Treatment Guideline Chart

Tendinopathy is a clinical syndrome characterized by tendon thickening persistent localized tendon pain, swelling, and impaired performance.

It is usually is a temporary condition if treated early but may also be recurrent or chronic, with symptoms lasting over 3 months.

Principles of therapy include identification and elimination of the cause of tendinopathy, behavior modification to minimize or eliminate sources of continuing irritation, and specialist referral for appropriate follow-up care.

Goal of therapy is to reduce pain and to return function.


Tendinopathy Treatment

Principles of Therapy

  • Identification of the cause and reduction of the biomechanical risk factors of tendinopathy
  • Resolution of inflammation (warmth, swelling, erythema, pain and/or loss of function) to help return to previous function, activities, and community participation
  • If diagnosis of tendinopathy is made, provide the following management strategies:
    • Patient education and counseling
    • Non-pharmacological treatment
      • Relative rest while identifying the cause and reducing the biomechanical risk factors
      • Warm or cold treatments depending on the patient’s tolerance and presence of erythema, swelling and warmth
      • Isometric to isotonic exercises for 6-12 weeks
      • Behavioral modification to minimize or reduce sources of continuing irritation
    • Pharmacological treatment should be initiated
      • Topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs)
      • Analgesics
    • Supplements may be considered if necessary
  • Referral to other healthcare professionals (orthopedic surgeon, rheumatologist, rehabilitation medicine doctor, or pain medicine specialist) for specialized management and follow-up care


Analgesics and Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
  • Effectively relieve pain and inflammation
  • It is unclear whether NSAIDs are more effective than other analgesics since majority of chronic tendinopathies are not inflammatory
  • Topical administration of NSAIDs (eg gels or patches) has also been used to reduce tendon pain
    • Eliminates the risk of gastrointestinal bleeding associated with systemic use
  • Analgesics and NSAIDs are good options for short-term (5-7 days or up to 10 days) treatment of pain
    • Studies showed efficacy of NSAIDs in the treatment of acute shoulder tendonitis but not with lateral epicondylitis and Achilles tendinopathy
  • No clear evidence on the efficacy of NSAIDs in the long-term treatment of chronic tendinopathy
Local Corticosteroid Injection
  • There are no evidence-based guidelines to recommend the use of local corticosteroids injection in tendinopathy
  • Effectiveness and risk of corticosteroid treatment vary with the duration of symptoms and route of drug delivery
  • Locally injected corticosteroids are more effective than oral NSAIDs for relief in the acute phase of tendinopathy pain but they do not alter long-term outcomes
    • Strong evidence support its use in relieving pain for up to 6 weeks but there is no evidence to support its benefit in long-term treatment beyond 6 months
  • May inhibit healing and decrease the tensile strength of the tissue which may predispose to spontaneous rupture
    • Corticosteroids should not be injected into major tendons like Achilles tendon and patellar tendon, which may be at risk of spontaneous rupture if already weakened
  • Risks associated with corticosteroid injections can be decreased by injecting under fluoroscopic guidance to ensure that the injection is around the tendon and not intratendinosus
Glyceryl Trinitrate (Patch)
  • Studies showed that the administration of glyceryl trinitrate patches over affected tendons deliver nitric oxide which acts as cellular messenger and helps in tendon healing
    • Provides pain relief and improves function in patients with lateral epicondylitis, Achilles tendinopathy and rotator cuff tendinopathy
  • Larger multicenter trials are needed to validate this treatment option

Non-Pharmacological Therapy

Relative Rest

  • Refers to avoidance of abuse and not absence of activity
    • Complete rest is not indicated, activity within pain tolerance should be continued
  • Appropriate during the acute phase of tendinopathy pain
  • Prevents ongoing damage, decreases pain and promotes tendon healing
  • Avoid activities that are heavy and may aggravate pain
  • Most physicians encourage continuation of daily activities as long as it does not worsen the pain
    • Tensile loading of the tendon enhances collagen production and promotes normal alignment of newly formed collagen fibers
  • Avoid complete immobilization to prevent stiffness, muscle or joint contracture, muscle atrophy and deconditioning
  • Brief sling immobilization is a suggested treatment for calcific tendinopathy
    • Prolonged immobilization may result in adhesive capsulitis
  • No specific recommendation for the length of rest needed
Activity Modification
  • Important that employers and coaches be aware of the treatment plan (ie limit the volume and intensity of loads on the injured tendon for a designated period)
    • Necessary to eliminate pain and promote tendon healing
Cold Application
  • Eg cold spray, ice compress, cold packs, icing through wet towel, cold air system
  • Effective for short-term pain relief by numbing the affected area
  • Reduces pain and swelling in acute inflammatory tendinopathies by blocking the inflammatory response
  • Slows the release of blood and proteins from the surrounding blood vessels by decreasing tissue metabolism
  • For cold spray can, spray from 15 cm at least onto the affected skin areas for at least 15 seconds or until with thin white film several times a day
  • When icing through wet towel, apply ice through wet towel for 10 minutes several times a day is very effective in reducing inflammatory pain without the possible side effects and further soft tissue injury
  • When using cold air system, the cold air should be directly blown onto the skin for 10 minutes
  • Contraindications: Frost bite injury, open wounds, cold intolerance, compromised blood flow
  • Side effects: Frost bite, rebound swelling
Heat Application
  • Eg warm compress, use of machine eg infrared rays
  • Help with flexibility by improving blood flow, reducing muscle spasm and increasing the distensibility and flexibility of soft tissues
  • Should be applied to areas with joint stiffness and muscle spasm for 20 minutes prior to flexibility exercises
  • Contraindications: Inflamed body part, open wound, body area with compromised blood flow
  • Side effects: Burns, increased inflammation
Physical Therapy
  • Has more intermediate-term and long-term benefits
  • Includes physical modalities, postural training and awareness, proper body mechanics and therapeutic exercises
  • Physical modalities include conventional strategies and novel or innovative technologies
  • Conventional strategies cover thermal modalities (ie superficial heat [hot moist pack, infrared ray], deep heat [therapeutic USG, diathermy, high intensity laser therapy]), electrotherapy, and combination of conventional modalities
    • Therapeutic USG produces high frequency vibrations that generate heat which penetrates superficial tissues and improve blood flow, reduces pain and promotes collagen synthesis, is effective for treatment of calcific tendinopathy, but evidence for consistent benefit in tendinopathies is weak
    • Electrotherapy uses electrical muscle stimulation to retard muscle atrophy secondary to disuse; it uses transcutaneous electrical nerve stimulation to desensitize peripheral nerves, block pain signals and/or increase endogenous opioids
    • Combination of conventional modalities is widely used and may be effective
      • Iontophoresis is effective in improving patellar and Achilles tendinopathy pain and function; corticosteroid is usually employed
      • Phonophoresis employs electrical and ultrasonographic impulses to deliver topical NSAIDs and corticosteroids to painful body parts
  • Novel or innovative technologies include a combination of the different conventional modalities, electromagnetic therapy, extracorporeal shock wave therapy (ESWT), light therapy (ie low level laser therapy [LLLT], high level laser therapy [HILT]), and taping
    • Combination of targeted radiofrequency and Capacitive and Resistive Energy Transfer (TECAR) therapy maybe considered
    • ESWT utilizes acoustic, low-energy shock waves directly over the painful area of the tendon to alter the structural and neurochemical properties of tissues; indicated for the treatment of lateral epicondylitis, calcific and noncalcific tendonitis of the supraspinatus and Achilles tendinopathy
      • Appears to be safe and effective in reducing pain and enhancing tendon healing
      • Types of ESWT being utilized include radial, piezoelectric and electroacoustic
  • Therapeutic exercises involves flexibility, strengthening, aerobic and neuromuscular training that should be done for <30-60 minutes, 3-5 days per week
    • Exercise program should be modified based on patient’s response after 6-12 weeks; if patient improves, the exercise program should be continued for 6-12 months
    • Includes warm up, stretching exercises, strengthening, aerobic exercises, cool down, and breathing/relaxation techniques
    • Stretching exercises can be done either before or after conditioning exercises, or following an activity when muscles are warm
      • Stretching before an activity does not prevent injury
      • Stretching with deep friction massage of the gastrocnemius-soleus complex are considered helpful in Achilles tendinopathy
    • Strengthening helps promote the formation of new collagen
      • Isometric strengthening exercises may be appropriate during the acute phase of tendinopathy
      • Progress to eccentric strengthening after the pain has subsided
      • A 12-week course of eccentric strengthening program was more effective than traditional concentric strengthening exercises for treating patellar and Achilles tendinopathy
      • There is improvement in pain levels, in addition to thinning and normalization of the tendons on US and MRI of patients with Achilles tendinopathy
      • Showed success in treating lateral epicondylitis by improvement in pain, strength and function
      • More effective when combined with static stretching exercises, therapeutic USG, ESWT, ionophoresis, and LLLT
      • A heavy-load, slow-speed concentric/eccentric exercise program may also used to decrease pain and improve function in patients with Achilles tendinopathy if without presumed fragility of the tendon structure
    • Aerobic exercises improve metabolic diseases such as obesity, diabetes mellitus type 2 and hyperlipidemia, which are considered as risk factors for some tendinopathy
Occupational Therapy
  • Biomechanical or activity modification
    • Several studies have found associations between abnormal biomechanics or specific performance characteristics and development of tendinopathy
    • Specific performance or biomechanics of major tasks that may contribute to tendinopathy should be analyzed and optimized
  • Work simplification
  • Workplace ergonomics
  • Therapeutic activities
Orthotics (Braces)
  • An external medical appliance that is used to immobilize, reinforce, unload and/or protect tendons during activity
    • Elbow bands can reduce pain in lateral epicondylitis
    • Thumb spica for De Quervain Tenosynovitis
  • Knee braces include soft, compression, wrap around, band straps, open or closed patella and open or closed popliteal, which are commonly prescribed by most physicians for those soft tissue with or without ligamentous injury

Investigational Treatments

Autologous Blood Injection
  • Uses whole blood or platelet-rich plasma (PRP)
  • Studies have shown improvement in pain and functional disability in patients treated with PRP injection
  • The injected blood may contain growth factors that stimulates healing of the affected tendon
  • Protocols for PRP administration vary but 1 to 4 intratendinous injections over 2 weeks is common
  • May be done when patient is unresponsive to both conservative and pharmacological therapies
  • Can be done either blindly or under ultrasound (US) guidance
Extracorporeal Shock Wave Therapy (ESWT)
  • Utilizes acoustic, low-energy shock waves directly over the painful area of the tendon to alter the structural and neurochemical properties of tissues
  • Decreases pain and enhances tendon healing
  • Appears to be safe and effective
  • May be used to treat lateral epicondylitis, calcific and noncalcific tendonitis of the supraspinatus and Achilles tendinopathy
Iontophoresis and Phonophoresis
  • Electrical and ultrasonographic impulses are used to deliver topical NSAIDs and corticosteroids to symptomatic subcutaneous tissues
  • Widely used and may be effective
  • Corticosteroid iontophoresis is effective in improving patellar and Achilles tendinopathy pain and function
  • Chronic tendinopathy is associated with neovascularization of affected tendon
  • Injection of a sclerosing agent (eg Polidocanol) under Doppler US guidance may help reduce neovascularity and appear to provide pain relief based on small clinical trials for chronic midportion Achilles and patellar tendinopathy
  • Larger clinical trials are needed to determine the effectiveness of this treatment

Therapeutic Ultrasonography

  • Produces high frequency vibrations that generate heat which penetrates superficial tissues and improve bloodflow
  • Reduces pain and promotes collagen synthesis
  • Effective for treatment of calcific tendinopathy
  • Evidence for consistent benefit in tendinopathies is weak
Ultrasound (US)-Guided Galvanic Electrolysis Technique
  • Used for the treatment of refractory tendon injuries
  • Treatment produces a dissociation of water, salts and amino acids in the extracellular matrix that creates new molecules through ionic instability which leads to the production of new immature collagen fibers that become mature by means of eccentric stimulus
Nutritional Supplements
  • Oral supplementation with glucosamine and chondroitin sulfate, vitamin C, hydrolyzed type 1 collagen, curcumin, boswellic acid and methylsulfonylmethane (MSM) may be considered at the early stages of tendinopathy
  • Combination of different nutritional supplements have been found to be more effective compared to those containing single ingredients
Other Therapies
  • Dry needling and acupuncture may be combined with local injection under US guidance and eccentric exercise to decrease pain for individuals with symptoms lasting >3 months with increased tendon thickness
  • Stem cell therapy (eg mesenchymal stem cells) are purported to have regenerative effects by direct incorporationinto injured and adjacent tissue
  • Prolotherapy which involves injection of dextrose and lidocaine intratendinously or at the enthesis to stimulate repair
  • Further studies are needed to prove the efficacy of radiofrequency, botulinum toxin, bone marrow aspirate, low-level laser therapy and Kinesio tape in tendinopathy
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