Approach Considerations
The goal of treatment is to reduce pain and to return to activity. Nonpharmacologic treatments of tendinopathy are as follows:
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Rest or decrease activity level. No clear recommendations are available for the duration of rest; however, patients should restrict activities that cause pain.
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Cooling is recommended for the first 24-48 hours.
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Splinting and/or immobilization; sling for rotator cuff tendonitis
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Strengthening and stretching exercises can be performed once the pain has subsided. Eccentric strength training can be effective in treating tendinopathies.
Treatment for iliotibial band syndrome is conservative and consists of a combination of rest, stretching, and strength training as well as a modification of the running technique. The goal of hip-strengthening exercises should be to improve muscular endurance rather than to build maximum strength. [7]
Low-intensity pulsed ultrasound was shown to be no more effective than placebo in the treatment of patellar tendinopathy. [8] Transcutaneous electrical nerve stimulation (TENS) provided no benefit over primary care management in a randomized trial in 241 adults with tennis elbow. [9]
Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in relieving tendinopathy pain, and may be administered topically or orally. However, because the vast majority of tendinopathies are not inflammatory, whether NSAIDs are more effective than other analgesics is unclear.
Corticosteroid injection may be considered for patients with tendonitis in whom conservative therapy with rest, immobilization, and anti-inflammatory agents has failed.The corticosteroid (eg, triamcinolone) is typically combined with a local anesthetic (eg, lidocaine) to provide prompt analgesia; in addition, pain relief confirms the diagnosis and accurate placement of the corticosteroid.
The efficacy of locally injected steroids is debated. A systematic review concluded that steroid injections provide short-term pain relief but may not have long-term efficacy. [10] Response to injection therapy may vary with the anatomic site of tendinopathy.
A randomized, controlled trial in 165 patients with unilateral lateral epicondylalgia of longer than 6 weeks' duration found that although results at 4 weeks favored corticosteroid injection, at 1 year the rate of much improvement or complete recovery was lower with corticosteroid injection than with placebo injection (83% vs 96%, respectively; relative risk [RR], 0.86; P = 0.01)). One-year recurrence was also higher with corticosteroid versus placebo (54% vs 12%; RR, 0.23; P< 0.001). [11]
Never use injections for Achilles tendonitis, because cases of Achilles tendon rupture have been reported following a single injection of corticosteroid. Avoid repetitive corticosteroid injections in any site, as well as injection directly into a tendon, because of the risk of tendon rupture. The use of ultrasound to direct these treatments improves accuracy and performance by facilitating visualization of the target and relevant adjacent structures. [12]
In patients with calcific tendonitis of the shoulder, a systematic review concluded that ultrasound (US)-guided needling and lavage has a high success rate and low complication rate. [13] In a randomized controlled study in 48 patients with calcific tendonitis of the rotator cuff that compared the combination of barbotage and US-guided corticosteroid injection in the subacromial bursa with subacromial bursa injection alone, both treatment groups demonstrated improvement at 1-year follow-up, but clinical and radiographic results were significantly better in the barbotage group. [14] After US-guided treatment, recovery may be enhanced by use of a rehabilitation protocol that focuses on mobility, strength, and function. [15]
A retrospective evaluation of double-needle US-guided percutaneous fragmentation and lavage (DNL) in 147 patients with rotator cuff calcific tendinitis found DNL to be safe and effective, with prompt relief of pain and function restoration. [16] However, a systematic review of the efficacy of US-guided needle lavage in treating calcific tendinitis found a lack of high-quality evidence to determine the relative efficacy. [17]
Surgical therapy
Patients with symptoms resistant to conservative therapy may benefit from arthroscopic or open surgical treatment for tendon decompression and tenodesis. A Japanese study in 23 patients with chronic lateral epicondylitis who underwent arthroscopic surgery found that the procedure provided significant improvement in pain and functional recovery up to 3 months after surgery. However, the visual analog scale (VAS) for pain and satisfaction criteria during activity did not fall below 10 points until 6 months postoperatively. [18]
A systematic review of surgical outcomes for the treatment of medial epicondylitis in 479 elbows included 13 studies of open approaches, two studies of arthroscopic approach, and one study with a percutaneous approach. Success rates were in the range of 63-100%, and the complication rate was low, at 4.3%. The rate of return to sports was 81-100%, and that of return to work was 66.7-100% (only one study reported a return-to-work rate lower than 90%). The evidence was insufficient to determine superiority among the three approaches. [19]
Isolated gastrocnemius recession has been shown to provide significant and sustained pain relief for chronic Achilles tendinopathy. Good function can be expected for activities of daily living, however ankle plantarflexion power and endurance deficits were noted. [20, 21]
Platelet-rich therapies
Platelet-rich therapies represent an experimental approach to treatment of tendinopathies and other musculoskeletal soft tissue injuries. In this technique, a quantity of the patient's blood is centrifuged and the active, platelet-rich fraction is extracted and applied to the injured tissue (eg, by injection). Platelet-rich plasma (PRP) has the potential to promote cell proliferation and differentiation, regulate angiogenesis, increase extracellular matrix synthesis, and modulate inflammation in degenerative tendons. [22] In theory, the growth factors produced by platelets should enhance tissue healing.
Although platelet-rich therapies are gaining wider use, however, few level one studies exist demonstrating a clear benefit. [23, 24] Systematic reviews of the literature have concluded that evidence of benefit for the use of PRP as a treatment for tendinopathies varies by site. There is evidence to support PRP injections for the treatment of lateral elbow and patellar tendinopathy, whereas evidence remains insufficient to support PRP for Achilles tendon or rotator cuff pathology. [25, 26]
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Hawkins test. The examiner forward flexes the arms to 90° and then forcibly internally rotates the shoulder. This movement pushes the supraspinatus tendon against the anterior surface of the coracoacromial ligament and coracoid process. Pain indicates a positive test result for supraspinatus tendonitis.
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Speed test.
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Yergason test.
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The proximal patellar tendon is most commonly affected in jumper's knee.
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Iliotibial band at the lateral femoral condyle, with the posterior fibers denoted.
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The Ober test.
