What is the recommended treatment for tendinitis?

Treatment for Tendinitis

The cornerstone of tendinitis treatment is relative rest combined with eccentric strengthening exercises, with NSAIDs reserved for short-term pain relief only—not as primary therapy—since most tendinopathies are degenerative rather than inflammatory conditions. 1, 2

Initial Management Approach

Activity Modification (First-Line)

• Reduce activities that worsen pain while continuing activities that don't exacerbate symptoms to prevent further damage while maintaining function 1, 2
• Avoid complete immobilization, which causes muscle atrophy and deconditioning 1
• For athletes and manual laborers, modify technique to minimize repetitive stresses on the affected tendon 1

Cryotherapy for Acute Pain Relief

• Apply ice through a wet towel for 10-minute periods for optimal short-term pain relief 1, 2
• Cryotherapy reduces tissue metabolism and may blunt inflammatory response in acute cases 1

Pharmacological Management

NSAIDs (Short-Term Use Only)

• Topical NSAIDs are preferred as first-line pharmacological treatment due to equivalent pain relief with elimination of gastrointestinal hemorrhage risk 1, 3
• Oral NSAIDs (e.g., naproxen 500 mg twice daily for acute tendinitis) provide short-term pain relief but do not alter long-term outcomes 1, 4
• Critical caveat: NSAIDs do not address the underlying degenerative pathology since most chronic tendinopathies lack significant inflammation 1, 5, 6

Corticosteroid Injections (Use With Extreme Caution)

• Corticosteroid injections may provide better acute pain relief than oral NSAIDs but do not improve long-term outcomes 1, 2
• Avoid injection directly into tendon substance—this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture 1, 3
• Peritendinous injections should be used cautiously and sparingly, as they may serve only to mask symptoms while promoting degeneration 1
• Avoid multiple corticosteroid injections as they weaken tendon structure despite short-term symptom relief 3

Rehabilitation (Essential Component)

Eccentric Strengthening Exercises

• Eccentric strengthening is the cornerstone of rehabilitation and may reverse degenerative changes 1, 2, 3
• Proven beneficial in Achilles and patellar tendinopathy, and likely helpful in other tendinopathies 1
• Tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers 1
• Stretching exercises are widely accepted and thought to be helpful 1

Orthotics and Braces

• Use to reinforce, unload, and protect tendons during activity 1, 2
• Helpful in correcting biomechanical problems such as excessive foot pronation or pes planus deformity 1, 2
• Selection should be based on the specific tendon affected and patient comfort 2

Advanced Treatment Options (For Persistent Symptoms After 6 Weeks)

Extracorporeal Shock Wave Therapy (ESWT)

• ESWT appears safe and effective for chronic tendinopathies but is expensive and requires further research to clarify optimal treatment strategies 1, 3

Other Modalities (Uncertain Benefit)

• Therapeutic ultrasonography, iontophoresis, and phonophoresis have uncertain benefit due to lack of well-designed RCTs 1
• Evidence for consistent benefit is weak 1

Emerging Therapies

• Sclerotherapy and nitric oxide patches show promise in current data but require larger multicenter trials 5
• Growth factors and stem cell treatment are preliminary but promising, requiring further study 5

Surgical Intervention

• Surgery should be reserved only for patients who have failed 3-6 months of well-managed conservative therapy 1, 2, 3
• Surgery is effective in carefully selected patients but carries morbidity and inconsistent outcomes 1, 5
• Do not proceed to surgery without adequate conservative trial 3

Critical Pitfalls to Avoid

• Do not misdiagnose tendinopathy as an inflammatory condition and rely solely on anti-inflammatory treatments 2, 6
• Most chronic tendinopathies are degenerative with little or no inflammation present 5, 7, 6
• Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate treatment 2
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease 3