What is the recommended treatment approach for a patient diagnosed with tendonitis, considering their overall health, age, activity level, and occupation?

Treatment of Tendonitis

Begin with 3-6 months of conservative management consisting of relative rest, eccentric strengthening exercises, topical NSAIDs, and cryotherapy before considering any invasive interventions. 1, 2, 3

Initial Conservative Treatment (First-Line for All Patients)

Activity Modification

• Reduce repetitive loading activities that stress the affected tendon while maintaining some movement to prevent muscle atrophy and deconditioning 1, 2
• Never completely immobilize the tendon for extended periods—this causes rapid muscle atrophy, loss of strength and extensibility 2, 3
• Use pain as your guide: continue activities that don't aggravate symptoms while avoiding those that worsen pain 2

Eccentric Strengthening Exercises

• Eccentric strengthening is the cornerstone of treatment and can reverse degenerative changes in the tendon 1, 2, 3
• Initiate once acute pain subsides 2
• This intervention has the strongest evidence for long-term benefit 4, 5

Pain Management

• Topical NSAIDs are preferable to oral formulations due to equivalent pain relief with fewer systemic side effects, particularly elimination of gastrointestinal hemorrhage risk 1, 2
• NSAIDs provide short-term pain relief but do not affect long-term outcomes or healing 1, 2, 3
• For acute tendonitis/bursitis requiring oral naproxen: start with 500 mg, followed by 500 mg every 12 hours or 250 mg every 6-8 hours, with initial daily dose not exceeding 1250 mg 6
• Cryotherapy through a wet towel for 10-minute periods provides effective acute pain relief by reducing tissue metabolism 1, 2

Adjunctive Therapies

• Deep friction massage may provide additional benefit 1

Expected Timeline and Outcomes

• Approximately 80% of patients with overuse tendinopathies recover completely within 3-6 months with appropriate conservative treatment 1, 2, 3
• Pain typically presents with insidious onset coinciding with increased activity, may initially subside after warm-up but gradually increases in intensity and duration 2

Second-Line Treatment Options (Only After Initial Conservative Measures)

Corticosteroid Injections

• Use with extreme caution—while they may be more effective than oral NSAIDs for acute pain relief, they do not improve long-term outcomes and may have deleterious effects on tendon healing 1, 2, 3
• CRITICAL PITFALL: Never inject directly into the tendon substance—this inhibits healing, reduces tensile strength, and may predispose to rupture 1, 2, 3
• Avoid multiple injections as they may weaken tendon structure despite short-term symptom relief 1, 2, 3

Advanced Modalities

• Extracorporeal shock wave therapy (ESWT) appears safe and effective for chronic tendinopathies but is expensive 1, 2, 3
• Ultrasonotherapy may decrease pain and increase collagen synthesis, though evidence is limited and inconsistent 1, 4
• Sclerotherapy and nitric oxide patches show promise but require larger trials for confirmation 4

Surgical Management

• Surgery is justified only if pain persists despite 3-6 months of well-managed conservative treatment 1, 2, 3
• Surgical options include excision of abnormal tendinous tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1
• Surgery remains the last option due to morbidity and inconsistent outcomes 4

Critical Pitfalls to Avoid

• Do not inject corticosteroids directly into the tendon substance 1, 2, 3
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment 1, 2, 3
• Do not completely immobilize for prolonged periods 1, 2, 3
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease before attributing symptoms solely to overuse 1, 2, 3
• Do not rely on NSAIDs alone for long-term management—they provide only short-term pain relief without affecting healing 1, 2, 3

Special Population Considerations

Elderly Patients

• Use the lowest effective dose of NSAIDs, as unbound plasma fraction increases with age despite unchanged total plasma concentration 6
• Consider lower starting doses and adjust based on response 6

Patients with Renal Impairment

• Naproxen is not recommended for patients with moderate to severe renal impairment (creatinine clearance < 30 mL/min) 6

Occupation and Activity Level

• Address causative factors such as improper training techniques, biomechanical abnormalities, or workplace ergonomics to prevent recurrence 7, 8
• For workers with repetitive strain: implement workplace modifications alongside treatment 5