What is the best treatment approach for an adult patient with a history of repetitive strain or overuse and diagnosed with tendinosis?

Tendinosis Treatment

Begin treatment with eccentric strengthening exercises combined with relative rest and activity modification, as this is the only intervention proven to reverse the degenerative collagen changes that define tendinosis. 1, 2

Understanding the Pathology

Tendinosis is fundamentally a degenerative condition, not an inflammatory one—the tissue shows collagen breakdown and disorganized fiber structure without significant inflammation. 1, 3, 4 This distinction is critical because it means anti-inflammatory treatments (NSAIDs, corticosteroids) address symptoms but cannot reverse the underlying pathology. 5, 3

First-Line Treatment Protocol

Eccentric Strengthening (The Cornerstone)

• Initiate eccentric exercises immediately as they are the only treatment proven to reverse degenerative changes and restore tendon structure. 1, 2
• These exercises involve controlled lengthening of the muscle-tendon unit under load. 1
• Continue for at least 3-6 months, as 80% of patients achieve full recovery within this timeframe. 2

Activity Modification

• Reduce repetitive loading activities that stress the affected tendon, but avoid complete immobilization which accelerates muscle atrophy and worsens outcomes. 1, 2
• Modify technique in athletes and manual laborers to minimize repetitive strain. 2

Pain Control

• Apply ice through a wet towel for 10-minute periods for acute symptom relief. 1, 2
• Use NSAIDs (oral or topical) for short-term pain relief to facilitate participation in eccentric exercises, recognizing they provide no long-term benefit and don't alter the degenerative process. 1, 2
• Topical NSAIDs are preferred for localized tendinosis due to fewer systemic side effects. 2
• Paracetamol up to 4g daily is a reasonable first-choice analgesic given its safety profile. 2

Second-Line Interventions

When First-Line Treatment Provides Insufficient Pain Relief

• Consider corticosteroid injections for better acute pain relief compared to oral NSAIDs, but understand they don't improve long-term outcomes and may reduce tendon tensile strength. 1, 2
• Limit to 2-3 injections maximum and use caution with major load-bearing tendons due to rupture risk. 6, 3

For Chronic Cases (Beyond 3 Months)

• Extracorporeal shock wave therapy (ESWT) is safe, noninvasive, and effective for chronic tendinopathies, though expensive. 1, 2, 6
• Deep transverse friction massage may reduce pain. 2

Surgical Management

Reserve surgery exclusively for carefully selected patients who fail 3-6 months of appropriate conservative therapy. 1, 2, 6 Surgery carries significant morbidity and produces inconsistent outcomes. 5

Critical Pitfalls to Avoid

• Never completely immobilize the affected area—this accelerates muscle atrophy and deconditioning. 2, 6
• Don't mislabel chronic cases as "tendinitis" when the pathology is degenerative tendinosis, as this leads to inappropriate treatment selection. 6, 4
• Avoid relying solely on NSAIDs or corticosteroids without implementing eccentric exercises, as pharmacological treatments alone cannot reverse the degenerative process. 1, 5
• If joint effusions are present, suspect intra-articular pathology rather than tendinosis and adjust your diagnostic approach. 1, 2, 6
• If multiple tendons are symptomatic, evaluate for rheumatic disease rather than assuming isolated overuse injury. 1

Monitoring and Expectations

Expect well-localized tenderness on palpation that reproduces the patient's activity-related pain. 1, 2 Most patients (approximately 80%) achieve full recovery within 3-6 months with appropriate conservative management. 2, 6 If symptoms persist beyond 6 months despite well-executed conservative therapy including eccentric exercises, refer for surgical consultation. 2