How do I treat tendinitis?

Treatment of Tendinitis

Start with relative rest, ice therapy (10 minutes through a wet towel), oral or topical NSAIDs, and eccentric strengthening exercises for 3-6 months before considering any invasive interventions. 1

First-Line Conservative Management (0-6 Months)

Relative Rest

• Reduce activities that cause pain while maintaining some movement to prevent muscle atrophy and deconditioning 1
• Complete immobilization must be avoided as it leads to weakness and worsens outcomes 1

Cryotherapy

• Apply ice through a wet towel for 10-minute periods for short-term pain relief 1
• Ice reduces tissue metabolism, swelling, and blunts inflammatory response in acute cases 1

NSAIDs

• Naproxen is FDA-approved specifically for tendinitis: start with 500 mg, then 500 mg every 12 hours or 250 mg every 6-8 hours (maximum 1250 mg first day, then 1000 mg/day thereafter) 2
• Topical NSAIDs provide equivalent pain relief to oral formulations while eliminating gastrointestinal hemorrhage risk 1
• NSAIDs offer short-term pain relief but do not alter long-term outcomes or healing 1
• Pain relief typically begins within 1 hour with naproxen 2

Eccentric Strengthening Exercises

• This is the cornerstone of rehabilitation and the most evidence-based intervention 1
• Eccentric loading stimulates collagen production and guides proper alignment of newly formed collagen fibers 1
• Proven beneficial in Achilles and patellar tendinosis, likely helpful in other tendinopathies 1
• Stretching exercises are widely accepted and generally helpful 1

Technique Modification

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

Second-Line Treatments (If First-Line Fails After 6-12 Weeks)

Orthotics and Braces

• Tennis elbow bands, shoe orthotics, or other braces can reinforce, unload, and protect tendons during activity 1
• Safe and widely used despite limited data supporting definitive conclusions 1

Corticosteroid Injections (Use With Caution)

• May provide better acute pain relief than oral NSAIDs but do NOT improve long-term outcomes 1
• Critical pitfall: Never inject directly into the tendon substance—this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture 1
• Peritendinous injections should be used cautiously as they may still have deleterious effects 1
• The role of inflammation in chronic tendinopathy is unclear, making corticosteroids potentially counterproductive 1

Extracorporeal Shock Wave Therapy (ESWT)

• Appears safe, noninvasive, and effective for chronic tendinopathies but is expensive 1
• Uses acoustic shock waves to impart structural and neurochemical alterations that may reduce pain and promote healing 1
• Further research needed to clarify optimal treatment strategies 1

Therapeutic Ultrasonography

• May decrease pain and increase collagen synthesis rate, but evidence for consistent benefit is weak 1
• Produces high-frequency vibrations that generate heat in superficial tissues 1

Iontophoresis and Phonophoresis

• Use electric and ultrasonographic impulses to deliver topical NSAIDs and corticosteroids to subcutaneous tissues 1
• Widely used and anecdotally effective, but well-designed controlled trials are lacking 1
• Benefits remain uncertain 1

Surgical Management (After 3-6 Months of Failed Conservative Treatment)

Surgery is effective in carefully selected patients who have failed 3-6 months of well-managed conservative therapy 1

• Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1
• The mechanism of surgical healing promotion is not entirely understood 1
• Surgery carries higher complication rates than conservative options and should be reserved for recalcitrant cases 1

Critical Pitfalls to Avoid

• Do not inject corticosteroids directly into the tendon substance—this is the most important caveat 1
• Do not proceed to surgery without at least 3-6 months of adequate conservative management 1
• Do not completely immobilize the affected area for prolonged periods 1
• If multiple tendons are symptomatic simultaneously, evaluate for underlying rheumatic disease or consider rheumatology referral 1

Expected Outcomes

• Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment 3, 4
• Most patients present with prolonged symptoms, by which time acute inflammation has subsided and been replaced by collagen degeneration 1