What is the recommended treatment for a tendon injury?

Treatment for Tendon Injury

The recommended treatment for tendon injury is conservative management with relative rest, ice therapy, topical NSAIDs for pain control, and eccentric strengthening exercises for 3-6 months before considering any invasive interventions. 1, 2

Initial Conservative Management (First-Line Treatment)

Activity Modification and Rest

• Implement relative rest by avoiding activities that worsen pain while maintaining activities that don't exacerbate symptoms—this prevents ongoing damage while avoiding muscle atrophy and deconditioning that occurs with complete immobilization 1, 2
• For athletes and manual laborers, modify technique to minimize repetitive stresses on the affected tendon 1

Pain Control Strategies

• Apply topical NSAIDs as first-line pharmacological treatment because they provide equivalent pain relief to oral NSAIDs while eliminating the risk of gastrointestinal hemorrhage 2, 3
• Use ice therapy through a wet towel for 10-minute periods to provide short-term pain relief and reduce swelling 1, 2, 3
• If oral NSAIDs are needed, naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours (not exceeding 1250 mg on day one, then 1000 mg daily thereafter) is appropriate for acute tendonitis 4

Rehabilitation Exercises (Essential Component)

• Eccentric strengthening exercises are the cornerstone of tendon rehabilitation—they stimulate collagen production, guide normal alignment of newly formed collagen fibers, and may reverse degenerative changes 1, 2, 3
• Include stretching exercises as they are widely accepted for tendon rehabilitation 1
• Exercises should be performed relatively pain-free to facilitate healing 5

Supportive Devices

• Consider tendon-specific braces or orthotics to reinforce, unload, and protect tendons during activity, though evidence for effectiveness is limited 1, 2

Second-Line Treatments (If Initial Management Insufficient)

Corticosteroid Injections (Use With Extreme Caution)

• Corticosteroid injections may provide better acute pain relief than NSAIDs but do not alter long-term outcomes and carry significant risks 2, 3
• They inhibit healing, reduce tensile strength of tissue, and may predispose to tendon rupture 1, 3
• Never inject directly into the tendon substance 3
• Avoid multiple injections as they weaken tendon structure 3

Adjunctive Physical Modalities

• Extracorporeal shock wave therapy (ESWT) appears safe and effective for chronic tendinopathies, though it requires further research and can be expensive 1, 3
• Therapeutic ultrasonography may decrease pain and increase collagen synthesis, though evidence is weak 1
• Deep transverse friction massage can reduce pain when combined with eccentric exercises 1

Surgical Management

• Reserve surgery only for patients who fail 3-6 months of well-managed conservative treatment 1, 2, 3
• Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1, 3

Expected Outcomes and Timeline

• Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment 1, 2
• Most tendon injuries resolve within 6 weeks when the rehabilitation program is implemented with ice and physical modalities 6

Critical Pitfalls to Avoid

• Do not misdiagnose tendinopathy as an inflammatory condition—most tendon injuries are degenerative in nature, not inflammatory, so relying solely on anti-inflammatory treatments is inadequate 2
• Avoid complete immobilization as it leads to muscle atrophy and deconditioning 2, 3
• Do not proceed to surgery without an adequate 3-6 months trial of conservative therapy 3
• Do not use corticosteroid injections as monotherapy or give multiple injections 3
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease 3