Treatment of Knee Tendinitis
Begin with relative rest, eccentric strengthening exercises, and NSAIDs (topical preferred over oral) for 3-6 months before considering any invasive interventions. 1, 2
First-Line Conservative Management
Activity Modification
- Reduce repetitive loading activities that stress the affected tendon while maintaining some activity to prevent muscle atrophy and deconditioning 1, 2
- Use pain as your guide—continue activities that don't aggravate symptoms while avoiding those that worsen pain 1
- Complete immobilization must be avoided as it causes rapid muscle atrophy, loss of strength, and extensibility 1, 2
Pain Control
- Topical NSAIDs are the preferred first-line pharmacologic option for knee tendinitis, providing equivalent pain relief to oral formulations while eliminating gastrointestinal hemorrhage risk 3, 1
- Oral NSAIDs (such as ibuprofen) provide short-term pain relief but do not affect long-term outcomes and carry systemic side effects 1, 2, 4
- Ice therapy applied through a wet towel for 10-minute periods provides effective short-term pain relief by reducing tissue metabolism 1
Eccentric Strengthening (The Cornerstone)
- Eccentric strengthening exercises are the most important component of rehabilitation and should be initiated once acute pain subsides 1, 2
- These exercises can reverse degenerative changes in the tendon and are proven beneficial across multiple tendinopathies 2, 5
- Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative management including eccentric exercises 1, 2
Second-Line Options (If Conservative Management Fails After 6 Weeks)
Corticosteroid Injections (Use With Extreme Caution)
- Critical warning: Corticosteroid injections provide only short-term pain relief but do not improve long-term outcomes and may have deleterious effects on tendon healing 1, 2, 5
- Never inject directly into the tendon substance—this inhibits healing, reduces tensile strength, and may predispose to rupture 1, 2
- Avoid multiple corticosteroid injections as they may weaken tendon structure despite providing short-term symptom relief 1, 6
Advanced Conservative Options
- Extracorporeal shock wave therapy (ESWT) appears safe and effective for chronic tendinopathy but is expensive 1, 6
- Therapeutic ultrasonography, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit 1
Surgical Management
- Surgery should only be considered after 3-6 months of well-managed conservative treatment failure 1, 2, 6
- Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release scarring 6
Critical Pitfalls to Avoid
- Do not rely on NSAIDs alone for long-term management—they provide only short-term pain relief and do not affect healing 1, 2, 5
- Never inject corticosteroids directly into the tendon substance 1, 2, 6
- Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment 1, 2, 6
- Avoid complete immobilization for prolonged periods—this causes rapid muscle atrophy and deconditioning 1, 2
- If multiple tendons are symptomatic, evaluate for underlying rheumatic disease before attributing symptoms solely to overuse 1, 2
Important Context
Most patients presenting with "tendinitis" actually have chronic degenerative tendinopathy ("tendinosis") rather than acute inflammation, despite the common misnomer 1. While there is emerging evidence that inflammation may play a role in chronic tendinopathy 7, the traditional anti-inflammatory approach with NSAIDs and corticosteroids has not demonstrated long-term benefit and may actually promote tissue degeneration 5, 8.