What is the treatment for tendinitis?

Treatment of Tendinitis

The cornerstone of tendinitis treatment is a 3-6 month trial of conservative therapy consisting of relative rest, eccentric strengthening exercises, cryotherapy, and NSAIDs for pain relief, as approximately 80% of patients will fully recover with this approach. 1, 2

Critical Terminology Clarification

Most cases labeled as "tendinitis" are actually degenerative conditions that should be termed "tendinosis" or "tendinopathy" rather than inflammatory "tendinitis," which fundamentally changes the treatment approach. 1, 2 True inflammatory tendinitis is rare in primary care; most patients have chronic degenerative changes with minimal inflammation. 1

First-Line Conservative Management (Weeks 0-6)

Relative Rest

• Continue activities that do not worsen pain while avoiding those that exacerbate symptoms. 1, 2
• Never completely immobilize the tendon, as this causes muscular atrophy and deconditioning. 1, 3, 2
• Tensile loading stimulates collagen production and guides proper alignment of newly formed collagen fibers. 1, 2

Cryotherapy

• Apply ice through a wet towel for 10-minute periods repeatedly. 1, 3, 2
• This reduces tissue metabolism, slows release of blood and proteins from surrounding vasculature, and provides effective short-term pain relief. 1, 2

Eccentric Strengthening Exercises

• This is the most critical rehabilitation component with proven efficacy in reversing degenerative changes. 1, 3, 2
• Evidence is strongest for Achilles and patellar tendinosis, but benefits extend to other tendinopathies. 1, 2
• Eccentric exercises stimulate collagen production and guide normal fiber alignment. 1, 2

NSAIDs for Pain Relief

• Topical NSAIDs are preferred as first-line because they provide equivalent pain relief while eliminating gastrointestinal hemorrhage risk. 1, 3, 2
• Oral NSAIDs (such as naproxen 500 mg twice daily) are FDA-approved for tendinitis and effective for short-term pain relief. 4
• Critical caveat: NSAIDs do not affect long-term outcomes or healing—they only provide symptomatic relief. 1, 3, 2
• For acute tendinitis, naproxen sodium 500 mg initially, then 500 mg every 12 hours or 250 mg every 6-8 hours (not exceeding 1250 mg day 1, then 1000 mg daily thereafter). 4

Technique Modification

• For athletes and manual laborers, modify techniques to minimize repetitive stresses on the affected tendon. 1, 3

Second-Line Interventions (After 6 Weeks of Conservative Management)

Orthotics and Braces

• Tennis elbow bands, shoe orthotics, and similar devices reinforce, unload, and protect tendons during activity. 1, 2
• These are safe and widely used despite limited high-quality evidence supporting their effectiveness. 1, 2

Corticosteroid Injections (Use with Extreme Caution)

• Corticosteroid injections provide short-term pain relief but do not improve long-term outcomes and may have deleterious effects on tendon healing. 1, 3, 2
• Never inject directly into the tendon substance—this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture. 1, 3, 2
• Peritendinous injections may be considered for acute pain relief, but their role remains unclear given the lack of inflammation in most tendinopathies. 1
• Optimal drugs, dosages, techniques, and intervals remain unknown. 1

Advanced Conservative Options (Chronic/Recalcitrant Cases)

Extracorporeal Shock Wave Therapy (ESWT)

• ESWT appears safe and effective for chronic tendinopathies through acoustic shock waves that impart structural and neurochemical alterations. 1, 3, 2
• Further research is needed to clarify optimal treatment strategies and mechanisms of action. 1, 3, 2

Other Modalities with Limited Evidence

• Therapeutic ultrasonography, iontophoresis, and phonophoresis are widely used but lack well-designed randomized controlled trials to support definitive recommendations. 1

Surgical Management

Surgery should only be considered after 3-6 months of well-managed conservative treatment failure. 1, 3, 2 Surgery is effective but carries higher complication rates than conservative options and should be reserved for recalcitrant cases. 1, 5 Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release scarring. 3

Critical Pitfalls to Avoid

• Do not mislabel degenerative tendinosis as inflammatory "tendinitis"—this leads to inappropriate treatment focus on anti-inflammatory measures. 1, 2
• Avoid multiple corticosteroid injections as they may weaken tendon structure despite providing short-term symptom relief. 3, 2
• Never inject corticosteroids directly into the tendon substance. 1, 3, 2
• Do not proceed to surgery without an adequate 3-6 month conservative trial. 1, 3, 2
• If multiple tendons are symptomatic simultaneously, evaluate for underlying rheumatic disease before proceeding with local treatment. 1, 3
• Maintain patience with conservative management—80% of patients recover within 3-6 months with appropriate treatment. 1, 2

Imaging Considerations

Reserve imaging for unclear diagnoses after thorough examination, recalcitrant pain despite adequate conservative management, or preoperative evaluation. 1 Plain radiography may reveal bony abnormalities but cannot demonstrate soft-tissue changes. 1 MRI is most sensitive and specific for detecting tendon tears, degeneration, and chronic changes. 1