What is the recommended treatment for volleyball-related tendinitis?

Treatment of Volleyball-Related Tendinitis

For volleyball-related tendinitis, initiate a structured 3-6 month conservative program consisting of relative rest, eccentric strengthening exercises (particularly decline squats), ice therapy, and topical NSAIDs, as approximately 80% of patients will achieve complete recovery with this approach. 1

Understanding the Condition

• Volleyball-related tendinitis is typically a degenerative condition (tendinosis), not an inflammatory one, despite the common misnomer "tendinitis"—this distinction is critical because it guides treatment away from anti-inflammatory strategies toward mechanical loading protocols. 1, 2

• The most common sites in volleyball players are the patellar tendon (jumper's knee), rotator cuff, and Achilles tendon, with patellar tendinopathy affecting approximately 18% of young volleyball players. 1, 3

First-Line Conservative Treatment Protocol

Relative Rest (Not Complete Immobilization)

• Allow continuation of activities that do not worsen pain while avoiding those that exacerbate symptoms—complete immobilization causes muscle atrophy and deconditioning and should be avoided. 1, 4, 2

• Tensile loading through controlled activity stimulates collagen production and guides proper alignment of newly formed collagen fibers. 5, 4

Eccentric Strengthening Exercises (Cornerstone of Treatment)

• Eccentric decline squats on a 25-degree decline board are superior to traditional eccentric protocols, particularly for patellar tendinopathy in volleyball players. 6

• Progress exercises by adding load rather than speed, and exercise into tendon pain (not avoiding it completely). 6

• For patellar tendinopathy specifically, decline squats with additional unstable surface during the competitive season effectively lower pain levels without interrupting play. 3

• Eccentric exercises have proven efficacy in reversing degenerative changes and are supported by the strongest evidence for Achilles and patellar tendinosis. 1, 2

Isometric Exercises for Acute Pain Relief

• A single bout of isometric contractions provides immediate pain reduction lasting at least 45 minutes and can be used before training or competition. 7

• Isometric contractions reduced pain from 7.0/10 to 0.17/10 in volleyball players with patellar tendinopathy, compared to only 6.33/10 to 3.75/10 with isotonic exercises. 7

• Isometric exercises also increase maximal voluntary isometric contraction by 18.7% and release cortical inhibition, providing insight into pain relief mechanisms. 7

Cryotherapy

• Apply ice through a wet towel for 10-minute periods to reduce tissue metabolism, slow vascular protein release, and provide short-term pain relief. 1, 5, 2

Pharmacological Management

• Topical NSAIDs are preferred over oral NSAIDs because they effectively relieve tendon pain while eliminating the increased risk of gastrointestinal hemorrhage. 5, 2

• NSAIDs provide short-term pain relief but do not alter long-term outcomes and should not be prioritized over mechanical loading exercises. 1, 4

• Never use corticosteroid injections directly into the tendon substance—they impair healing, reduce tensile strength, and predispose to spontaneous rupture. 4, 2

• If corticosteroid injection is considered, only peritendinous (outside the tendon) injection may be used with extreme caution, though even this carries uncertain risk. 5, 4

Expected Recovery Timeline

• Approximately 80% of patients with overuse tendinopathies recover completely within 3-6 months with appropriate conservative treatment. 1, 5, 2

• Both pain and sporting function improve over 12 months with eccentric protocols in volleyball players who continue to train and play. 6

Second-Line Interventions

Bracing and Orthotics

• Tennis elbow bands or similar braces reinforce, unload, and protect tendons during activity and are safe and widely used, though definitive effectiveness data are limited. 2

• Shoe orthotics may correct biomechanical problems such as excessive foot pronation or pes planus deformity. 5

Advanced Therapies

• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research to clarify optimal treatment strategies. 5, 2

• Cast immobilization or fixed-ankle walker-type devices may be considered in particularly acute or refractory cases. 5

Surgical Management

• Surgery is warranted only if pain persists despite 3-6 months of well-managed conservative treatment. 5, 2, 8

• Surgical techniques include excision of abnormal tendon tissue (tendonectomy), longitudinal tenotomies to release scarring and fibrosis, and resection/drilling of the inferior pole of the patella. 5, 8

• Both open surgical techniques and arthroscopic approaches can be used, though the literature does not clarify which is more effective. 8

Critical Pitfalls to Avoid

• Never inject corticosteroids directly into tendon substance—only peritendinous injections should be considered, and even these should be used with extreme caution. 5, 4, 2

• Avoid complete immobilization—it leads to muscle atrophy and deconditioning; tensile loading is therapeutic. 4, 2

• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment that includes eccentric exercises and appropriate load management. 5, 4, 2

• Do not rely on NSAIDs alone for long-term management—they provide only short-term symptom relief and do not modify functional outcomes. 1, 4

• Do not mislabel degenerative conditions as inflammatory "tendonitis"—this leads to inappropriate treatment focus on anti-inflammatory strategies rather than mechanical loading. 1, 2