Tendon Supplements: What Works?
Tendinopathy (which used to be called tendinitis) is a common and painful condition that is becomes more common as we age, due to changes in tendon health and function. Tendinopathy is so common, and sometimes so debilitating and persistent, that there is a widespread hunt to find a supplement that improves tendon health - whether it is taken as a tablet, applied to the skin, or injected into the tendon. This post looks at some of the more common supplements on the market, and reviews the available scientific research on their effectiveness.
Oral tendon supplements such as TENDONACTIV, include a combination of cellular products found in healthy human tendons (mucopolysaccharides and collagen type 1) with other substances including vitamin C, MSM (Methylsulfonylmethane) or bromelain. There are very few high-quality studies available in the current research, so the jury is still out on their effectiveness. Some studies suggest that these supplements may provide short term pain relief for tendinopathy and might increase the rate of healing 1-4.
Another commonly advertised tendon supplement is topical Glyceryl Trinitrate, usually applied in the form of a patch over the painful tendon. Several low-quality studies suggest it may provide short-term pain relief and ongoing tendon healing benefits for up to 3 years after application 5-7. Other higher-quality studies showed no effect at all, either short term or long term 8. Current research into Glyceryl Trinitrate is conflicting, so we cannot yet draw strong conclusions about its effectiveness.
The use of injectable tendon supplements has increased significantly in recent years. The most common include: autologous blood, platelet rich plasma (PRP) and hyaluronic acid.
Autologous blood injections are the injection of the patient’s own blood directly into the damaged part of a tendon, in the hope of stimulating healing. Unfortunately, once again, only a very few small-scale studies have been published, so we cannot draw conclusions with any confidence. These injections may have a small positive effect on pain and function when combined with exercise 9-11. Further high-quality research is still needed.
Platelet rich plasma (PRP) injections involve a sample of the patient’s blood being processed in a centrifuge to collect the platelets – the cells in the blood thought to be most responsible for assisting in tendon healing. These concentrated platelets are then injected into the damaged tendon. PRP injections have been researched more thoroughly, and we can suggest with reasonable confidence that PRP injections might be helpful in decreasing pain and promoting tendon healing, particularly when paired with physiotherapy exercises 10, 12-17. PRP injections have been compared with placebo injections in a large number of moderate-quality studies, and PRP offers better long term outcomes 18-23.
Hyaluronic Acid is a polysaccharide found throughout the body’s connective tissues. It is widely used by the cosmetics industry, and has more recently been trialled as an injection for tendinopathy. The research is very limited at present, but may indicate improved short term pain levels 24-26.
Areas of future interest to prevent or treat tendinopathy include hormone replacement therapy (HRT) and mesenchymal stem cell treatment. HRT has shown promising results in preventing tendinopathy in active post-menopausal women 27, however further research is required. Stem cell therapy is in the very early stages of research, but is currently failing to show positive results 28, 29.
In summary, no tendon supplement has yet been convincingly shown to have strong positive effects, and one should use caution in spending money on these adjuncts to treatment. For information about treatment options that are more likely to be of benefit, see our post on Tendinopathy Treatment.
1. Gumina, S., Passaretti, D., Gurzi, M. D., & Candela, V. (2012). Arginine L-alpha-ketoglutarate, methylsulfonylmethane, hydrolyzed type I collagen and bromelain in rotator cuff tear repair: a prospective randomized study. Current medical research and opinion, 28(11), 1767-1774.
2. Fusini, F., Bisicchia, S., Bottegoni, C., Gigante, A., Zanchini, F., & Busilacchi, A. (2016). Nutraceutical supplement in the management of tendinopathies: a systematic review. Muscles, ligaments and tendons journal, 6(1), 48.
3. Ingwersen, K. G., Jensen, S. L., Sørensen, L., Jørgensen, H. R., Christensen, R., Søgaard, K., & Juul-Kristensen, B. (2017). Three Months of Progressive High-Load Versus Traditional Low-Load Strength Training Among Patients With Rotator Cuff Tendinopathy: Primary Results From the Double-Blind Randomized Controlled RoCTEx Trial. Orthopaedic Journal of Sports Medicine, 5(8), 2325967117723292.
4. Binh, B. H., Ramirez, P., & Martinez-Puig, D. (2014). THU0338 A Randomized, Placebo-Controlled Study to Evaluate Efficacy and Safety of A Dietary Supplement Containing Mucopolysaccharides, Collagen Type I and Vitamin C for Management of Different Tendinopathies. Annals of the Rheumatic Diseases, 73(Suppl 2), 299-299.
5. Paoloni, J. A., Murrell, G. A. C., Burch, R. M., & Ang, R. Y. (2009). Randomised, double-blind, placebo-controlled clinical trial of a new topical glyceryl trinitrate patch for chronic lateral epicondylosis. British journal of sports medicine, 43(4), 299-302.
6. Cumpston, M., Johnston, R. V., Wengier, L., & Buchbinder, R. (2009). Topical glyceryl trinitrate for rotator cuff disease. The Cochrane Library.
7. Ozden, R., Uruc, V., Doğramaci, Y., Kalaci, A., & Yengil, E. (2014). Management of tennis elbow with topical glyceryl trinitrate. Acta Orthop Traumatol Turc, 48(2), 175-80.
8. Kane, T. P., Ismail, M., & Calder, J. D. (2008). Topical glyceryl trinitrate and noninsertional Achilles tendinopathy: a clinical and cellular investigation. The American journal of sports medicine, 36(6), 1160-1163.
9. Kazemi, M., Azma, K., Tavana, B., Moghaddam, F. R., & Panahi, A. (2010). Autologous blood versus corticosteroid local injection in the short-term treatment of lateral elbow tendinopathy: a randomized clinical trial of efficacy. American journal of physical medicine & rehabilitation, 89(8), 660-667.
10. Creaney, L., Wallace, A., Curtis, M., & Connell, D. (2011). Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections. British journal of sports medicine, bjsports82503.
11. De Vos, R. J., Van Veldhoven, P. L. J., Moen, M. H., Weir, A., Tol, J. L., & Maffulli, N. (2010). Autologous growth factor injections in chronic tendinopathy: a systematic review. British medical bulletin, 95(1), 63-77.
12. Filardo, G., Kon, E., Di Matteo, B., Di Martino, A., Tesei, G., Pelotti, P., ... & Marcacci, M. (2014). Platelet-rich plasma injections for the treatment of refractory Achilles tendinopathy: results at 4 years. Blood Transfusion, 12(4), 533.
13. Monto, R. R. (2014). Platelet-rich plasma efficacy versus corticosteroid injection treatment for chronic severe plantar fasciitis. Foot & ankle international, 35(4), 313-318.
14. Mishra, A. K., Skrepnik, N. V., Edwards, S. G., Jones, G. L., Sampson, S., Vermillion, D. A., ... & Rettig, A. C. (2014). Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. The American journal of sports medicine, 42(2), 463-471.
15. Horstmann, H., Clausen, J. D., Krettek, C., & Weber-Spickschen, T. S. (2017). Evidence-based therapy for tendinopathy of the knee joint: Which forms of therapy are scientifically proven?. Der Unfallchirurg, 120(3), 199.
16. Everhart, J. S., Cole, D., Sojka, J. H., Higgins, J. D., Magnussen, R. A., Schmitt, L. C., & Flanigan, D. C. (2017). Treatment Options for Patellar Tendinopathy: A Systematic Review. Arthroscopy: The Journal of Arthroscopic & Related Surgery.
17. de Vos, R. J., Weir, A., van Schie, H. T., Bierma-Zeinstra, S. M., Verhaar, J. A., Weinans, H., & Tol, J. L. (2010). Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. Jama, 303(2), 144-149.
18. Carr, A. J., Murphy, R., Dakin, S. G., Rombach, I., Wheway, K., Watkins, B., & Franklin, S. L. (2015). Platelet-rich plasma injection with arthroscopic acromioplasty for chronic rotator cuff tendinopathy: a randomized controlled trial. The American journal of sports medicine, 43(12), 2891-2897.
19. Dragoo, J. L., Wasterlain, A. S., Braun, H. J., & Nead, K. T. (2014). Platelet-rich plasma as a treatment for patellar tendinopathy: a double-blind, randomized controlled trial. The American journal of sports medicine, 42(3), 610-618.
20. de Vos, R. J., Windt, J., & Weir, A. (2014). Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med, 48(12), 952-956.
21. Kesikburun, S., Tan, A. K., Yılmaz, B., Yaşar, E., & Yazıcıoğlu, K. (2013). Platelet-rich plasma injections in the treatment of chronic rotator cuff tendinopathy: a randomized controlled trial with 1-year follow-up. The American journal of sports medicine, 41(11), 2609-2616.
22. Coombes, B. K., Bisset, L., & Vicenzino, B. (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. The Lancet, 376(9754), 1751-1767.
23. Moraes, V. Y., Lenza, M., Tamaoki, M. J., Faloppa, F., & Belloti, J. C. (2014). Platelet‐rich therapies for musculoskeletal soft tissue injuries. The Cochrane Library.
24. Frizziero, A., Vittadini, F., Barazzuol, M., Gasparre, G., Finotti, P., Meneghini, A., ... & Masiero, S. (2017). Extracorporeal shockwaves therapy versus hyaluronic acid injection for the treatment of painful non-calcific rotator cuff tendinopathies: preliminary results. The Journal of sports medicine and physical fitness, 57(9), 1162-1168.
25. Kumai, T., Muneta, T., Tsuchiya, A., Shiraishi, M., Ishizaki, Y., Sugimoto, K., ... & Takakura, Y. (2014). The short-term effect after a single injection of high-molecular-weight hyaluronic acid in patients with enthesopathies (lateral epicondylitis, patellar tendinopathy, insertional Achilles tendinopathy, and plantar fasciitis): a preliminary study. Journal of Orthopaedic Science, 19(4), 603-611.
26. Flores, C., Balius, R., Álvarez, G., Buil, M. A., Varela, L., Cano, C., & Casariego, J. (2017). Efficacy and Tolerability of Peritendinous Hyaluronic Acid in Patients with Supraspinatus Tendinopathy: a Multicenter, Randomized, Controlled Trial. Sports Medicine-Open, 3(1), 22.
27. Peters, J. A., Zwerver, J., Diercks, R. L., Elferink-Gemser, M. T., & van den Akker-Scheek, I. (2016). Preventive interventions for tendinopathy: A systematic review. Journal of science and medicine in sport, 19(3), 205-211.
28. Usuelli, F. G., Grassi, M., Maccario, C., Lanfranchi, L., Montrasio, U. A., & de Girolamo, L. (2017). Intratendinous adipose-derived stromal vascular fraction (SVF) injection provides a safe, efficacious treatment for Achilles tendinopathy: results of a randomized controlled clinical trial at a 6-month follow-up. Knee Surgery, Sports Traumatology, Arthroscopy, 1-11.
29. Pas, H. I., Moen, M. H., Haisma, H. J., & Winters, M. (2017). No evidence for the use of stem cell therapy for tendon disorders: a systematic review. Br J Sports Med, bjsports-2016.