Elevation

3. Physical Therapy 2:

   • Eccentric strengthening exercises
   • Proprioception training
   • Functional rehabilitation
   • Progress through phases:
     • Initial (0-4 weeks): Pain control and protected range of motion
     • Intermediate (4-8 weeks): Progressive strengthening
     • Advanced (8-12 weeks): Sport/occupation-specific training

Important Cautions with Corticosteroid Use

• Corticosteroid injections can cause:

  • Tendon atrophy 3
  • Collagen necrosis 4
  • Collagen disorganization 4
  • Inflammatory cell infiltration 4
  • Negative effects on mechanical properties of tendons 4

• Research shows corticosteroids:

  • Reduce tendon cell proliferation in vitro 4
  • Reduce extracellular matrix synthesis, particularly type I collagen 4
  • May provide short-term benefit but worse intermediate and long-term outcomes compared to other treatments 5, 3

Treatment Algorithm

1. Initial Presentation:

   • Begin with NSAIDs and RICE protocol
   • Initiate physical therapy with focus on eccentric strengthening

2. If inadequate response after 2-4 weeks:

   • Consider corticosteroid injection for localized tendinitis
   • OR short course of oral corticosteroids for more widespread involvement
   • Continue physical therapy

3. After corticosteroid treatment:

   • Resume progressive physical therapy
   • Monitor for signs of tendon weakening or atrophy

4. If symptoms persist beyond 3-6 months:

   • Consider surgical consultation 2

Return to Activity Criteria

Return to full activity when patient demonstrates 2:

• Complete resolution of pain during and after activity
• Full range of motion compared to uninjured side
• Strength symmetry >90% compared to uninjured side
• Successful completion of sport-specific functional tests

Key Considerations

• The traditional view of tendinitis as primarily inflammatory has been challenged by recent research showing little or no inflammation in many cases 5
• Long-term studies on corticosteroid treatment for tendinitis are limited 6
• The ideal treatment remains unclear, but evidence supports eccentric strengthening protocols over corticosteroids for long-term outcomes 5
• Systemic glucocorticoids are strongly recommended against in ankylosing spondylitis, which may have implications for other inflammatory conditions 1