Management of Extensor Tendinitis
Begin with 3-6 months of conservative therapy consisting of relative rest, ice therapy, eccentric strengthening exercises, and NSAIDs, as approximately 80% of patients will fully recover with this approach. 1
Understanding the Condition
Most extensor tendinopathies are degenerative rather than inflammatory conditions and should be labeled as "tendinosus" or "tendinopathy" rather than "tendonitis." 1 The pathology involves fibroblasts, vascular hyperplasia, and disorganized collagen rather than true inflammation. 2
First-Line Conservative Management (0-6 months)
Relative Rest
- Allow continuation of activities that do not worsen pain while avoiding those that exacerbate symptoms. 1, 3
- Complete immobilization must be avoided as it causes muscular atrophy and deconditioning. 1
- Tensile loading of the tendon stimulates collagen production and guides normal alignment of newly formed collagen fibers. 1
Cryotherapy
- Apply ice through a wet towel for 10-minute periods for optimal effectiveness. 1, 3
- This reduces tissue metabolism, slows release of blood and proteins from surrounding vasculature, and provides short-term pain relief. 1
- Most effective for reducing swelling and pain in acute inflammatory presentations. 1
Eccentric Strengthening Exercises
- This is a critical component as eccentric exercise stimulates collagen production and guides normal alignment of newly formed collagen fibers. 1, 3
- Evidence is strongest for Achilles and patellar tendinosis, but may be beneficial for other tendinopathies including extensor tendons. 1
- Stretching exercises are widely accepted and thought to be helpful. 1
Analgesics
- Topical NSAIDs are preferred as they effectively relieve tendon pain while eliminating the increased risk of gastrointestinal hemorrhage associated with systemic NSAIDs. 1, 3
- Systemic NSAIDs are effective for pain relief but offer no long-term outcome benefit. 1
- NSAIDs may offer additional benefit in acute inflammatory presentations due to anti-inflammatory properties. 1
Second-Line Interventions
Orthotics and Braces
- Tennis elbow bands or similar braces reinforce, unload, and protect tendons during activity. 1, 3
- These are safe, widely used, and often helpful despite limited data supporting definitive conclusions regarding effectiveness. 1
- Useful for correcting biomechanical problems. 1
Corticosteroid Injections
- Use with significant caution as they may inhibit healing and reduce tensile strength of tissue, predisposing to spontaneous rupture. 1, 3
- May be more effective than oral NSAIDs for acute phase pain relief but do not alter long-term outcomes. 1, 3
- Never inject directly into the tendon substance due to deleterious effects; peritendinous injections only if used. 1
- Optimal drugs, dosages, techniques, intervals, and post-injection care remain unknown. 1
Additional Modalities
- Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research to clarify optimal treatment strategies. 1
- Therapeutic ultrasonography may decrease pain and increase collagen synthesis rate, but evidence for consistent benefit is weak. 1
- Iontophoresis and phonophoresis are widely used and anecdotally effective but lack well-designed RCTs. 1
- Technique modification for athletes and manual laborers minimizes repetitive stresses on tendons. 1
Surgical Management
Reserve surgery for patients who have failed 3-6 months of well-managed conservative treatment. 1, 3 Surgery is effective but should only be considered after exhausting conservative options. 1
Common Pitfalls to Avoid
- Avoid complete immobilization which leads to muscular atrophy and deconditioning. 1
- Do not inject corticosteroids directly into tendon substance. 1
- Do not mislabel degenerative conditions as inflammatory "tendonitis" as this may lead to inappropriate treatment focus. 1
- Recognize that most patients (80%) recover within 3-6 months with appropriate conservative treatment, so patience with conservative management is warranted. 1, 3