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Tendinopathies (Main)

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Other Names

  • Tendinitis
  • Tendinosis
  • Tendinopathy


  • Pain in or around tendons that is activity related is traditionally called tendonitis
  • Tendinitis refers to acute injuries, while tendinopathy or tendinosis refers to chronic degenerative changes of the tendon
  • Tendinopathy is a broad term encompassing painful, degenerative conditions occurring in and around tendons in response to overuse [1]
  • Most cases of tendinopathy are due to overuse, repetitive injuries, although acute trauma can cause the same symptoms
  • Failure rate of management is as high as 25%[2]


Chronic Tendinopathy

  • The prolonged repetitive stress puts mechanical stress on the tendon leading to "microtears" or "microruptures"
  • Subsequently, the healing process is altered
  • Histologic changes seen in chronic tendinopathies includes:[3]
    • Collagen degradation
    • Vascular ingrowth
    • Fibrocartilage metaplasia
    • Also noted is the absence of inflammatory cells

Tendon Biomechanics

Models of Tendinopathy

  • Inflammation
    • Research suggests there is little to no inflammation present when a tendinitis becomes a tendinopathy
    • This is being called into question. Dean et al has shown that inflammatory response is a key component of chronic tendinopathy[4]
    • For example, an increase number of cytokines, inflammatory prostaglandins, and metalloproteinases (MMPs) and tendon cell apoptosis seem to be provoked by continuing mechanical stimuli[5]

Risk Factors


  • Training errors
  • Hill work
  • Technique
  • Fatigue
  • Playing surface
  • Footwear
  • Increasing training volume or intensity too quickly
  • Excessive use of static stretching


  • Genetics
    • COL5A1
    • MMP3
    • Tenascin-C
  • Age
    • <18: Myotendinous junction
    • 18-55: Increasing incidence achilles, patellar
    • >55: Rotator cuff
  • Gender
    • Achilles (Male = Female)
    • Patellar (Male > Female)
    • Men: 60% of running related tendinopathy
  • Systemic Disease
  • Hormonal changes
    • Perimenopauysal women due to loss of estrogen
  • Medications

Tendinopathies by Region

Upper Extremity

Lower Extremity


Clinical Features

  • General: Relevant Clinical Exam Tests
  • Physical exam will require evaluation of the affected joints(s)
  • In the case of tendinopathies, patients will have pain with activation of affected muscles and tendons
  • They will typically be pain at the insertion point of the tendon


  • Primarily a clinical diagnosis
  • Radiographs
    • 3 view initial imaging modality of choice
    • May show enthesiophytes in chronic cases
  • MRI
    • To exclude other diagnosis
  • CT
    • Not necessary




  • General
    • Risks of long term use include gastrointestinal, cardiovascular and renal complications
    • Overall, the evidence suggests both oral and local NSAIDS are effective in relieving the pain associated with tendinopathy in the short term (7–14 days)[1]
  • Shoulder bursitis/ tendinitis
    • Naproxen more effective than placebo, less effective than corticosteroid injection of shoulder bursitis tendinitis at 4 weeks[6]
    • Boudreault et al: systematic review demonstrated low-to-moderate evidence they provide short term pain relief, no change in function[7]
      • Category 1A evidence, Similar efficacy to corticosteroid injections
  • Lateral epicondylitis
    • Systematic review showed some support for NSAID use up to 2 weeks[8]
    • No difference between placebo and naproxen at 1 year follow up[9]

Topical NSAIDS

  • Needs to be updated

Topical Nitroglycerin

  • General
    • Limited research[10]
    • Challoumas et al were able to review 10 randomized clinical trials investigating nitroglycerin and tendinopathies: 4 for the rotator cuff, 3 for wrist extensors, 2 for achilles and 1 for patellar tendon.[11]
    • Although the evidence in the individual studies were not great, all of them reported improved pain with topical GTN compared to placebo.

Physical Therapy

Eccentric Strengthening

  • General
    • Multiple studies have shown improvement in tendinopathies using eccentric exercises[12]
  • Achilles Tendinopathy
    • 82% of patients randomized to the eccentric strengthening protocol described improvement in pain levels compared with 36% in the concentric training group[13]
  • Lateral Epicondylitis
    • Eccentric strengthening protocols have also been successful in the treatment of lateral epicondylitis[14]
  • Rotator Cuff tendonitis
    • In one study, 125 patients were randomized to arthroscopic acromioplasty, a formal supervised rotator cuff strengthening program, or a placebo laser treatment.[15]
    • Both the acromioplasty group and the physical therapy group had improved pain scores at 6 months compared with the placebo group
    • There was no difference in pain scores between the two treatment groups.

Extracorporeal Shock Wave Therapy

  • General
    • Optional treatment modality used by some physical therapists
  • Rotator Cuff Tendinitis
    • In patients with calcific tendonitis of the rotator cuff, SWT was beneficial for function, pain and size of calcifications compared to placebo[16]
  • Lateral Epicondylitis
    • 2007 systematic review attempt to summarize the research on SWT for lateral epicondylitis but was limited by significant heterogeneity among included studies.[17]
    • Nonetheless, they concluded there was evidence for effectiveness of shock wave treatment for tennis elbow
    • One randomized, multicenter trial found no difference[18]
  • Patellar Tendinopathy
    • SWT was superior to controls up to 3 years following initiation of therapy[19]
  • Achilles Tendinopathy
    • SWT produced similar improvements in pain and function when compared to eccentric loading[20]

Low Level Laser Treatment (LLLT)

  • General
    • Four systematic reviews have addressed LLLT and all agreed the best current level of evidence does not support its use in the treatment of tendinopathy[21][22][23][24]

Iontophoresis and Phonophoresis

  • General
    • Iontophoresis and phonophoresis involve using ionizing current or ultrasound to deliver medications locally.
    • Typically corticosteroids or NSAIDS
  • Two adequately powered studies showed no benefit[25][26]
  • Lateral Epicondylitis
    • Two adequately powered studies showed no benefit[27][28]

Transverse Friction Massage

  • General
    • Three studies, including a cochrane review and none showed benefit over other physical therapy modalities[29][30][31]

Therapeutic Ultrasound

  • General
    • US results in decreased pain and increased pressure tolerance in patients with epicondylitis, tendinitis, and tenosynovitis[32]
    • Systematic review found no benefit in most disease entities except lateral epicondylitis[33]
  • Lateral Epicondylitis
    • Greater improvements in pain score, weight lifting, grip strength compared to placebo[34]
  • Calcific Tendinitis Shoulder
    • In patients with symptomatic calcific tendinitis of the shoulder, ultrasound treatment helps resolve calcifications and is associated with short-term clinical improvement[35][36]

Therapeutic Hyperthermia

  • Supraspinatous Tendinopathy
    • Patients who received hyperthermia experienced significantly better pain relief compared to ultrasound or exercise[37]
  • Patellar and Achilles Tendinopathy
    • Better improvement in pain compared to ultrasound at 434 MHz[38]


Corticosteroid Injection

  • General
    • Mainstay treatment for many tendinopathies
  • Lateral Epicondylitis
    • Studies show benefit early in treatment, but the long term efficacy has not been demonstrated[39]
    • At six weeks, treatment with corticosteroid injections was more effective than physiotherapy[40]
    • In this study, at 6 weeks, corticosteroid injections were superior, however long-term differences favored physical therapy[41]
    • Early local corticosteroid injection is effective for lateral epicondylitis.[42]
  • Subacromial Bursitis/ Rotator Cuff tendinopathy
    • Some studies have found benefit, others have not
    • Systematic review little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease[43]
    • Triamcinolone was superior to naproxen in the relief of pain (P = 0.04) and the clinical index (P = 0.04) [6]
    • Another study concluded subacromial injection of corticosteroids is an effective short-term therapy for the treatment of symptomatic subacromial impingement syndrome[44]
    • Akgun et al found improvement at acute (1 month) and subacute (3 months) especially when combined with NSAIDS[45]
    • Several studies have found no benfit[46][47]
  • Achilles Tendonitis
    • Risks involved
    • Case reports of achilles tendon rupture after corticosteroid injections[48][49][50]
    • Gill et al performed 83 consecutive inejctions without complication using fluroscopy[51]

Dextrose Prolotherapy

  • General
    • Limited research[52]
  • Rotator cuff tendinopathy
    • Dextrose prolotherapy was superior to placebo for long term pain improvement and patient satisfaction[53]
  • Lateral Epicondylitis
    • A double blind, randomized controlled trial demonstrated that dextrose prolotherapy was well tolerated and effective at reducing pain and improving strength testing in patients with lateral epicondylosis[54]
  • Adductor tendonitis
    • For soccer and rugby players with chronic groin pain from osteitis pubis and/or adductor tendinopathy, dextrose prolotherapy demonstrated a significant reduction in chronic pain[55]
  • Patellar tendonitis
    • In athletes with patellar tendinopathy, there was a reduction in pain and improvement in ultrasound hypoechogenicity following ultrasound guided dextrose prolotherapy[56]
  • Achilles Tendonitis
    • In patients with Achilles tendinopathies, dextrose prolotherapy demonstrated a significant reduction in pain at rest and during tendon loading activities. [57]
    • When combined with eccentric exercises, gave more rapid improvement in symptoms than eccentric exercises alone, however long term VISA-A scores were similar.[58]

Needle Tenotomy

  • General
    • Limited literature
  • Lateral Epicondylitis
    • Nearly 2/3 of patients reported improvement in pain up to 28 months [59]
  • Patellar Tendinitis
    • Improvement in post-procedure pain score and sonographic findings[60]
  • There are favorable case reports for Achilles (4), proximal gluteus medius (1), proximal iliotibial tract (1), proximal hamstring (1), common extensor elbow (1), and proximal rectus femoris (1)[61]


  • General
    • Involves injecting a chemical into a blood vessel and subsequent angiosclerosis
  • Lateral Epicondylitis
    • Sclerotherapy has a potential to reduce the tendon pain and increase grip strength, in patients with chronic painful tennis elbow.[62]
  • Patellar Tendinopathy
    • Sclerosing injections with polidocanol resulted in a significant improvement in knee function and reduced pain in patients with patellar tendinopathy[63]
  • Achilles Tendinopathy
    • Sclerosing neovessels appears to be an effective treatment for painful chronic Achilles tendinosis[64]
    • Treatment with sclerosing polidocanol injections in patients with chronic painful mid-portion Achilles tendinosis showed remaining good clinical results at a 2-year follow-up[65]
    • Injections with the sclerosing substance Polidocanol have the potential to reduce tendon pain during activity in patients with chronic painful mid-portion Achilles tendinopathy[66]

UltraSound Guided Galvanic Electrolysis (USGET)

  • General
    • Ultrasound guided procedure consisting of application of a non-thermal galvanic current through tendons
    • Relatively new technique still requiring investigation
  • Achilles Tendonitis
    • Abat et al found combining USGET with physical therapy was superior to physical therapy plus standard electrophysical therapy[67]

Regenerative Medicine

Stem Cell Therapy

  • General
    • Suffer from lack of standardization in properation or methods of application (i.e. how much and how often)
    • Also which source of stem cells is superior?
  • Lateral Epicondylitis
    • From baseline through 52 weeks of periodic follow-up, VAS scores progressively decreased and tendon defects significantly increased.[68]
  • Patellar Tendonitis
    • Pascual-Garrido et al found inoculation with bone marrow stem cells improved pain in 7 of 8 patients at 5 years follow up[69]

Platelet Rich Plasma

  • General
    • Growing, widespread use in acute and chronic tendon injuries despite overall conflicting evidence and lack of consensus
    • There is no standardization of PRP preperation or application.
    • Examples of lack of consensus include Leukocyte rich or leukoocyte poor? How frequently to inject?
    • Systematic review by Filardo et al: Helped with patellar tendonitis and lateral epicondylitis but not with rotator cuff or achilles tendon[70]
    • Systematic review by Fitzpatrick et al: shown good clinical evidence that favors the use leukocyte-rich PRP (LR-PRP) under ultrasound guidance for the treatment of patellar tendinopathy, lateral epicondylitis, Achilles tendonitis and rotator cuff tendinopathy[71]

Complementary and Alternative Medicine


  • General
    • Very, very limited research
  • Rotator Cuff tendinitis
    • In one study of athletes with rotator cuff tendinitis, a single-blinded study of acupuncture treatment for 4 weeks was superior to placebo for pain relief[72]
    • When using a placebo TENS compared to acupuncture, there was no difference in the treatment of rotator cuff tendinitis[73]
  • Lateral Epicondylitis
    • In patients with lateral epicondylitis, a cochrane review of two small studies demonstrated short term pain benefit of less than 24 hours[74]
  • Achilles Tendinopathy
    • A non-blinded study found acupuncture improved pain and function compared to eccentric exercises[75]


  • General
    • Considered last option when non-surgical plan fails to provide adequate relief of pain and return of function
  • Rotator Cuff Tendinopathy
    • ?Unclear surgical guidelines
  • Lateral Epicondylitis
    • Patients tend to have a low rate of complications[76]
  • Achilles Tendinopathy
    • Overall, poor quality data[77]


  • Chronic Pain
  • Loss of function
  • Inability to return to work

See Also


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  2. ohrer H, David S, Nauck T. Surgical treatment for achilles tendinopathy - a systematic review. BMC Musculoskelet Disord. 2016 May 10;17:207. doi: 10.1186/s12891-016-1061-4. Review. PubMed PMID: 27165287; PubMed Central PMCID: PMC4862213.
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Created by:
John Kiel on 14 June 2019 10:09:02
Last edited:
7 October 2020 11:24:45