The primary goal in treating tendonitis (inflammation of the tendons) is to reduce pain and enable return of the activity. Relative rest of the affected area, stretching, ice and analgesics have been shown as an effective approach to his problem. Surgery is necessary only in severe and protracted cases.

Conventional treatments

Conservative treatments are often used successfully to fight acute symptoms of pain and inflammation; however, they do not modify the histological structure of the tendon. Even when such treatment is started early, the pain can last longer than three months and up to six months if the therapy was delayed for any reason.

The most important step in reducing pain is to rest and thus reduce repetitive loading of the damaged tendon. Still, complete immobilization should be avoided to prevent the development of muscular atrophy. Cryotherapy or icing is also an effective modality for reducing swelling and pain by blunting the inflammatory response. The recommendation is to apply the ice through a wet towel for 10-minute periods.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen are effective in reducing the inflammation through the inhibition of the synthesis of inflammatory cells and other factors, such as prostaglandins. Topical NSAIDs can also reduce pain in cases of tendonitis and they do not contain risk of gastrointestinal hemorrhage when compared to systemic ones.

Corticosteroid injections have some short-term benefits in providing pain relief, although more research is needed for optimal dosages, intervals and techniques. Injections are associated with an increased pain for the first 24 hours upon applying them, but after three to four days therapeutic benefits are becoming evident. As tendon rupture can be a side-effect of this treatment, indication must be carefully evaluated.

Eccentric strengthening protocol

Eccentric exercises are based on the structural adaptation of the muscles and tendons to protect them from increased stresses, therefore preventing reinjury. The basic principles of eccentric strengthening are length of the tendon, load and speed.

When the tendon is pre-stretched, there is an increase of its resting length, so less strain is put on that tendon during movement. Progressive increase of the load exerted on the tendon results in an increase in the inherent strength of the tendon itself. By increasing the speed of contraction, the development of a greater force ensues.

Eccentric strengthening protocol has proved especially beneficial in Achilles and patellar tendonitis. Exercises should be performed under the supervision of a physical therapist, but when mastered, they can be done at home as well.

Other modalities of treatment

Therapeutic ultrasonography can decrease pain and increase the rate of collagen remodeling producing high frequency vibrations that generate heat. Extracorporeal shock wave therapy (ESWT) reduces pain and promotes tendon healing via high-energy acoustic shockwaves.

Iontophoresis and phonophoresis employ electric and ultrasonographic impulses respectively, in order to deliver topical corticosteroids or NSAIDs to the subcutaneous tissues. Both methods are widely used, although well-designed randomized controlled trials are lacking.

If pain persists and the condition becomes chronic despite the conservative treatment and the use of analgesics, surgical evaluation may be warranted. The specific type of surgery depends on the localization of tendonitis and the estimated amount of damage.