Treatment Guideline Chart

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
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