Treatment of tendinopathy: what works, what does not, and what is on the horizon

Abstract

Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear.

Level of evidence: Level II, systematic review.

Fig. 1A–C

An eccentric training protocol for the treatment of Achilles tendinopathy is demonstrated. (A) The patient starts in a single-leg standing position with the weight on the forefoot and the ankle in full plantar flexion. (B) The Achilles is then eccentrically loaded by slowly lowering the heel to a dorsiflexed position. (C) The patient then returns to the starting position using the arms or contralateral leg for assistance to avoid concentric loading of the involved Achilles tendon.

Fig. 2A–B

(A) A 5-mg/24-hour glyceryl trinitrate patch is cut into quarters and (B) placed over the area of maximal tenderness/pain as shown in a patient with lateral epicondylitis. The patch is left in place for 24 hours and then replaced with a new quarter patch.

Fig. 3A–C

Injection of a sclerosing agent is shown using Doppler ultrasound for guidance. (A) The presence of neovessels is detected in the Achilles tendon using color Doppler ultrasound before injection. (B) A 23-gauge needle is passed into the area of neovascularization under ultrasound guidance and the sclerosant is injected. (C) Ablation of blood flow within the neovessels is demonstrated after injection of the sclerosing agent.