From the Guidelines
Tendinitis treatment should prioritize relative rest, icing, and eccentric strengthening exercises to promote healing and pain relief, as supported by the most recent and highest quality study 1.
Key Recommendations
- Relative rest and reduced activity prevent further damage and promote healing and pain relief 1.
- Cryotherapy provides acute relief of tendinopathy pain, with repeated applications of melting ice water through a wet towel for 10-minute periods being most effective 1.
- Eccentric strengthening is an effective treatment of tendinopathy and may reverse degenerative changes 1.
- NSAIDs are recommended for short-term pain relief but have no effect on long-term outcomes 1.
Treatment Approach
Tendinitis is inflammation of a tendon, typically caused by overuse or injury. Treatment begins with rest, ice, compression, and elevation (RICE) of the affected area for 24-48 hours. Take over-the-counter anti-inflammatory medications like ibuprofen (400-800mg three times daily with food) or naproxen (220-440mg twice daily with food) for 7-10 days to reduce pain and inflammation, as suggested by 1. Gentle stretching and strengthening exercises should be started once acute pain subsides, gradually increasing intensity over 2-3 weeks. Apply heat before exercise to increase blood flow and ice afterward to reduce inflammation. For persistent cases lasting more than 2-3 weeks, physical therapy may be necessary. Avoid activities that worsen pain and modify movements that strain the affected tendon.
Additional Considerations
Locally injected corticosteroids may be more effective than oral NSAIDs for relief in the acute phase of tendon pain, but they do not tend to alter long-term outcomes, and their use should be approached with caution 1. Surgery is an effective option in carefully selected patients who have failed three to six months of conservative therapy 1.
Imaging and Diagnosis
Imaging studies such as plain radiography, ultrasonography, and magnetic resonance imaging can be helpful if the diagnosis remains unclear, as outlined in 1. Examination should include thorough inspection to assess for swelling, asymmetry, and erythema of involved tendons; range-of-motion testing; palpation for tenderness; and examination maneuvers that simulate tendon loading and reproduce pain.
From the FDA Drug Label
In treating acute nonspecific tenosynovitis, care should be taken to ensure that the injection of the corticosteroid is made into the tendon sheath rather than the tendon substance. Management of Pain, Primary Dysmenorrhea, and Acute Tendonitis and Bursitis Because the sodium salt of naproxen is more rapidly absorbed, naproxen sodium is recommended for the management of acute painful conditions when prompt onset of pain relief is desired.
Tendinitis can be treated with triamcinolone via injection into the tendon sheath, or with naproxen orally. The recommended dose of naproxen for acute tendonitis is 500 mg, followed by 500 mg every 12 hours or 250 mg every 6 to 8 hours as required, with a maximum daily dose of 1000 mg 2. For triamcinolone, the dose is not specified for tendinitis, but for intra-articular administration, the initial dose is 2.5 mg to 5 mg for smaller joints and from 5 mg to 15 mg for larger joints 3.
From the Research
Definition and Causes of Tendinitis
- Tendinopathy is a common overuse injury associated with sport, resulting from a failure of a chronic healing response associated with both chronic overloaded and unloaded states 4.
- The term tendinopathy is preferred to tendinitis because of the presence of a disordered and degenerative healing process, rather than inflammation, in the pathologic tendon 5.
Symptoms and Diagnosis
- Insidious onset of pain and dysfunction is a common presentation for most tendinopathies, and patients typically report that a change in activity affected the use of the tendon 5.
- Diagnosis is typically based on history and physical examination findings, but radiography is an acceptable initial imaging modality, and ultrasonography and magnetic resonance imaging may be useful when the diagnosis is unclear 5.
Treatment Options
- Eccentric exercises provide excellent clinical results both in athletic and sedentary patients, with no reported adverse effects, and are considered the most common and consistently effective treatment for tendinopathy 4, 6.
- Combining eccentric loading and low-energy shock wave therapy produces higher success rates compared with eccentric training alone or shock wave therapy alone 4.
- Corticosteroid injections can reduce pain and improve long-term function in patients with Achilles or patellar tendinopathy, but may be less effective in the intermediate and long terms, and can increase the risk of atrophy for Achilles and patellar tendons 7.
- Platelet-rich plasma injections have inconclusive evidence on their ability to decrease tendinopathy-related pain and improve function, and other injectable substances such as autologous blood, polidocanol, and corticosteroids are not supported by strong clinical evidence 4, 6.
- Nonsteroidal anti-inflammatory drugs and cryotherapy can help control pain, and topical nitroglycerin, extracorporeal shock wave therapy, and hyaluronic acid injections are additional nonsurgical treatment options with varying levels of evidence 5, 8.