What is the first‑line treatment for uncomplicated tendinitis, including activity modification, non‑steroidal anti‑inflammatory drugs (e.g., ibuprofen), physical‑therapy eccentric loading, and alternatives for patients with NSAID contraindications?

First-Line Treatment for Uncomplicated Tendinitis

Begin with eccentric strengthening exercises combined with relative rest and activity modification, using topical NSAIDs for short-term pain relief—this approach achieves complete recovery in approximately 80% of patients within 3-6 months. 1, 2

Initial Conservative Management (First 3-6 Months)

Activity Modification

• Reduce repetitive loading of 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. 2
• Critical pitfall: Never completely immobilize the tendon for extended periods, as this causes rapid muscle atrophy and loss of strength. 2

Eccentric Strengthening Exercises (Cornerstone of Treatment)

• Eccentric exercises are the most important component of treatment—they can reverse degenerative changes in the tendon by stimulating collagen production and guiding normal alignment of newly formed collagen fibers. 1, 3
• Progress from basic strengthening to sport-specific exercises as symptoms improve. 3
• These exercises should be initiated once acute pain subsides. 2

Pain Management

For patients who can tolerate NSAIDs:

• Topical NSAIDs are preferable to oral formulations because they provide equivalent pain relief while eliminating the risk of gastrointestinal hemorrhage. 1, 2
• NSAIDs are effective for short-term pain relief but do not affect long-term outcomes. 1, 2
• Note: Recent research shows NSAIDs may not affect gene expression in tendinopathic tissue, suggesting limited biological impact beyond analgesia. 4

For patients with NSAID contraindications:

• Use alternative analgesics (acetaminophen) for pain control. 5
• Cryotherapy through a wet towel for 10-minute periods provides effective acute pain relief by reducing tissue metabolism. 1, 2
• Deep friction massage may provide additional benefit when combined with other interventions. 1, 3

Understanding the Diagnosis

Most patients presenting to primary care have chronic degenerative tendinopathy ("tendinosus") rather than acute inflammation, despite the common misnomer "tendinitis." 5, 2 This is why anti-inflammatory treatments have limited long-term efficacy—there is little or no inflammation present in these conditions. 6

Expected Timeline and Prognosis

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

Second-Line Options (If First-Line Treatment Insufficient)

Corticosteroid Injections (Use with Extreme Caution)

• Corticosteroids may provide better short-term pain relief than oral NSAIDs in the acute phase, but they do not improve long-term outcomes and may have deleterious effects on tendon healing. 5, 1, 2
• Critical pitfall: NEVER inject directly into the tendon substance—this inhibits healing, reduces tensile strength, and may predispose to spontaneous rupture. 5, 1, 2
• Peritendinous injections should also be used with caution as they may inhibit healing. 5

Extracorporeal Shock Wave Therapy (ESWT)

• Appears safe and effective for chronic tendinopathies but is costly and should not be considered first-line treatment. 1, 2, 3
• Further research is needed to clarify optimal treatment strategies. 5

Other Modalities with Limited Evidence

• Therapeutic ultrasonography may decrease pain and increase collagen synthesis, but evidence is weak. 5, 1
• Orthotics and braces are safe adjuncts that may help correct biomechanical problems, though definitive evidence is lacking. 5

Surgical Management

Surgery should be reserved exclusively for carefully selected patients who have failed 3-6 months of well-managed conservative treatment. 5, 1, 2, 3 Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis. 5, 1

Critical Pitfalls to Avoid

• Do not inject corticosteroids directly into the tendon substance. 5, 1, 2
• Avoid multiple corticosteroid injections as they may weaken tendon structure despite short-term symptom relief. 1, 2
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment. 1, 2, 3
• Do not completely immobilize the affected area for extended periods. 1, 2
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease before attributing symptoms solely to overuse. 1, 2