Treatment of Tendon Enthesophytes
For tendon enthesophytes, initiate conservative management with relative rest, NSAIDs, ice therapy, and eccentric strengthening exercises, while avoiding corticosteroid injections near the tendon substance due to rupture risk. 1
Initial Conservative Management
First-line therapy should focus on activity modification and pain control:
- Relative rest by reducing activities that provoke pain while maintaining some movement to prevent muscle atrophy and deconditioning 1
- Ice therapy applied through a wet towel for 10-minute periods provides short-term pain relief and reduces swelling 1
- NSAIDs (oral or topical) for pain relief, with topical formulations preferred to eliminate gastrointestinal hemorrhage risk 1, 2
- For acute pain, naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours (not to exceed 1250 mg first day, then 1000 mg daily thereafter) 2
Physical Therapy and Exercise
Eccentric strengthening exercises are the cornerstone of rehabilitation:
- Eccentric exercise protocols stimulate collagen production and guide normal alignment of newly formed collagen fibers 1
- These have proven beneficial in Achilles and patellar tendinosis and should be applied to other tendinopathies 1
- Stretching exercises are widely accepted as helpful adjuncts 1
- Avoid complete immobilization as this leads to muscular atrophy and deconditioning 1
Adjunctive Therapies
Additional supportive measures may be beneficial:
- Orthotics and braces (e.g., tennis elbow bands, shoe orthotics) help reinforce, unload, and protect tendons during activity, though evidence is limited 1
- Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research to clarify optimal treatment strategies 1
Critical Cautions
Avoid interventions that may compromise tendon integrity:
- Corticosteroid injections should be used with extreme caution as they may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 1
- Peritendinous injections have unknown effects and should be avoided, particularly for Achilles, patellar, and quadriceps tendons 1
- While corticosteroids may provide short-term pain relief superior to oral NSAIDs, they do not alter long-term outcomes 1
Special Considerations for Inflammatory Arthropathies
If enthesophytes occur in the context of ankylosing spondylitis or spondyloarthropathy:
- For active enthesitis despite NSAIDs, locally administered parenteral glucocorticoids may be considered, but peri-tendon injections of Achilles, patellar, and quadriceps tendons should be avoided 1
- Physical therapy is strongly recommended over no treatment 1
- Active physical therapy interventions (supervised exercise) are preferred over passive modalities (massage, ultrasound, heat) 1
Surgical Intervention
Surgery should be reserved for refractory cases:
- Surgical evaluation is warranted if pain persists despite 3-6 months of well-managed conservative treatment 3
- Operative management with enthesophyte excision and tendon repair has shown success in chronic cases with persistent symptoms affecting activities of daily living 4
Duration and Monitoring
Most patients recover with conservative management: