Getting tendinopathy treatment (and terminology) right
Tendinopathy, tendinitis, tendinosis, paratenonitis—they are not synonymous. Here you’ll find a review of their pathophysiology and best approaches to treatment.
PRACTICE RECOMMENDATIONS
› Recommend eccentric exercises to treat patients with tendinosis; research has consistently shown them to be an effective and safe treatment for many types of this disorder. A
› Use corticosteroid injections with caution for tendinosis; pain relief is typically short lived, and good evidence exists for long-term relapse and worse outcomes including post-injection tendon rupture, especially in the lower extremity. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
A review of 10 RCTs demonstrated the effectiveness of ESWT for tennis elbow.2 ESWT for greater trochanteric pain syndrome (GTPS, formerly known as trochanteric bursitis) appears to be more effective than corticosteroids and home exercises for outcomes at 4 months and equivalent to home exercises at 15 months.20 In patellar tendinosis, ESWT has been shown to be an effective treatment, especially under ultrasound guidance.12 Studies involving the use of ESWT for Achilles tendinosis have had mixed results for midsubstance tendinosis, and more positive results for insertional tendinosis.15 For a video on how the therapy is administered, see https://www.youtube.com/watch?v=Fq5yqiWByX4.
Glyceryl trinitrate patches: Mixed results
Basic science studies have shown that nitric oxide modulates tendon healing by enhancing fibroblast proliferation and collagen synthesis,2,14 but that it should be used with caution in cardiac patients and in those who take PDE-5 inhibitors. Common adverse effects include rash, headache, and dizziness.
In clinical studies, glyceryl trinitrate (GTN) patches show mixed results. For the upper extremity, GTN appears to be helpful for pain in the short term when combined with physical therapy, but long-term positive outcomes have been absent.21 In one Level 1 study for patellar tendinosis comparing GTN patches with EE to a placebo patch with EE, no significant difference was noted at 24 weeks.22 Benefit for Achilles tendinosis also appears to be lacking.3,23
Corticosteroid injections: Mechanism unknown
The mechanism for the beneficial effects of corticosteroid injections (CSIs) for tendinosis remains controversial. Proposed mechanisms include lysis of peritendinous adhesions, disruption of the nociceptors in the region of the injection, and decreased vascularization.10,15 Given tendinosis is generally regarded as a noninflammatory condition, and the fact that these medications have demonstrated potential negative effects on tendon healing, exercise caution when considering CSIs.2,24
Although steroids can effectively reduce pain in the short term, intermediate- and long-term studies generally show no difference or worse outcomes when they are compared to no treatment, placebo, or other treatment modalities. In fact, strong evidence exists for negative effects of steroids on lateral epicondylosis in both the intermediate (6 months) and long (1 year) term.24 Particular care is required when administering a CSI for medial epicondylosis, as the ulnar nerve is immediately posterior to the medial epicondyle.25
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