What is the recommended treatment for tendonosis?

Recommended Treatment for Tendonosis

The recommended first-line treatment for tendonosis includes relative rest, cryotherapy, eccentric strengthening exercises, and short-term pain management with analgesics for 3-6 months before considering more invasive interventions. 1, 2, 3

Understanding Tendonosis

• Tendonosis is a degenerative condition, not an inflammatory one, and is often incorrectly labeled as "tendonitis" 1
• Most commonly affects the rotator cuff, medial and lateral elbow epicondyles, patellar tendon, and Achilles tendon 1, 2
• Presents as gradually increasing load-related localized pain that worsens with activity 2
• Approximately 80% of patients fully recover within 3-6 months with appropriate conservative treatment 1, 2, 3

First-Line Treatment Approach

• Relative rest: Reduce activities that worsen pain while continuing activities that don't exacerbate symptoms 2

  • Complete immobilization should be avoided as it leads to muscle atrophy and deconditioning 2, 3

• Cryotherapy: Apply ice through a wet towel for 10-minute periods for optimal short-term pain relief 2, 3

  • Ice application after exercise has been studied but shows similar outcomes to exercise alone 4

• Eccentric strengthening exercises: Essential component that may reverse degenerative changes in the tendon 1, 2, 3

  • Progressive loading protocols have shown very promising results, particularly for Achilles tendonosis 5

• Pain management:

  • Topical analgesics are recommended as first-line for pain control due to fewer systemic side effects 2, 3
  • NSAIDs (oral or topical) provide short-term pain relief but do not affect long-term outcomes 2, 3, 6, 7

Second-Line Treatments

• Corticosteroid injections: May provide better acute pain relief than oral NSAIDs but do not improve long-term outcomes 2, 3, 6

  • Should be used cautiously as they may inhibit healing and reduce tendon strength 2
  • Direct injection into the tendon substance should be avoided 3

• Supportive devices: Orthotics and braces can reinforce, unload, and protect tendons during activity 2

  • Selection should be based on the specific tendon affected and patient comfort 2

• Alternative therapies with limited evidence:

  • Ultrasonography may decrease pain and increase collagen synthesis 3, 7
  • Extracorporeal shock wave therapy (ESWT) appears safe but shows inconsistent results 3, 7
  • Sclerotherapy and nitric oxide patches show promising early results but need larger trials 7

Surgical Management

• Surgery should be reserved for patients who have failed 3-6 months of well-managed conservative therapy 1, 2, 3
• Surgical techniques generally involve excision of abnormal tendinous tissue 3
• Short-term results after surgery are frequently very good, but long-term follow-up studies show possible deterioration over time 5
• Higher complication rates compared to conservative treatment options 6

Common Pitfalls to Avoid

• Misdiagnosing tendonosis as an inflammatory condition and relying solely on anti-inflammatory treatments 1, 2
• Complete immobilization for prolonged periods 2, 3
• Overreliance on corticosteroid injections, which may provide short-term relief but can compromise tendon integrity 2, 6, 7
• Premature progression to surgical intervention before adequate trial of conservative measures 1, 3, 6