What medications are useful in treating tendinopathy, such as tennis elbow?

Medications for Tendinopathy (Tennis Elbow)

NSAIDs (oral or topical) are the first-line medication for pain relief in tennis elbow, with topical formulations preferred to avoid gastrointestinal complications, while corticosteroid injections provide superior short-term pain relief but should be used cautiously due to potential tendon weakening and no long-term benefit. 1

First-Line Pharmacologic Treatment

NSAIDs (Preferred Initial Medication)

• Oral NSAIDs effectively relieve tendinopathy pain and may offer additional benefit in acute inflammatory tendonitis through their anti-inflammatory properties 1
• Topical NSAIDs are preferable as they reduce tendon pain while eliminating the increased risk of gastrointestinal hemorrhage associated with systemic NSAIDs 1, 2
• NSAIDs should be used at the lowest effective dose for the shortest duration necessary 3
• The FDA warns that NSAIDs can cause ulcers and bleeding in the stomach and intestines at any time during treatment, with risk increasing with longer use, older age, smoking, and alcohol consumption 3

Important caveat: Recent research suggests tendinopathy involves little or no inflammation, which may limit the effectiveness of anti-inflammatory medications beyond simple analgesia 4

Second-Line: Corticosteroid Injections

Use With Significant Caution

• Injected corticosteroids may be more effective than oral NSAIDs for relief in the acute phase of tendon pain, but they do not alter long-term outcomes 1
• Combination treatment with corticosteroid injection plus NSAIDs shows significantly higher short-term efficacy (90.9% vs 40% complete/near-complete relief at one month) compared to NSAIDs alone 5

Critical Safety Concerns

• No evidence-based guidelines support the use of local corticosteroid injections in tendinopathy, and there may be deleterious effects on the tendon when injected into the tendon substance 1
• Corticosteroids may inhibit healing and reduce the tensile strength of the tissue, predisposing to spontaneous rupture 1
• The effects of peritendinous corticosteroid injections are unknown and should be used with caution 1
• The optimal drugs, dosages, techniques, intervals, and post-injection care remain unknown 1

Clinical recommendation: Reserve corticosteroid injections for patients with severe acute pain who have failed NSAIDs, understanding this provides only short-term relief without improving long-term outcomes 1, 2

Emerging Pharmacologic Adjuncts

Iontophoresis/Phonophoresis

• These modalities use electric and ultrasonographic impulses to deliver topical NSAIDs and corticosteroids to symptomatic subcutaneous tissues 1
• Widely used and anecdotally effective, but well-designed RCTs are lacking to permit reliable recommendations 1
• Corticosteroid iontophoresis is effective for treatment of patellar tendinosis pain and function 1

Nitric Oxide Patches

• Current data support the use of nitric oxide patches, but larger multicenter trials are needed to confirm early results 4

Novel Biologics (Not Standard Practice)

• Preliminary work with growth factors (platelet-rich plasma) and stem cells is promising, but further study is required 4
• One study showed injectable recombinant human collagen scaffold combined with autologous platelet-rich plasma (STR/PRP) resulted in 59% reduction in pain scores at 6 months with no severe adverse events 6

Treatment Algorithm

1. Initial 3-6 months: Topical or oral NSAIDs combined with relative rest, ice therapy, and eccentric strengthening exercises 2
2. If inadequate response: Consider single corticosteroid injection for severe acute pain, understanding limited long-term benefit and potential tendon damage 1, 2, 5
3. Adjunctive options: Tennis elbow bands, though limited data supports effectiveness 1, 2
4. Refractory cases after 3-6 months: Surgical evaluation, as approximately 80% of cases resolve with conservative treatment 2, 7

Common Pitfalls to Avoid

• Avoid repeated corticosteroid injections due to cumulative tendon weakening effects 1
• Do not rely solely on medications—the pathoanatomy is "angiofibroblastic tendinosis" (non-inflammatory), so rehabilitative resistance exercise is essential for tissue revitalization 8
• Avoid complete immobilization, which prevents muscle atrophy and deconditioning 1, 2
• Do not use NSAIDs in late pregnancy or without considering contraindications like prior asthma attacks with aspirin, planned heart bypass surgery, or high bleeding risk 3