What is the best treatment approach for an adult patient with tendinosis, considering their history of repetitive strain or overuse?

Tendinosis Treatment

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

Foundation of Treatment: Eccentric Exercise Protocol

• Eccentric strengthening exercises are the cornerstone of tendinosis management because they reverse degenerative collagen changes, reduce symptoms, and increase tendon strength—effects not achieved by any other conservative modality. 1, 2
• Initiate eccentric exercises early in the treatment course rather than waiting for other interventions to fail. 2, 3
• The evidence for eccentric exercise is stronger than for any other non-surgical treatment, with consistent benefit demonstrated across multiple tendon sites. 4, 5

Activity Modification and Relative Rest

• Reduce repetitive loading activities that stress the affected tendon, but never completely immobilize the area as this accelerates muscle atrophy and deconditioning. 1, 2
• For athletes and manual laborers, modify technique to minimize repetitive tendon stresses rather than stopping all activity. 2
• The duration of activity restriction is not clearly defined by evidence, so titrate based on pain response—activities should not reproduce sharp or stabbing pain. 1

Pain Management Strategy

• Apply ice through a wet towel for 10-minute periods to provide acute pain relief, though this addresses symptoms rather than the underlying degenerative process. 1, 2
• Use NSAIDs only for short-term pain relief (days to weeks, not months) to facilitate participation in eccentric exercises, recognizing they provide no long-term benefit and do not alter the degenerative pathology. 1, 2, 3
• Topical NSAIDs are preferred over oral formulations for localized tendinosis as they provide equivalent pain relief with fewer systemic side effects. 2
• Paracetamol up to 4g daily is an acceptable first-line oral analgesic due to its favorable safety profile. 2

Corticosteroid Injection Considerations

• Reserve corticosteroid injections exclusively for acute pain relief when pain prevents participation in eccentric exercise programs, not as primary treatment. 1, 2
• Corticosteroids provide better short-term pain relief than oral NSAIDs but do not alter long-term outcomes, may inhibit healing, and reduce tendon tensile strength. 1, 2
• Use extreme caution with major load-bearing tendons (Achilles, patellar) due to rupture risk. 3
• Limit to 2-3 injections maximum, and use ultrasound guidance for accuracy. 6

Advanced Non-Surgical Options for Refractory Cases

• Consider extracorporeal shock wave therapy (ESWT) for chronic tendinopathy persisting beyond 3 months of appropriate conservative treatment—it is safe, noninvasive, and effective but expensive. 1, 2, 6
• Deep transverse friction massage may reduce pain as an adjunctive therapy. 2
• Evidence for therapeutic ultrasound, iontophoresis, and phonophoresis is inconsistent and uncertain. 1, 6

Surgical Referral Criteria

• Surgery is indicated only for carefully selected patients who have failed 3-6 months of appropriate conservative therapy that included eccentric exercises, activity modification, and pain control. 1, 2, 6
• Approximately 80% of patients fully recover within 3-6 months with proper outpatient conservative management, so surgery should remain a last resort. 2, 6

Critical Clinical Pitfalls to Avoid

• Do not label chronic tendinosis as "tendinitis"—the pathology is degenerative collagen breakdown, not inflammation, which fundamentally changes treatment approach. 1, 7
• The presence of joint effusions is uncommon with tendinopathy and should raise suspicion for intra-articular pathology requiring different management. 1, 2, 6
• If multiple tendons are symptomatic simultaneously, evaluate for rheumatic disease rather than treating as isolated overuse injuries. 1
• Expect well-localized tenderness on palpation that reproduces the patient's activity-related pain; diffuse or poorly localized pain suggests alternative diagnoses. 1, 2

Diagnostic Confirmation

• Patients typically present with insidious onset of load-related pain described as "sharp" or "stabbing" that initially occurs during activity but may progress to rest pain. 1, 3
• Most patients report new activity or increased intensity of current activity before symptom onset, though not all provide this history. 1, 2
• Plain radiography is acceptable initial imaging to exclude bony pathology, but ultrasound or MRI should be reserved for unclear diagnoses or surgical planning. 1, 2