Treatment of Tendonitis
The most effective treatment for tendonitis includes relative rest while maintaining activities that don't worsen pain, eccentric strengthening exercises, cryotherapy, and short-term use of NSAIDs for pain relief, with surgery reserved only for cases that fail 3-6 months of conservative therapy. 1, 2
Initial Management Approach
- Relative rest is essential to prevent ongoing damage and promote healing, but complete immobilization should be avoided to prevent muscle atrophy and deconditioning 1
- Continue activities that do not exacerbate symptoms to maintain function while reducing activities that worsen pain 2
- Apply ice through a wet towel for 10-minute periods to provide optimal short-term pain relief by reducing tissue metabolism and blunting inflammatory response 1, 2
- Eccentric strengthening exercises have proven beneficial in Achilles and patellar tendinopathies and may reverse degenerative changes 1, 2
- Stretching exercises are generally helpful and widely accepted as part of the treatment regimen 1
Pharmacological Management
- NSAIDs effectively relieve tendinopathy pain and may offer additional benefit in acute inflammatory tendonitis due to their anti-inflammatory properties 1
- Topical NSAIDs can reduce tendon pain with fewer systemic side effects compared to oral NSAIDs 1, 2
- Naproxen is FDA-approved for relief of the signs and symptoms of tendonitis, with a recommended starting dose of 500 mg, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as required 3
- The initial total daily dose of naproxen should not exceed 1250 mg, with subsequent daily doses not exceeding 1000 mg 3
- Use the lowest effective dose for the shortest duration consistent with treatment goals 3
Corticosteroid Injections
- Locally injected corticosteroids may provide better acute pain relief than oral NSAIDs but do not alter long-term outcomes 1, 2
- Use corticosteroid injections with caution as they may inhibit healing and reduce tendon strength, potentially predisposing to spontaneous rupture 1, 2
- The optimal drugs, dosages, techniques, intervals, and post-injection care remain unknown 1
Supportive Devices and Additional Modalities
- Orthotics and braces can reinforce, unload, and protect tendons during activity 1
- These supportive devices are particularly helpful in correcting biomechanical problems such as excessive foot pronation or pes planus deformity 1
- Therapeutic ultrasonography may decrease pain and increase collagen synthesis rate, but evidence for consistent benefit is weak 1
- Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research to clarify mechanisms of action and optimal treatment strategies 1
- Iontophoresis and phonophoresis use electric and ultrasonographic impulses to deliver topical medications but lack well-designed randomized controlled trials to permit reliable recommendations 1
Advanced Treatment Options
- Approximately 80% of patients with overuse tendinopathies fully recover within three to six months with appropriate conservative treatment 2
- Surgery should be reserved for patients who have failed 3-6 months of conservative therapy 1, 2
- Recent research suggests that traditional treatments aimed at controlling inflammation may not be the most effective options since little or no inflammation is present in many tendinopathies 4
- Newer treatments such as sclerotherapy, nitric oxide patches, growth factors, and stem cells show promise but require further study 4
Common Pitfalls and Caveats
- Avoid misdiagnosing tendinopathy as purely inflammatory when many cases involve degenerative changes 2, 4
- Do not rely solely on anti-inflammatory treatments for chronic tendinopathies 2, 4
- Avoid complete immobilization as it leads to muscle atrophy and deconditioning 1
- Be cautious with corticosteroid injections directly into the tendon substance due to potential deleterious effects 1
- Remember that NSAIDs and corticosteroids may provide short-term pain relief but their long-term effectiveness has not been demonstrated 4