What is the recommended treatment for a patient with tendinosis?

Treatment for Tendinosis

The first-line treatment for tendinosis consists of eccentric strengthening exercises combined with relative rest, cryotherapy, and short-term NSAIDs for pain relief, with approximately 80% of patients recovering completely within 3-6 months using this conservative approach. 1, 2

Understanding the Condition

Tendinosis is a degenerative condition, not an inflammatory one, which is why the term "tendinitis" is misleading and should be avoided. 1 The pathology involves hypoxic tendon degeneration with failed healing rather than acute inflammation, typically occurring at the osteotendinous junction where tendons are relatively hypovascular. 1

First-Line Conservative Treatment

Eccentric Strengthening Exercises (Cornerstone of Treatment)

• Eccentric exercises are the most effective treatment for tendinosis, with the strongest available evidence showing they can reverse degenerative changes by stimulating collagen production and guiding normal alignment of newly formed collagen fibers. 2, 3, 4
• Perform strengthening exercises at 60-70% of one-repetition maximum for 8-12 repetitions across 2-4 sets, training 2-3 days per week with at least 48 hours rest between sessions. 2
• Allow 2-3 minutes rest between sets to optimize strength gains. 2
• For experienced exercisers, Heavy Slow Resistance training at ≥80% of 1RM provides effective long-term improvements. 2

Activity Modification

• Implement relative rest by reducing repetitive loading activities that reproduce pain, but avoid complete immobilization as this causes muscular atrophy and deconditioning. 1, 2, 5
• The natural history involves gradually increasing load-related localized pain coinciding with increased activity. 1

Pain Management

• Apply cryotherapy through a wet towel for 10-minute periods for acute pain relief, which is widely accepted and effective. 1, 2, 5
• Use topical NSAIDs preferentially over oral NSAIDs as they provide effective pain relief with fewer systemic side effects, particularly eliminating gastrointestinal hemorrhage risk. 1, 2, 5
• Oral NSAIDs (such as naproxen 500 mg twice daily) provide short-term pain relief but do not affect long-term outcomes. 1, 6
• For acute tendinosis or bursitis, naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours (not exceeding 1250 mg first day, then 1000 mg daily thereafter). 6

Complementary Therapies

• Deep transverse friction massage reduces pain and may provide additional benefit. 1, 2, 5
• Perform stretching exercises 2-3 days per week, holding static stretches for 10-30 seconds after warming muscles through light aerobic activity, with 60 seconds total stretching time per exercise repeated 2-4 times. 2
• Incorporate low-impact aerobic exercises (walking, cycling) for 30-60 minutes per day at moderate intensity on most days to maintain cardiovascular fitness and support tendon health. 2

Treatment Progression Algorithm

1. Weeks 0-6: Initiate eccentric exercises, relative rest, cryotherapy, and topical NSAIDs
2. Weeks 6-12: Gradually increase resistance, repetitions, or frequency as strength improves 2
3. Months 3-6: Continue conservative management if showing improvement
4. After 6 months: Consider surgical evaluation only if pain persists despite well-managed conservative treatment 1, 2

Location-Specific Considerations

Rotator Cuff Tendinopathy

• Affects one in 50 adults, particularly common in overhead athletes and laborers. 1
• Hawkins' test (92% sensitive) and Neer's test (88% sensitive) help identify supraspinatus impingement. 1

Elbow Tendinopathy

• Lateral epicondylosis is 7-10 times more common than medial, affecting the dominant arm 75% of the time. 1
• Most common after age 40 in activities requiring repetitive wrist extension. 1

Patellar Tendinopathy

• Pain exacerbated by stairs and prolonged sitting, with decline squat test reproducing symptoms. 1, 2
• Consider medially directed patellar taping for short-term relief when rehabilitation is hindered by elevated symptom severity. 2

Achilles Tendinopathy

• Common among adult runners with increasing incidence with age. 1
• Address anatomic misalignment with shoe orthotics to correct overpronation or pes planus, and consider heel lift orthotics to unload the tendon. 1

Interventions to Use With Caution

• Corticosteroid injections provide short-term pain relief but do not change long-term outcomes and should be used cautiously. 1, 7
• Never inject corticosteroids directly into the tendon substance as this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture. 2
• Multiple corticosteroid injections weaken tendon structure despite short-term symptom relief. 2

Surgical Management

• Surgery is justified only after 3-6 months of well-managed conservative treatment has failed. 1, 2, 5
• Surgical techniques include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis. 1, 2
• Surgery carries higher complication rates than conservative options and should be reserved for recalcitrant cases. 7

Critical Pitfalls to Avoid

• Do not misdiagnose tendinosis as "tendinitis" - this leads to inappropriate focus on anti-inflammatory treatments rather than addressing the degenerative pathology. 1, 8
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment. 2
• Do not allow complete immobilization as this causes muscle atrophy and deconditioning. 1, 2
• Evaluate for underlying rheumatic disease if multiple tendons are symptomatic. 2
• Address underlying biomechanical issues or technique problems (especially in athletes) to prevent recurrence. 1, 5, 8

Expected Outcomes

• Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment. 1, 2, 5, 8
• If favorable outcomes are not observed after a realistic trial period, reassess the intervention strategy. 2

Patient Education

• Explain that tendinosis represents chronic degeneration rather than acute inflammation, setting realistic expectations for recovery. 2
• Emphasize that pain doesn't necessarily correlate with tissue damage, particularly important given hypersensitivity to light touch in some cases. 2
• Build confidence through education addressing hypersensitivity concerns. 2