Tendinopathy – 9 Interesting Facts

Interesting Facts

  1. Tendinopathy is a clinical syndrome most commonly resulting from repetitive motion or overuse of a tendon resulting in pain, swelling, and impairment of function; process is inflammatory in the early stage but may progress to a degenerative process in the subacute and chronic phases
  2. Commonly involved anatomical locations include tendons of the rotator cuff, lateral and medial elbow, first dorsal compartment of the wrist (de Quervain tenosynovitis), lateral hip/greater trochanter area, knee, and ankle (Achilles tendinopathy)
  3. Symptoms include localized, nonradiating pain over site of affected tendon that is typically limited to activity and improves on removal of the offending mechanical load
  4. Diagnosis is clinical and based on the presence of a risk factor for a given tendinopathy (eg, overuse, altered occupational ergonomics) and suggestive physical examination results; pain with provocative physical maneuvers usually confirms the diagnosis 1
  5. Diagnostic imaging is not routine; order plain radiographs if there was a traumatic mechanism of injury or if calcific tendonitis is a concern; ultrasonography or MRI can confirm the diagnosis if uncertain
  6. Initial management is conservative with relative rest and a structured exercise-based rehabilitation program; NSAIDs can be used short term for pain but should not be continued for more than 7 to 14 days 1
  7. A peritendinous corticosteroid injection can improve pain and allow patients to participate in physical therapy; however, there is no long-term outcome benefit. For chronic tendinopathies, topical nitroglycerin may improve outcomes 1 2
  8. For recalcitrant pain, additional treatment modalities (eg, extracorporeal shock wave therapy, ultrasound-guided injections of platelet-rich plasma, sclerotherapy, prolotherapy, percutaneous tenotomy [dry needling]) may be considered, although evidence is lacking for some 1 2 3 4
  9. Prognosis for most tendinopathies is good with conservative treatment

Pitfalls

  • In the setting of recent trauma, point tenderness on palpation of a tendon may represent alternative pathology (eg, an avulsion fracture)
    • Obtain a plain radiograph to exclude fracture when indicated

Terminology

Clinical Clarification

  • Tendinopathy is a clinical syndrome most commonly resulting from repetitive motion or overuse of a tendon, resulting in pain, swelling, and impairment of function; process is inflammatory in the early stage but may progress to a degenerative process in the subacute and chronic phases
  • Tendinopathy is an umbrella term that encompasses tendinitis (a term often overused), tendinosis, and tenosynovitis
    • Tendinitis exists when tendon inflammation is present; typically it is limited to the initial days or weeks after tendon injury
    • Tendinosis refers to the chronic, sometimes degenerative process and scarring that persists after resolution of the initial inflammation
    • Tenosynovitis refers to inflammation of both the tendon and its sheath (in cases where the tendon glides within a sheath); also known as peritenonitis or peritendinitis
  • Calcific tendinitis is a variant most commonly affecting rotator cuff tendons characterized by inflammation around crystal hydroxyapatite that progresses through stages; calcific tendinitis is most painful during the resorptive phase

Diagnosis

Clinical Presentation

History

  • Symptoms vary depending on the location of the involved tendon
  • Characteristic features typically include:
    • History of repetitive motion or overuse in the workplace or with recreational or athletic pursuits
      • May report precipitating change in intensity, duration, or type of activity over past weeks to months, change in sports equipment or shoes, change in workplace ergonomics, a new hobby, or other alteration of mechanical stress on a tendon
    • Uncommonly, may report use of a fluoroquinolone preceding symptom onset, which has been implicated in tendinopathy
    • Pain is the most common symptom
      • Localized, nonradiating pain over site of affected tendon
      • Pain is typically limited to activity and improves on removal of the mechanical load
        • Exception: in earliest phase of injury, pain may improve with activity and worsen during cool-down phase after exercise

Physical examination

  • Direct the examination to the area of discomfort
    • Swelling may be visible or palpable over superficial tendons
    • Reproducible pain is present on palpation of affected tendon
      • Nonspecific finding does not exclude pathology in other underlying structure (eg, avulsion fracture)
      • Associated bursa may also exhibit swelling and tenderness
    • Range of motion, both active and passive, may be decreased
    • Increased pain with contraction against resistance and passive stretching of the affected musculotendinous unit
    • Findings neurologic examination are normal
  • In addition to the directed examination, use a general examination to evaluate load-related pain and function
    • For the upper limb, include evaluation of ability to lift, carry, and grasp
    • For the lower limb, include evaluation of gait, squat, ability to step up and step down, and hop

Causes and Risk Factors

Causes

  • Most common cause is mechanical overload resulting in repetitive microtrauma to tendon
  • In some cases caused or exacerbated by impingement on another structure (ie, supraspinatus tendon impinged on by the undersurface of the acromion or a subacromial spur)
  • Less commonly may develop without overuse injury in the setting of certain medical comorbidities (eg, diabetes, hyperlipidemia, hyperuricemia, some systemic inflammatory disorders) or, rarely, owing to drug toxicity (fluoroquinolones)

Risk factors and/or associations

Age
  • Older age increases risk
Sex
  • Generally more frequent in males 1
  • In women, being postmenopausal is a risk factor 1
Other risk factors/associations
  • Extrinsic factors
    • Occupations that involve repetitive motion
    • Poor workplace ergonomics
    • Athletic participation
      • Training errors, which do not allow for appropriate adaptation of the musculotendinous unit to mechanical overload
        • Increased frequency of activity
        • Increased duration of activity
        • Increased intensity of activity
        • Inadequate recovery time
      • Faulty or improper athletic equipment, including footwear
    • Associations of tendinopathies with specific activities
      • Rotator cuff tendinopathy
        • Swimmers
        • Throwing athletes
        • Physical laborers
        • People who use wheelchairs
        • Sedentary workers
      • Elbow tendinopathy
        • Lateral epicondylitis
          • Occupations and activities requiring repetitive wrist extension
            • Tennis, particularly using one-handed backhand strokes; will affect 40% to 50% of tennis players 5
            • Painters, plumbers, carpenters, auto mechanics, cooks
            • Playing musical instruments
        • Medial epicondylitis
          • Occupations and activities requiring repetitive wrist flexion activities
            • Golf
            • Baseball
            • Javelin throwing
            • Work that requires handling objects heavier than 5 kg for 2 hours a day or greater than 10 kg more than 10 times per day 5
      • First dorsal compartment of the wrist tendinopathy (de Quervain tendinopathy)
        • Typists
        • Prolonged use of hand tools
        • Parents who frequently bottle-feed a baby
        • Tennis and other racket sports
        • Rowing
        • Golf
        • Skiing
      • Gluteal tendinopathy
        • Stair climbing
        • Walking hills
      • Patellar tendinopathy
        • Soccer
        • Running
        • Rugby
        • Volleyball
        • Basketball
      • Achilles tendinopathy
        • Running, especially running on hills or on slippery surfaces
        • Soccer
        • Also common in nonathletes with sedentary lifestyles
    • Use of fluoroquinolone drugs
      • Observational studies showed an increased risk of tendon injury with exposure to fluoroquinolone antibiotic therapy 6
      • Highest risk within first month after drug exposure
  • Intrinsic biomechanical factors
    • Misalignment resulting in tendon impingement
    • Joint laxity
    • Muscle weakness; deconditioning
    • Obesity
    • Diabetes or glucose intolerance (deposition of glycation end-products in the tendon)
    • Hypercholesterolemia (deposition of cholesterol in the tendon)
    • Hyperuricemia (deposition of uric acid crystals in the tendon)
    • A variety of systemic conditions may be associated with enthesopathy (inflammatory or other pathologic change at the tendon insertion into the bone)
      • Rheumatoid arthritis
      • Ankylosing spondylitis
      • Reiter syndrome

Diagnostic Procedures

Primary diagnostic tools

  • Diagnosis is clinical, based on the presence of risk factors, suggestive history, and physical examination findings 1
    • Presence of specific physical examination findings and pain with provocative maneuvers are usually sufficient to confirm the diagnosis of a given tendinopathy
  • Plain radiographs are not routine but should be obtained if there is a traumatic mechanism of injury (as opposed to overuse)
    • Consider for shoulder tendonitis to look for calcification within the tendon (calcific tendonitis) 7
  • Advanced imaging studies (ultrasonography or MRI) are generally unnecessary but may be helpful to rule out other causes or if initial therapies are ineffective 1

Laboratory

  • Laboratory testing not usually indicated
    • However, if tendinopathy is present in multiple sites or is recurrent without apparent overuse, consider testing for:
      • Metabolic risk factors 8
        • Hemoglobin A1C
        • Lipid profile
        • Uric acid
      • Presence of a systemic inflammatory disease of which tendinopathy is a feature (if other clinical features are present)
        • Erythrocyte sedimentation rate or C-reactive protein
        • Rheumatoid factor and/or anticyclic citrullinated peptide antibodies if rheumatoid arthritis is suspected

Imaging

  • Plain radiographs
    • Indicated when the mechanism of injury includes trauma and there is concern for bone injury 7
    • Indicated for patients with symptoms and signs suggestive of rotator cuff tendinopathy to identify calcific tendon deposits
      • Calcific deposit will be localized within the tendon
      • Type and size of deposit do not correlate with severity
  • Ultrasonography
    • Indicated if the diagnosis is in doubt or after a course of physical therapy has failed 7
    • May be preferred to MRI owing to ease of use at the point of care
    • Allows dynamic evaluation of muscle, tendon, and joints
    • Can be used for simultaneous guidance for injection therapies
    • Typical findings
      • Diffuse and/or focal tendon thickening
      • Focal hypoechoic areas or areas of extended hypoechogenicity
      • Loss of the normal fibrillar echotexture
      • Ill-defined tendon borders and peritendinous edema
      • Microruptures and tendon tears can be identified, if present
  • MRI
    • Consider when the diagnosis is in question or when a course of physical therapy has failed
    • Gold standard when a full anatomic overview of the involved region is necessary 7
    • Offers excellent resolution of soft tissue structures; therefore, may be preferred over ultrasonography in some patients

Functional testing

  • Clinical presentation and provocative diagnostic maneuvers for specific common tendinopathies
    • Rotator cuff tendinopathy
      • Rotator cuff consists of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles and tendons. Pathology can range from simple impingement to tendinopathy to partial- or full-thickness tendon tears
      • Impingement of the acromion, coracoacromial ligament, coracoid process, or AC (acromioclavicular) joint on the rotator cuff as it passes beneath them during glenohumeral motion results in tendinopathy
      • Tendinopathy typically presents with shoulder pain, diminished range of motion, and limitation in overhead activities
      • Supraspinatus tendinopathy is the most common tendinopathy involving the rotator cuff
        • Pain is localized to the shoulder region
        • When performing an arc of abduction, pain will occur in midrange
      • Hawkin-Kennedy impingement test and Neer impingement test can be used to evaluate for impingement; result is positive if pain is elicited
        • Hawkin-Kennedy test 9
          • Examiner forward-flexes the humerus to 90° and forcibly internally rotates the shoulder (drives the greater tuberosity farther under the coracoacromial ligament)
        • Neer impingement test 9
          • Examiner stands behind seated patient; scapular rotation is prevented with one hand while the other hand raises the arm in forced forward elevation, causing the greater tuberosity to impinge against the acromion
    • Bicipital tendinopathy
      • Pain is localized to the anterior shoulder or down the anterior side of the arm
      • Tenderness is elicited in bicipital groove (groove between the greater and lesser tuberosities of the humerus)
      • Results of provocative testing suggestive of bicipital tendinopathy may include: 10
        • Pain with resisted supination with the elbow flexed to 90° (Yergason test)
        • Pain in the bicipital groove on resisted arm flexion with straight elbow and palm up; resolution of the pain with palm down (Speed test)
    • Elbow tendinopathies
      • Lateral epicondylitis (extensor carpi radialis brevis tendinopathy)
        • Presents with epicondylar pain that runs along the lateral elbow to the wrist, which is aggravated by wrist extension or forearm supination
        • Tenderness and possibly fullness (thickened tendon) are appreciable at lateral epicondyle and origin of wrist extensor muscles
        • Grip strength may be diminished
        • Results of provocative testing suggestive of lateral epicondylitis include:
          • Pain with resisted wrist extension 11
          • Pain noted over lateral epicondyle with active extension of the middle finger against resistance with the elbow positioned in extension (Maudsley test)
        • Weak grip and difficulty lifting objects
      • Medial epicondylitis (pronator teres and flexor carpi radialis tendinopathy)
        • Presents with epicondylar pain radiating from the medial elbow to the wrist
        • Pain can prevent ability to do simple tasks such as holding a cup or mug, turning a doorknob, or shaking hands
        • Tenderness and possibly fullness (thickened tendon) and warmth may be appreciable at medial epicondyle and wrist flexor tendons
        • Grip strength may be diminished
        • Results of provocative testing suggestive of medial epicondylitis include pain with resisted flexion 12
    • de Quervain tenosynovitis (abductor pollicis longus and extensor pollicis brevis tendinopathies)
      • Typically has a history of chronic, repetitive trauma or unaccustomed repetition of movement (eg, firm grasping and movement of the hand in a radial direction)
      • Gradual onset of pain that is constant and localized immediately over or just proximal to the radial styloid over first compartment of wrist
      • May radiate proximally to the forearm or distally down the thumb
      • May be palpable swelling and tenderness over the first dorsal compartment at the wrist
      • Results of provocative testing suggestive of de Quervain tenosynovitis include pain exacerbated by grasping maneuvers and ulnar deviation of the wrist 13
      • Finkelstein test can elicit pain 14
        • Patient is instructed to hold the affected thumb in the palm by closing the fingers over the thumb, and then to ulnar-deviate the wrist (similar to turning a door knob)
        • Pain near the radial styloid with this maneuver is a positive finding
    • Gluteal tendinopathy (tendinopathies of the gluteus medius and minimus tendons as they insert at the greater trochanter) is included in the pain syndrome known as greater trochanteric pain syndrome, which also includes trochanteric bursitis
      • Presents with dull, aching pain over the lateral and posterior aspect of the greater trochanter, most common in middle-aged or older women
        • Pain commonly reported while lying on the affected side; may interfere with sleeping
        • Pain may be provoked by standing, walking, stair climbing, and crossing the legs
      • Discrete area of tenderness is appreciable on deep palpation over lateral aspect of hip directly over and adjacent to the greater trochanter
      • FABER (Flexion, ABduction, External Rotation) positioning results in pain over the greater trochanter without a loss of range of motion 15
        • With knee flexed, the affected hip joint is passively flexed, abducted, and externally rotated. The ankle is placed just above the contralateral patella forming a figure “4”
        • The pelvis is stabilized by applying pressure to the contralateral ilium and downward pressure is applied to the ipsilateral knee causing further external rotation of the affected hip
    • Patellar tendinopathy
      • Presents with discomfort in the area of the proximal patellar tendon and inferior patellar pole; may be present only after activity in mild cases but progress to constant pain when severe
      • Often related to an increase in activity, especially sports involving jumping
      • With the knee flexed at 30°, tenderness is localized to the inferior pole of the patella 14
    • Achilles tendinopathy
      • Presents with pain after strenuous activities (early phase) or during activity or at rest (later phase)
      • Diffuse swelling and tenderness over Achilles tendon are often noted, especially in the acute phase
        • Findings are most common in the middle third of the tendon; may also involve insertion of the tendon at the calcaneus
        • Location of swelling and tenderness does not move with dorsiflexion of the ankle joint
      • Local heat may be noted; crepitus is rare
      • If any concern for Achilles rupture, perform Thompson test 16
        • Patient lies in prone position with feet hanging off table. Provider squeezes gastrocnemius
          • Absence of plantar flexion indicates rupture of Achilles tendon
        • Sensitivity of 96% and specificity of 93%

Differential Diagnosis

Most common

  • Differential is site specific, depending on the tendon involved
  • In general, consider other localized musculoskeletal conditions
    • Bursitis
      • Inflammation or irritation of a bursa owing to acute trauma, chronic microtrauma, systemic inflammatory diseases, crystal deposition, or infection
      • Shoulder (subacromial bursitis), elbow (olecranon bursitis), knee (prepatellar bursitis), and hip (trochanteric bursitis) are the most commonly affected areas
      • Superficial bursitis presents similarly with tenderness and swelling of anatomic area involving bursa; overlying skin may exhibit warmth or erythema; presence of fever suggests septic bursitis
      • Bursitis and tendinopathy may coexist or be difficult to differentiate when tendon is associated with an overlying or underlying bursa
      • Imaging with ultrasonography or MRI may be helpful to differentiate bursitis from tendinopathy when necessary
    • Arthropathy
      • Intrinsic joint disease may be caused by a wide variety of conditions often including inflammation and/or infection
      • Presents similarly with swelling and tenderness of joint; warmth may be present
      • Pain characteristically increases with both passive and active motion of the joint
      • Differentiating features on physical examination include swelling and tenderness that usually occur uniformly across entire joint in patients with arthropathy as opposed to a localized to area primarily involving tendon in patients with tendinopathy

Treatment

Goals

  • Relieve pain
  • Improve function of the musculotendinous unit

Disposition

Admission criteria

  • Hospital admission is not indicated

Recommendations for specialist referral

  • Consult a physical therapist for a structured rehabilitation program for most patients, in particular for:
    • Athletes
    • Those with work duties that provoke their symptoms
    • Those with metabolic comorbidities that may impair healing
  • Early consultation with a sports medicine physician can be beneficial for athletes and other patients with sports-related tendinopathy for diagnostic and treatment recommendation
  • Consult a sports medicine physician, orthopedist, or physiatrist for patients unresponsive to initial conservative measures and activity modification

Treatment Options

Local application of cold

  • Duration of about 20 minutes every few hours for first 2 days may improve pain in the acute phase of injury 17

Rest

  • Discontinue specific activities that provoke the pain
  • Relative rest (avoidance of overuse) rather than absolute rest (absence of activity) is recommended 1 14

Treat pain as needed

  • Preferred mediation is an NSAID 1
    • Use standard dosing for short-term use (7-14 days)route of administration may be either oral or topical (equal efficacy) 1
    • Avoid long-term NSAID use given that inflammatory phase of tendonitis occurs primarily in acute phase
    • Topical formulation may be preferred to minimize adverse gastrointestinal effects: efficacy is similar to oral NSAID

Exercise-based rehabilitation program and adjunct modalities

  • Refer the patient to a physical therapist for exercise-based rehabilitation program for gradual increase in tendon load 1
    • Structured exercise-based rehabilitation program is the most important and evidence-based approach for pain relief and improved function 1
    • Mild pain during loading is not considered detrimental if short lived
  • Physical therapist may offer adjunct physical therapy modalities (eg, friction massage, therapeutic ultrasound)

Corticosteroids administered by local injection (usually mixed with a local anesthetic) 1 2

  • May reduce pain in the short term (several weeks) 1 2
  • Used primarily to relieve pain so that the patient is able to participate in a rehabilitative exercise program
  • Considered an effective and appropriate first treatment for de Quervain tenosynovitis 13 18
  • Not appropriate for blind instillation at some anatomic sites
    • Avoid with patellar and Achilles tendinopathies (risk of accidental intratendinous injection and subsequent tendon weakening or rupture)

Adjunctive interventions may be required if pain and/or decreased function are recalcitrant to a physical rehabilitation program

  • Noninvasive therapies
    • Topical nitroglycerin (glycerin trinitrate patches that deliver nitric oxide locally)
      • Data suggest improved clinical outcomes with tendinopathies involving the rotator cuff 19 and Achilles tendon 20 21; mixed results are available for lateral elbow tendonitis 22; no benefit has been noted for patellar tendinopathy 23
      • Data suggest improvements in pain, strength, and ability to do activities of daily living with administration up to 6 months 22
      • Most benefit is noted in patients with chronic rather than acute or subacute tendinopathies 24
      • Headache and skin irritation may occur
    • Extracorporeal shock wave therapy
      • May be effective for rotator cuff tendinopathy particularly when calcific 1
      • Evidence is mixed for lateral epicondylitis 3 25
      • Low-level evidence suggests possible effectiveness for some lower limb conditions in all phases of rehabilitation 26
  • Percutaneous injection therapies, which are typically guided using ultrasonography
    • Barbotage (for calcific tendinopathy):
      • Needle lavage and aspiration of calcium deposits guided by ultrasonography 14
      • Effective approach for calcium deposit removal and improved outcomes in rotator cuff tendinopathy 27
    • Newer therapies with limited evidence include:
      • Platelet-rich plasma injection
        • Delivers growth factors to the damaged tendon
        • Autologous preparations may vary in composition based on the commercial system used to prepare patients’ blood; renders comparison of clinical trial data difficult
        • Recent data suggest that injections of platelet-rich plasma were more effective than control injections for treatment of symptomatic tendinopathy 4
        • Efficacy data for specific tendinopathies include:
          • Lateral epicondylitis: high quality evidence exists for both short- and long-term efficacy 28
          • Rotator cuff tendinopathy: few available studies render mixed results; not routine, but it may offer a safe and effective alternative to corticosteroid injection 28
          • Patellar tendinopathy: few available studies provide high-quality evidence for efficacy in chronic refractory patellar tendinopathy; additional data are necessary for robust treatment recommendations 28
          • Achilles tendinopathy: mixed evidence does not support routine use 28
      • Sclerotherapy
        • Injection of a sclerotic agent (eg, polidocanol) to destroy pathologic neovascularization (and sensory nerves that develop with neovascularization)
        • Data suggest positive outcomes in patients with epicondylar, patellar, and Achilles tendinopathy when guided with ultrasonography 27
      • Prolotherapy
        • Injection of hypertonic glucose to induce a local inflammation and repair process
        • Hyperosmolar dextrose and morrhuate sodium are most commonly used agents
        • Limited data suggest significant pain reduction in patients with lateral epicondylitis 2
      • Percutaneous tenotomy (dry needling)
        • Repeated fenestration of the tendon resulting in localized bleeding and fibroblast proliferation followed by healing; guidance with ultrasonography allows targeting of hypoechogenic and neovascularized areas 27
        • Data including patients with rotator cuff tendinopathy, lateral epicondylitis, and Achilles tendinopathy suggest improvement in patient-reported outcome measures; concomitant injection of autologous blood products may further improve outcomes 29
  • Open surgery is rarely indicated 1
    • Percutaneous ultrasonic tenotomy (Tenex) can be used to debride tendinopathic tissue 30 31
      • Paucity of literature that this is effective but may be considered if conservative measures fail

Drug therapy

  • Nitroglycerin (glyceryl trinitrate) transdermal patch
    • Nitroglycerin Transdermal patch – 5 mg/24 hour; Adults: Doses used in clinical trials, 1.25 mg/24 hours (1/4 of a patch) applied topically every 24 hours to the area most tender to palpation. 1 24
    • Treatment dose and duration are varied in clinical trials (up to 24 weeks) 24
    • NOTE: Off-label use. Products vary in drug delivery systems. Cutting or trimming the patch is not recommended by the manufacturer as it may alter the drug reservoir, delivery mechanism, and adhesion of the patch.
  • Diclofenac gel
    • Diclofenac Sodium Topical gel; Adults: Apply 1 g to the most painful area of the tendon for 30 to 45 seconds every 8 hours. 32

Nondrug and supportive care

Exercise-based rehabilitation program

  • Progressive loading programs are recommended
    • Goal of therapy is to increase tolerance to increased load on the tendon through exposure to controlled tendon reloading and graduated strengthening under the guidance of a physical therapist
  • Eccentric exercises are commonly prescribed; however, integration with isometric and heavy, slow resistance exercises are also effective 1 33

Additional physical modalities 17

  • Commonly used in clinical practice despite lack of objective evidence of efficacy for tendonitis in general
  • Modalities may include friction massage directly over the tendon and therapeutic ultrasound

Some forms of tendinopathy may benefit from splinting; strapping may also be appropriate

  • Lateral or medial epicondylitis 34 35
    • Bracing with counterforce elbow strap may help to control force loads
    • Consider neutral-position wrist immobilization splint
  • de Quervain tenosynovitis
    • Standard initial treatment involves immobilization with thumb spica splint 14
  • Achilles tendonitis
    • Night splints are considered for patients who have significant pain on awakening in the morning
    • Heel lifts are reasonable to consider

Implement ergonomic modifications, if appropriate, to protect from further injury (eg, alteration of computer work station)

Implement changes in performance technique, when appropriate, to prevent further injury or exacerbate existing injury (eg, proper racket technique)

Correct abnormalities in body mechanics that contribute to development of tendinopathy (eg, orthotics or heel lifts to correct for limb malalignment associated with Achilles tendinopathy) 14

Procedures
Corticosteroid injection, with or without local anesthetic

General explanation

  • Little consensus exists regarding which specific corticosteroid to use or appropriate dosage for a given site 36
    • Generally a short-duration (eg, hydrocortisone) or intermediate-duration (eg, methylprednisolone) corticosteroid is recommended 36
    • Corticosteroid preparations may be injected separately or together with lidocaine (duration of action about 1 hour) or bupivacaine (duration of action about 6-8 hours) as adjuncts for pain control 36
  • Must be injected around but not directly into the tendon owing to risk of tendon rupture
  • Single injection is often sufficient for patient to tolerate initial phases of physical rehabilitation program
  • Do not repeat subsequent injections in the same site more than once every 3 months when additional injections are required 36

Indication

  • Pain reduction sufficient to enable adequate participation in physical rehabilitation program

Contraindications 36

  • Overlying or adjacent infection; bacteremia
  • Osteochondral fracture

Monitoring

  • Monitor for improvement in pain and function

Complications and Prognosis

Complications

  • Tendon tear or rupture
    • Tendon tear or complete rupture can occur with forceful eccentric strain in patients with advanced tendinopathy and may be the initial event signaling the presence of tendinopathy (more common in Achilles tendinopathy)
    • Intratendinous corticosteroid injection can predispose a tendon to rupture
  • Chronic tendinopathy leading to disability

Prognosis

  • Prognosis with conservative therapy is good for most tendinopathies

Screening and Prevention

Prevention

  • Avoid or manage extrinsic risk factors for tendinopathy such as athletic training errors and poor workplace ergonomics
  • Correct or improve intrinsic risk factors such as correction of altered body mechanics resulting in misalignment and muscle weakness
  • Avoid obesity (lose weight if obese); manage metabolic conditions that can lead to tendinopathy (eg, diabetes, hyperlipidemia, hyperuricemia)

Sources

Cardoso TB et al: Current trends in tendinopathy management. Best Pract Res Clin Rheumatol. 33(1):122-40, 2019

Cross Reference