Tendinopathy is a clinical syndrome characterized by tendon thickening and localized tendon pain, swelling or impaired performance.
It usually is a temporary condition if treated early but may also be recurrent or chronic.
Principles of therapy include: ddentification & elimination of the cause of tendinopathy, behavior modification to minimize or eliminate sources of continuing irritation, specialist referral for appropriate follow up care and to reduce pain & to return function


Tendinopathy Treatment

Principles of Therapy

  • Identification & elimination of the cause of tendinopathy
  • Behavior modification to minimize or eliminate sources of continuing irritation
  • Specialist referral for appropriate follow up care
  • To reduce pain & to return function


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

Non-Pharmacological Therapy

Relative Rest

  • Refers to avoidance of abuse & not absence of activity
  • Appropriate treatment during the acute phase of tendinopathy pain
  • Prevents ongoing damage, decreases pain & promotes tendon healing
  • Avoid activities that are heavy & 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 & promotes normal alignment of newly formed collagen fibers
  • Avoid complete immobilization to prevent muscle atrophy & 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
  • Effective for short-term pain relief
  • Reduces pain & swelling in acute inflammatory tendinopathies by blocking the inflammatory response
  • Slows the release of blood & proteins from the surrounding blood vessels by decreasing tissue metabolism
  • Based on a recent systematic review of cryotherapy, application of ice through wet towel for 10-minutes is very effective
Strengthening & Stretching Exercises
  • Appropriate during the acute phase of tendinopathy pain
  • Performed after the pain has subsided
  • Helps promote the formation of new collagen
  • Eccentric strengthening is an effective therapy for tendinopathies
    • A 12-week course of eccentric strengthening program was more effective than the traditional concentric strengthening exercises for treating patellar & Achilles tendinopathy
      • There is improvement in pain levels, & thinning & normalization of the tendons on ultrasound & magnetic resonance imaging (MRI) of patients w/ Achilles tendinopathy
    • Showed success in treating lateral epicondylitis by improvement in pain, strength & function
    • More effective when combined w/ static stretching exercises, therapeutic ultrasonography, extracorporeal shock wave therapy (ESWT), ionophoresis, or low level laser therapy
  • Perform stretching exercises following activity, when muscles are warm
    • Stretching before an activity does not prevent injury & may lead to decrease in muscle strength
  • Regular stretching should be done 3-5 days/week
  • Stretching w/ deep friction massage of the gastrocnemius-soleus complex are considered helpful in Achilles tendinopathy
  • Modify the exercise program based on patient’s response after 6-12 weeks
  • If patient improves, continue the exercise program for 6-12 months

Activity Modification

  • Important that employers & coaches be aware of the treatment plan (eg limit the volume & intensity of loads on the injured tendon for a designated period)
    • Necessary to eliminate pain & promote tendon healing
Biomechanical Modification
  • Several studies have found associations between abnormal biomechanics or specific performance characteristics & development of tendinopathy
  • Specific performance or biomechanics of the task should be evaluated & analyzed by a knowledgeable sports medicine clinician, ergonomics specialist, or a trained physiotherapist or kinesiologist
Orthotics & Braces
  • Used as adjuncts to reinforce, unload & protect tendons during activity
  • Safe, widely used & helpful in correcting biomechanical problems (eg excessive foot pronation, pes planus deformity)

Investigational Treatments

Autologous Blood Injection
  • Uses whole blood or platelet-rich plasma
  • Studies have shown improvement in pain & functional disability in patients treated w/ platelet-rich plasma injection
  • The injected blood may contain growth factors that stimulates healing of the affected tendon
  • May be done only when patient is unresponsive to both conservative & pharmacological therapies
Extracorporeal Shock Wave Therapy (ESWT)
  • Utilizes acoustic, low-energy shock waves directly over the painful area of the tendon to alter the structural & neurochemical properties of tissues
  • Decreases pain & enhances tendon healing
  • Appears to be safe & effective
  • May be used to treat lateral epicondylitis, calcific & noncalcific tendonitis of the supraspinatus & Achilles tendinopathy
Iontophoresis & Phonophoresis
  • Electrical & ultrasonographic impulses are used to deliver topical nonsteroidal anti-inflammatory drugs (NSAIDs) & corticosteroids to symptomatic subcutaneous (SC) tissues
  • Widely used & may be effective
  • Corticosteroid iontophoresis is effective in improving patellar tendinopathy pain & function
  • Chronic tendinopathy is associated w/ neovascularization of affected tendons
  • Injection of a sclerosing agent (eg Polidocanol) may help reduce neovascularity based on small clinical trials for chronic midportion Achilles & patellar tendinopathy
    • Injections appear to provide pain relief
    • Injections are done under Doppler ultrasound guidance
  • 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 & improve blood flow
  • Reduces pain & promotes collagen synthesis
  • Effective for treatment of calcific tendinopathy
  • Evidence for its consistent benefit in tendinopathies is weak
Editor's Recommendations
Most Read Articles
Pearl Toh, 26 Nov 2020
Inhaled corticosteroid (ICS) should be the mainstay of long-term asthma management — such is the key message of the latest Singapore ACE* Clinical Guidance (ACG) for asthma, released in October 2020.
Roshini Claire Anthony, 2 days ago

Individuals with obstructive sleep apnoea (OSA) may have an increased risk of COVID-19, with the risk reducing with adherence to positive airway pressure (PAP) therapy, according to a study presented at ATS 2021.

Roshini Claire Anthony, 08 Jun 2021

Year 6 and 7 cumulative data from the Mirena Extension Trial suggest that the efficacy and safety of the levonorgestrel-releasing intrauterine system (LNG-IUS) as a contraceptive method is maintained over this time frame.

06 May 2021
In a webinar held on 27 March 2021, paediatric endocrinology nurses Karen Blair, Kate Davies, and Siti Zarina Yaakop shared insights and clinical experience based on their frontline roles in caring for patients with central precocious puberty (CPP) and supporting their family members.