What are the symptoms and treatment options for tendinitis?

Symptoms and Treatment of Tendinitis

The primary symptoms of tendinitis include insidious onset of load-related localized pain that coincides with increased activity, with patients typically describing their pain as "sharp" or "stabbing." 1, 2

Clinical Presentation

• Pain initially presents during activity but may subside after a warm-up period in early stages; as tendinitis progresses, pain increases in intensity and duration and may be present even at rest 1, 2
• Most patients report engaging in a new activity or increasing the intensity of a current activity before symptom onset 1, 2
• Physical examination reveals well-localized tenderness that reproduces the patient's activity-related pain 1
• Inspection may show muscle atrophy (suggesting chronicity), asymmetry, swelling, and erythema 1, 2
• Range of motion is often limited on the symptomatic side 1, 2
• Joint effusions are uncommon with tendinopathy and suggest possible intra-articular pathology instead 1, 3
• The presence of multiple symptomatic tendons should prompt evaluation for rheumatic disease 1, 2

Diagnosis

• Diagnosis is primarily clinical, based on history and physical examination findings 1, 2
• Plain radiography has limited ability to demonstrate soft-tissue changes but may reveal bony abnormalities 1, 2
• Further imaging (ultrasonography, MRI) should be reserved for unclear diagnoses, recalcitrant pain despite adequate conservative management, or preoperative evaluation 1, 2
• Ultrasonography can show tendon thickening, decreased echogenicity, and calcification 1
• MRI can demonstrate tendon tears, degeneration, chronic tendinopathy, and partial tears 1

Treatment Options

First-Line Treatments

• Relative rest is recommended to decrease repetitive loading of the damaged tendon while allowing activities that don't worsen pain 1, 2
• Complete immobilization should be avoided to prevent muscular atrophy and deconditioning 1, 3
• Cryotherapy (ice) is effective for short-term pain relief, applied through a wet towel for 10-minute periods 1, 2
• NSAIDs effectively relieve tendinopathy pain in the short term but do not alter long-term outcomes 1, 2
• Topical NSAIDs can provide similar pain relief with fewer systemic side effects 1, 3
• Eccentric strengthening exercises are beneficial in tendinosis and may help reverse degenerative changes 1, 2
• Stretching exercises are generally helpful for maintaining range of motion 1

Second-Line Treatments

• Corticosteroid injections may provide better acute pain relief than oral NSAIDs but do not alter long-term outcomes and should be used with caution 1, 2
• Orthotics and braces can reinforce, unload, and protect tendons during activity 1
• Extracorporeal shock wave therapy (ESWT) is a safe, noninvasive option for chronic tendinopathies, though expensive 1, 3
• Therapeutic ultrasonography may decrease pain and increase collagen synthesis, but evidence for consistent benefit is weak 1

Third-Line Treatment

• Surgical intervention should be considered if conservative treatment fails after 3-6 months 1, 2

Common Pitfalls and Caveats

• Many conditions labeled as "tendinitis" may actually be tendinosis (degenerative changes without significant inflammation), especially in chronic cases 4
• Corticosteroid injections directly into the tendon substance should be avoided as they may inhibit healing and reduce tensile strength, potentially predisposing to spontaneous rupture 1
• The presence of joint effusions suggests intra-articular pathology rather than tendinopathy 1, 3
• Tendinopathies are often accompanied by other pathologies (e.g., rotator cuff tears, labral tears) that may require specific treatment 5
• Complete immobilization can lead to muscular atrophy and deconditioning, worsening outcomes 1, 3