What is the management for synovial tendinitis?

Management of Synovial Tendinitis

Begin with 3-6 months of conservative treatment consisting of relative rest, eccentric strengthening exercises, NSAIDs, and cryotherapy before considering any invasive interventions. 1, 2, 3

Initial Conservative Management (First-Line Treatment)

Core Treatment Components

• Relative rest is essential—continue activities that don't worsen pain while avoiding complete immobilization, which causes muscle atrophy and deconditioning 1, 2
• Eccentric strengthening exercises are the cornerstone of treatment and can reverse degenerative changes in the tendon, with proven efficacy across multiple tendinopathies 1, 2, 3, 4
• Cryotherapy through a wet towel for 10-minute periods provides short-term pain relief 1, 2
• Topical NSAIDs are preferable to oral NSAIDs as they eliminate gastrointestinal hemorrhage risk while effectively relieving tendon pain 1
• Oral NSAIDs provide short-term pain relief but have no effect on long-term outcomes 2, 3, 5

Biomechanical Correction

• Shoe orthotics are safe and often helpful in correcting biomechanical problems such as excessive foot pronation or pes planus deformity 1
• Technique modification for athletes and manual workers minimizes repetitive strains on tendons 2

Expected Outcomes

• Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 1, 2, 3

When to Consider Rheumatology Referral

If multiple tendons are symptomatic, evaluate for underlying rheumatic disease such as seronegative spondyloarthropathies or rheumatoid arthritis. 3, 6

• Refer urgently to rheumatology if arthritis involves more than one joint, particularly small joints of hands or feet, or if there's been a delay of three months or longer between symptom onset and seeking medical advice 7
• Clinical examination is the method of choice for detecting synovitis; in doubtful cases, ultrasound, power Doppler, and MRI may be helpful 7, 6
• For seronegative spondyloarthropathies causing tenosynovitis, surgical synovial débridement should be performed early (6 weeks) rather than waiting 3 months 6

Second-Line Treatments (After 6 Weeks to 3 Months)

Corticosteroid Injections

• CRITICAL PITFALL: Never inject directly into the tendon substance—this inhibits healing, reduces tensile strength, and may predispose to rupture 1, 2, 3, 8
• Only peritendinous injections should be considered 1
• Local corticosteroid injections may be more effective than oral NSAIDs for pain relief in the acute phase, but do not improve long-term outcomes 2, 3, 4
• Injections should be limited to every third or fourth month 8

Alternative Modalities

• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research to clarify optimal treatment strategies 1, 2, 4
• Sclerotherapy and nitric oxide patches show promise based on current data, but larger multicenter trials are needed 4
• Cast immobilization or fixed-ankle walker-type device may be considered in particularly acute or refractory cases 1
• Ultrasonotherapy may decrease pain and increase collagen synthesis, although evidence is limited 2

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

Surgery is warranted only if pain persists despite 3-6 months of well-managed conservative treatment. 1, 2, 3

• Referral to a podiatric foot and ankle surgeon or orthopedic specialist is appropriate when conservative measures fail 1
• Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1, 2
• At surgery, the undersurface of the tendon must be inspected for longitudinal split tears, which must be repaired with nonabsorbable suture 6
• Surgery remains the last option due to morbidity and inconsistent outcomes 4

Critical Pitfalls to Avoid

• Never inject corticosteroids directly into the tendon substance—only peritendinous injections 1, 2, 3, 8
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment 1, 2, 3
• Avoid complete immobilization for prolonged periods—it leads to muscle atrophy and deconditioning 1, 2, 3
• Do not rely on NSAIDs alone for long-term management—they provide only short-term symptom relief 1, 3, 4
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease before proceeding with isolated tendon treatment 3, 6

Diagnostic Considerations

• Well-localized tenderness over the affected tendon that reproduces activity-related pain 2, 3
• Insidious onset of load-related pain coinciding with increased activity 3
• MRI is reserved for unclear diagnoses, recalcitrant pain despite adequate conservative management, or preoperative evaluation 3
• Ultrasound is an inexpensive and accurate method to assist in diagnosis and may replace MRI as more experienced ultrasonographers become available 6