Treating Tendinopathy: What Harms and What Helps
Tendinopathy (often still called tendinitis) is an extremely common cause of pain around our joints. The condition is usually caused by unaccustomed activity or overuse, and it results in the breakdown of some fibres inside a tendon. It is such a common problem in the aging population that it has been called the “mid-life crisis of a tendon” by researchers Luk, Tsang and Leung in 2014. Here we will review the current research to find out which treatments help, and which treatments might be potentially harmful.
For many years tendinopathy was thought to be an inflammatory problem – hence the ‘itis’ in the old name of tendinitis. Because of this belief, anti-inflammatory medications (both oral and injectable) were the treatment of choice. However, this theory has since been proven wrong. More recent studies have actually shown that non-steroidal anti-inflammatory oral medications may slow down tendon healing 1. Corticosteroids are strong anti-inflammatories, and some patients get short-term relief from a corticosteroid injection. Unfortunately, there is now good evidence showing that these injections result in longer-term damage and breakdown of tendon cells, rather than assisting the healing process 2, 3, 4, 5, 6, 7. It takes a long time for established treatment practices to be phased out, and anti-inflammatory treatments are often still prescribed for tendinopathy treatment, despite the strong evidence against it.
Some treatment options have anecdotal support from some patients, but the available evidence does not allow us to draw strong conclusions. This may be because the research has been of a low quality, or because the benefit from the treatment is usually very small and hard to measure. Further high quality, large studies are needed, before we can confidently recommend:
• Acupuncture 8, 9, 10.
• Low Level Laser Therapy 11, 12.
• Wait and see approach (natural history) 8, 13.
• Shockwave Therapy 6, 14, 15, 16.
• Sclerotherapy 17, 18, 19.
So, what does work? It comes back to the original issue with the tendon – the fibres have been overloaded in some way, and have started to break down. Complete rest may feel good for a while, but a tendon that isn’t doing any work will not get stronger, and may just keep getting weaker. Tendons rebuild their fibres and get stronger again when they are given the right amount of load and work. Specific exercise has been consistently shown to be the most effective and safe treatment for tendinopathy – both for short-term pain relief and for long-term tendon healing. Numerous high-quality studies have proven the effectiveness of specifically-prescribed eccentric and heavy weight exercise 4, 6, 20, 21. Speak to your Physiotherapist about a specific exercise program to treat your painful tendons.
Surgery has been shown to be effective in select patient groups - usually in those who have tried and failed with other treatments 6, 8, 22. However, some studies have found exercise is still more effective than surgery in some patients 23. Surgery is certainly not a ‘quick-fix’ for tendinopathy. It has significantly higher risks than other treatment options, so it should usually be kept as a last resort, rather than a first-line treatment.
1. Magra, M., & Maffulli, N. (2006). Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe.
2. 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.
3. 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.
4. Kongsgaard, M., Kovanen, V., Aagaard, P., Doessing, S., Hansen, P., Laursen, A. H., ... & Magnusson, S. P. (2009). Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scandinavian journal of medicine & science in sports, 19(6), 790-802.
5. Gaujoux-Viala, C., Dougados, M., & Gossec, L. (2008). Efficacy and safety of steroid injections for shoulder and elbow tendonitis: A meta-analysis of randomized controlled trials. Annals of the rheumatic diseases.
6. 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.
7. Dean, B. J. F., Lostis, E., Oakley, T., Rombach, I., Morrey, M. E., & Carr, A. J. (2014, February). The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. In Seminars in arthritis and rheumatism (Vol. 43, No. 4, pp. 570-576). WB Saunders.
8. 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.
9. Chang, W. D., Lai, P. T., & Tsou, Y. A. (2014). Analgesic effect of manual acupuncture and laser acupuncture for lateral epicondylalgia: a systematic review and meta-analysis. The American journal of Chinese medicine, 42(06), 1301-1314.
10. Ural, F. G., Öztürk, G. T., Bölük, H., & Akkuş, S. (2017). Ultrasonographic Evaluation of Acupuncture Effect on Common Extensor Tendon Thickness in Patients with Lateral Epicondylitis: A Randomized Controlled Study. The Journal of Alternative and Complementary Medicine.
11. Bjordal, J. M., Lopes-Martins, R. A., Joensen, J., Couppe, C., Ljunggren, A. E., Stergioulas, A., & Johnson, M. I. (2008). A systematic review with procedural assessments and meta-analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskeletal Disorders, 9(1), 75.
12. Haslerud, S., Magnussen, L. H., Joensen, J., Lopes‐Martins, R. A. B., & Bjordal, J. M. (2015). The efficacy of low‐level laser therapy for shoulder tendinopathy: a systematic review and meta‐analysis of randomized controlled trials. Physiotherapy Research International, 20(2), 108-125.
13. Sayegh, E. T., & Strauch, R. J. (2015). Does nonsurgical treatment improve longitudinal outcomes of lateral epicondylitis over no treatment? A meta-analysis. Clinical Orthopaedics and Related Research®, 473(3), 1093-1107.
14. 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.
15. Sims, S. E., Miller, K., Elfar, J. C., & Hammert, W. C. (2014). Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand, 9(4), 419-446.
16. Sanzo, P. (2015). The Treatment of Chronic Rotator Cuff Tendinopathy of the Shoulder with Radial Shockwave Therapy. Clinical Practice, 4(1), 6-11.
17. Hoksrud, A., Torgalsen, T., Harstad, H., Haugen, S., Andersen, T. E., Risberg, M. A., & Bahr, R. (2012). Ultrasound-guided sclerosis of neovessels in patellar tendinopathy: a prospective study of 101 patients. The American journal of sports medicine, 40(3), 542-547.
18. Morath, O., Kubosch, E. J., Taeymans, J., Zwingmann, J., Konstantinidis, L., Südkamp, N. P., & Hirschmüller, A. (2017). The effect of sclerotherapy and prolotherapy on chronic painful Achilles tendinopathy–a systematic review including meta‐analysis. Scandinavian Journal of Medicine & Science in Sports.
19. Öhberg, L., & Alfredson, H. (2002). Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment. British Journal of Sports Medicine, 36(3), 173-175.
20. Magnussen, R. A., Dunn, W. R., & Thomson, A. B. (2009). Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clinical Journal of Sport Medicine, 19(1), 54-64.
21. Ortega-Castillo, M., & Medina-Porqueres, I. (2016). Effectiveness of the eccentric exercise therapy in physically active adults with symptomatic shoulder impingement or lateral epicondylar tendinopathy: A systematic review. Journal of science and medicine in sport, 19(6), 438-453.
22. Traina, F., Perna, F., Ruffilli, A., Mazzotti, A., Meliconi, R., Berti, L., & Faldini, C. (2016). Surgical treatment of insertional Achilles tendinopathy: a systematic review. Journal of biological regulators and homeostatic agents, 30(4 Suppl 1), 131-138.
23. Bahr, R., Fossan, B., Løken, S., & Engebretsen, L. (2006). Surgical treatment compared with eccentric training for patellar tendinopathy (jumper's knee): a randomized, controlled trial. JBJS, 88(8), 1689-1698.