What is the recommended treatment approach for a patient with tendinopathy and osteoarthritis?

Treatment of Tendinopathy and Osteoarthritis

For patients presenting with both tendinopathy and osteoarthritis, begin with exercise therapy and relative rest for the tendinopathy combined with weight loss if overweight, then add acetaminophen or topical NSAIDs as first-line pharmacologic agents, reserving oral NSAIDs and corticosteroid injections for inadequate response. 1

Core Treatment Foundation (Apply to All Patients)

Non-Pharmacological Interventions (Highest Priority)

Exercise is the cornerstone of treatment for both conditions and should be initiated immediately: 1

• Strengthening exercises targeting local muscle groups around affected joints and tendons 1
• Aerobic fitness training including walking, cycling, or aquatic exercise for at least 30 minutes most days of the week 1
• Aquatic exercise is equally effective as land-based exercise and should be chosen based on patient preference and aerobic conditioning level 1
• Eccentric strengthening exercises specifically for tendinopathy can reverse degenerative tendon changes 2

Weight loss is mandatory if the patient is overweight or obese: 1

• Even 5-10% body weight reduction significantly reduces joint pain and mechanical stress 3, 4

Relative rest for tendinopathy: 1

• Reduce repetitive loading activities that provoke symptoms, but avoid complete immobilization which leads to muscle atrophy 1, 2
• Gradually increase activity as symptoms improve 1

Additional Non-Pharmacological Options

• Local heat or cold applications provide temporary symptom relief 1, 3
• Manual therapy combined with supervised exercise for osteoarthritis 1
• Assistive devices (walking aids, braces, insoles) for biomechanical instability 1
• Self-management programs emphasizing behavioral changes and pacing of activities 1

Pharmacological Treatment Algorithm

First-Line: Safest Systemic Options

Start with acetaminophen (paracetamol): 1, 3, 4

• Dose: Up to 4,000 mg/day in divided doses 1, 4
• Safest oral analgesic with minimal toxicity 1
• Counsel patients to avoid all other acetaminophen-containing products including OTC cold remedies 1

Topical NSAIDs are preferred over oral NSAIDs for localized pain: 1, 3, 4

• Apply to affected joints 3-4 times daily 4
• Minimal systemic absorption and negligible bleeding risk 3, 4
• Particularly effective for knee and hand osteoarthritis 1

Second-Line: When First-Line Inadequate

Oral NSAIDs or COX-2 inhibitors: 1, 3

• Use at the lowest effective dose for the shortest duration 1
• Always prescribe with a proton pump inhibitor for gastroprotection, choosing the one with lowest cost 1
• Consider individual risk factors including age, cardiovascular disease, renal function, and gastrointestinal history 1
• Contraindicated in patients on antiplatelet therapy (e.g., ticagrelor/Brilinta) due to significantly increased bleeding risk 4

Tramadol as an alternative opioid option: 1

• Consider when NSAIDs are contraindicated or ineffective 1

Third-Line: Interventional Options

Intra-articular corticosteroid injections for osteoarthritis: 1, 3, 4

• Effective for moderate to severe pain flares 1, 3, 4
• Particularly useful for knee and hip osteoarthritis 1, 4
• Provides temporary relief without systemic bleeding risk 4

Corticosteroid injection for tendinopathy: 2, 5

• Inject only into the tendon sheath, never into the tendon substance to avoid tendon weakening 2
• Highly effective for acute tendinopathy, especially De Quervain's tenosynovitis 2
• Avoid multiple injections as they may weaken tendon structure despite short-term relief 2
• Use selectively in resistant cases as recurrences are frequent 5

Treatments NOT Recommended

Do not use the following for osteoarthritis: 1

• Glucosamine or chondroitin sulfate 1
• Topical capsaicin (conditionally recommended against) 1
• Electroacupuncture 1

Advanced Treatment Options for Refractory Cases

Extracorporeal shock wave therapy (ESWT): 2, 6

• Safe, noninvasive option for chronic tendinopathy 2
• Strong evidence for long-term benefit in patellar tendinopathy 6
• Expensive but effective 2

Platelet-rich plasma (PRP): 6

• Most robust evidence for treating osteoarthritis and long-term benefit in patellar tendinopathy 6
• Consider for refractory cases 6

Critical Pitfalls to Avoid

For tendinopathy: 1, 2, 7

• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease (rheumatoid arthritis, spondyloarthritis) with antibody serology (anti-CCP, HLA-B27) and inflammatory markers 1, 2, 7
• Do not proceed to surgery without adequate 3-6 month trial of conservative treatment 2
• Avoid complete immobilization 2

For osteoarthritis: 1, 3

• Do not delay surgical referral until there is prolonged and established functional limitation 1
• Patient factors (age, sex, smoking, obesity, comorbidities) should not be barriers to joint replacement referral 1

Surgical Referral Criteria

Refer for joint replacement surgery when: 1, 3, 4

• Pain and functional limitation substantially affect quality of life despite comprehensive conservative treatment for 3-6 months 1, 3, 4
• Symptoms are refractory to non-surgical treatment 1
• Patient preference after failed conservative care 3

Do not routinely refer for arthroscopic lavage and debridement unless there is clear mechanical locking, not for gelling, giving way, or radiographic loose bodies 1

Follow-Up and Monitoring

Schedule regular follow-up: 3

• Reassess at 6-12 weeks to determine if escalation of therapy is needed 3
• Monitor kidney and liver function if using NSAIDs 3
• Tailor periodic review to individual patient needs 1