Current Treatments

Ideally, tendinopathy treatments would break the cycle of failed healing and help repair the damaged collagen. New treatments of this kind are in the pipeline. Meantime, physical therapy is probably the most useful and important currently available treatment if you can find a good therapist in your area.

A great list of treatments with references to research articles for their efficacy can be found in full text form at Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon from Clin Orthop Relat Res. Jul 2008; 466(7): 1539–1554. I've included a similar list of treatments here, with some more recent additions. Whenever you see a list this long, you know that no one treatment works for everyone.

Please note that this site does not endorse any particular product, treatment, or website. The information is intended to help you learn about treatments so you can choose what's best for you. Also note that the numbers in brackets after some sentences on this page are references found on the References page.

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Rest

By the time you feel pain from tendinopathy, your injury has been gradually building for many weeks. Remember that tendons heal slowly. You will probably need to wait several months before a reasonable amount of repair has occurred, so have patience with this slow healing process.

You'll need to avoid activities that cause pain, which can be a problem when some of those activities involve your work. Whenever possible, try to get the injurious aspects of your job done some other way (such as voice recognition software instead of keyboard typing), or try to change your job while you heal. Check with your doctor and physical therapist for specific suggestions and guidance.

Although you need to rest the injured body part(s), keep doing the normal daily activities that don't cause you pain. You need to prevent atrophy and stiffness from disuse. Your doctor might want you to wait a few weeks before starting exercises but, when you are ready, your physical therapist can create a gradual strengthening program for you. Loading from the proper exercises can help stimulate healing. Rest alone is not likely to return the tendon to normal.

If you feel impatient with your injury, you might try to join a support group for RSI, whether it is a local group in your community or an online group. You can learn coping skills, get emotional support, learn about treatment options, and save yourself costly trial and error mistakes. People who have been there will tell you not to do more than your rate of healing will accommodate.

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Physical Therapy Exercises

Gentle strengthening exercises can help heal tendinopathy, as long as you are careful to progress gradually. Studies have shown that loading a tendon parallel to its length helps the collagen fibers grow with better parallel alignment and encorages the healing process. Find a physical therapist who has a lot of experience with tendinopathy, and make sure he/she is willing to go as slowly as your body requires. The term “mechanotherapy” has been coined to describe the way loading through exercise can stimulate repair and remodeling in tendon. You can read a paper by Dr. Khan about mechanotherapy and listen to a podcast interview with him on this topic.

Some studies have shown that eccentric exercise is especially helpful. [50, 51, 52, 53, 54]  Eccentric exercise is when a muscle is forced to lengthen while it contracts because it is being used as a brake or to absorb energy while doing "negative work." On the other hand, concentric exercise is when a muscle shortens as it contracts because it is acting as an engine doing "positive work." Your quadriceps muscles perform eccentric exercise when you walk down a hill, ski, or decelerate when landing from a jump. Your quadriceps muscles perform concentric exercise when you ride a bike or swim. Given the same load, eccentric exercise places more stress on the muscles and tendons than concentric exercise. You might ask your physical therapist about trying eccentric exercises as part of your strengthening program. You'll want to work with a physical therapist for at least a few weeks; later, you can develop a program to do on your own at home.

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Ice

Using ice packs, or cryotherapy, is one of the most common modalities for tendinopathy. Many physical therapists suggest that you use ice following your exercises or whenever you need some pain reduction during the day. Don't use ice just prior to your exercises. Ice might not have any long-term beneficial effect on tendinopathy, but it can be an excellent form of pain control (as long as you take care not to leave the ice on for too long at one time). Ice is also anti-inflammatory.

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Physical Therapy Modalities

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NSAIDS

Non-steroidal anti-inflammatories (NSAIDS) are commonly used to help reduce the pain of tendinopathy, but concerns have been building over the years that NSAIDs may actually impede the healing process in bone and tendon.  Early studies in vitro found that some NSAIDS impede the proliferation of tendon cells and the production of glycosaminoglycans. Later, a 2013 study in Journal of Applied Physiology postulated that NSAIDS may impede healing at the tendon to bone junction (enthesis), which is where tendinopathy often occurs. Another 2013 study, this one in Journal of Orthopedic Surgery and Research, into the effects of NSAIDS on tenocytes found that “pharmaceuticals such as DF (Diclofenac) and TA (triamcinolone acetonide) which are commonly used in the symptomatic treatment of musculoskeletal disorders may have profound negative effects on tendon regeneration on a progenitor cell level and therefore should be used with caution.”

NSAIDS are also associated with increased risk of heart attack/stroke and GI damage. One study in Osteoarthritis and Cartilage found that use of NSAIDS may be associated with the progression of osteoarthritis.

Because of all these concerns, long-term use of NSAIDs for tendinopathy is not a good idea, though they can possibly be helpful when used only short-term. This topic is still being debated and studied, especially as more research is done on the nature of the inflammatory component of tendinopathy.

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Cortisone Injections

Cortisone injections can sometimes temporarily lessen the pain of tendinopathy, but they don't help the injury heal, with the possible exception of cases where they reduce pain just long enough to get someone able to tolerate PT exercises that stimulate healing. Cortisone injections have been shown to cause adverse effects on the tissue in the area of the injection if repeated injections are given. You are probably better off avoiding cortisone injections since they can harm the tissue and slow collagen synthesis.

A 2014 paper summarized the role of cortisone in tendinopathies this way, “Overall it is clear that the local administration of glucocorticoid has significant negative effects on tendon cells in vitro, including reduced cell viability, cell proliferation and collagen synthesis.There is increased collagen disorganisation and necrosis as shown by in vivo studies.The mechanical properties of tendon are also significantly reduced.This review supports the emerging clinical evidence that shows significant long-term harms to tendon tissue and cells associated with glucocorticoid injections.”

Another 2014 paper gives one possible mechanism for cortisone’s damaging effect on tendons.

A 2015 study looked at the effect of steroids on mesenchymal stem cells or MSCs (cells that are important in healing) and found that “Commonly used intraarticular corticosteroids had a dose-dependent, profound, and differential effect on MSCs in this in vitro model, with betamethasone being the most toxic.” They also state “these agents may hinder MSCs' innate regenerative capacity in exchange for temporary analgesia.”

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Braces And Orthotics

Braces are often used for the wrist, elbow, knee, and ankle. Some people find that braces can add stability and support during activity. Braces should not be worn all the time because you can lose strength and flexibility, but they can be helpful if worn part-time. Some carpal tunnel syndrome patients like to sleep with wrist braces to avoid positions that cause numbness while sleeping. Ask your doctor or physical therapist if braces or supports might help you. If you try them, take care not to become too dependent on them.

Orthotics in your shoes can be very helpful if you have a structural imbalance that requires them. Check with a reputable podiatrist or sports doctor, and test the orthotics very gradually and cautiously (sudden changes in your position can make your injury worse)

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Technique And Ergonomic Corrections

Using the correct technique when playing sports can be very helpful. Poor biomechanics can make your injury worse. Make sure you talk with a qualified coach to improve your technique, and make sure your equipment fits you properly.

Correcting ergonomic problems can be very helpful in healing chronic workplace tendon injuries. Ergonomic improvements are better prevention than cure, but better late than never. You can find lots of information on ergonomics on the web. If you’re having trouble with your wrists/forearms/elbows from using a computer, you might try dictation software and/or a pen tablet (I have used and liked the Wacom pen tablet).

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Soft Tissue Mobilization

Physical therapists sometimes perform friction massage and soft tissue mobilization. Many kinds of alternative medicine practitioners perform bodywork such as Feldenkrais and Alexander Technique. Some practitioners also try to help with your posture and body mechanics. Studies with rats have shown that soft tissue mobilization can increase fibroblast activity and speed healing. [48, 49]

Physical therapists usually say that massage can cause mild discomfort but should not cause intense pain. You'll need to learn how your body reacts; some people can have massage that causes discomfort at the time but they feel fine later, while other people can have the same level of discomfort during massage but a painful flare-up later. Sometimes a mild flare-up can lead to improvement later, and sometimes not. Proceed cautiously until you learn how your soft tissue reacts to various hands-on procedures.

A number of practitioners offer aggressive hands-on techniques to manually break up adhesions and stimulate healing by promoting tissue remodeling. Some approaches are more formalized with names and acronyms and are taught to practitioners following certain protocols. One approach is called Augmented Soft Tissue Mobilization or ASTM. These treatment programs are more likely to help people who have a specific injury to one location rather than someone with a propensity for chronic tendon trouble in multiple areas. Be sure you are a good candidate for this type of treatment before trying it. The idea of “breaking up adhesions” has been questioned, as summarized in this blog post by a sports medicine physiotherapist

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Prolotherapy & PRP Injections

Prolotherapy involves injections that purposely provoke irritation in the hope of promoting a healing response. The injections often cause flare-ups and things can get worse before they get better. Some people have emailed to tell me that prolotherapy cured them when nothing else did, and other people have said it made them worse and they wished they hadn't tried it. The results vary greatly depending on the injected material and the training and experience of the practitioner, but prolotherapy does have some risk. It is different from but sometimes confused with platelet-rich plasma therapy, described below. Prolotherapy is considered an alternative medicine treatment and does not have consistent studies documenting effectiveness.

Platelet-rich plasma therapy (PRP) involves processing some of your own blood to concentrate the platelets and then re-injecting that blood back into your injury site in hopes that it may help with healing. This treatment has been successful for some athletes and has received some press. PRP may be more effective when combined with stem cell therapy, but not enough research has been done yet to know for sure. Recent research has called into question whether PRP is at all useful, and the answer isn’t yet known. An overview of the conflicting study results is given in the article Platlet-Rich Plasma For Tendinopathy and Osteoarthritis: A Narrative Review.

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Low Intensity Laser & PEMF

Low Intensity Laser Therapy has been used to treat chronic soft tissue injuries for years, and it is now being offered at some clinics. One maker of these devices is Bio Flex. It is something you can look into in your area. The Bio Flex website has a section that gives links to studies into the treatment's effectiveness.

Pulsed electromagnetic fields, or PEMF, has been used to improve healing in bone fractures and to treat low back pain, and it has more recently been tried for tendinoparhy. Some preliminary studies in rats showed possible benefits for tendon healing, but we don't have enough research to know if it helps chronic tendon injuries in humans.

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Glyceryl Trinitrate Patches

Nitirc oxide, or NO, is produced by enzymes called nitric oxide synthases, or NOS. Researchers found that the three NOS isoforms are up-regulated following tendon injury and that inhibiting NOS activity with oral drugs reduces the cross-sectional area and failure load of healing Achilles tendon in rats.[28,29,30] These studies implied that NO might help healing in tendons.

Several studies have shown promise for the use of topical glyceryl trinitrate (GTN) patches directly over the painful region of tendinopathy. [58, 60, 61, 62, 63] The patches are not FDA approved for tendinopathy, but they are sometimes used this way as an off-label application of the patches. You can check with your doctor or physical therapist if you want to try them. The main potential side effect with this therapy has been possible headaches in some patients.

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Surgery

Surgery has been a last resort for tendinopathy. Some studies show positive results for surgery, especially in sports injuries, but you'll get a much more negative impression of surgical procedures from support groups. Perhaps surgery is more successful in athletes than non-athletes, or perhaps the people with the most stubborn injuries are the ones that end up in support groups. At any rate, investigate the surgical procedure thoroughly before you consider it for yourself, and be sure to give your injury plenty of time to heal on its own before you resort to surgery.

When surgery is indicated, some new methods are being employed, such as the Tenex Health TX method, for removing damaged tissue. This technique is minimally invasive (much smaller incision) and has a shorter recovery time than traditional open surgery. A video of an actual procedure along with more explanation is available on The Doctors, and patient information and testimonial videos are available on the Tenex website.

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Intratissue Percutaneous Electrolysis

Intratissue Percutaneous Electrolysis (EPI®) is an ultrasound-guided technique that causes non-thermal electrochemical ablation from a cathode flow that is aimed at the area of tendon degeneration. The tissue undergoes healing and remodeling as a result of the treatment. Multiple treatments can be given until full relief is seen.

EPI®) is not available in all countries (it is currently used in Spain). The EPI® treatment has been studied in patellar tendinopathy, combined with eccentric exercises. Promising results were seen, but more study is needed.

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Nutrition & Supplements

Basic good nutrition is advisable in order to give your body the best chance to heal, but not much scientific research has been done to investigate the effects of specific nutritional supplements on the healing of tendinopathy. If you are overweight and/or have diabetes, your tendons may improve by losing weight and improving your blood sugar; studies have shown a correlation between diabetes and tendinopathy.

Ascorbic acid (vitamin C) stimulates Type I collagen synthesis when used in cultures of healthy fibroblast cells. However, when ascorbic acid was added to cells from carpal tunnel syndrome patients, it did not stimulate the normal amount of Type I collagen, and the small amount of Type I collagen that was produced had an abnormally high alpha2(I) to alpha1(I) ratio.[1] Adding vitamin C to the injured cells simply made them produce more abnormal collagen, not normal collagen.

Some supplements that claim to help heal tendons and ligaments contain the amino acids glycine, lysine, and proline. This idea seems logical since those three amino acids are very abundant in tendon and ligament collagen. However, merely providing more amino acids probably won't change the injured tenocyte behavior of making abnormal collagen. Still, you should be sure to get enough high-quality protein in your diet so you're not deficient in amino acids.

Collagen peptides have become popular for the health of skin, joints, cartilage, and tendons. Collagen peptides are amino acid chains that are the building blocks of collagen. The hope is that the peptides might work not just as raw ingredients for collagen building, but also as signaling agents that could help stimulate collagen synthesis. This effect might work better for healthy skin and tendon than for injured tendon, but one supplement in particular, TendoForte, has some research behind it. A study in patients with Achilles tendinopathy found that taking TendoForte in combination with an exercise program did better than a placebo with the exercise program.

Although glucosamine sulfate and chondroitin sulfate might help osteoarthritis, they are not likely to help tendinopathy. Osteoarthritis causes a decrease in collagen, proteoglycans, and glycosaminoglycans (GAGs) in cartilage. Tendinopathy causes a decrease in collagen in the injured tendon, but it actually causes an increase in proteoglycans and GAGs, such as chondroitin sulfate and hyaluronan.[7,8,13,18,40] Gluscosamine sulfate and chondroitin sulfate might help build proteoglycans, but since the levels of GAGs and proteoglycans are already abnormally high in tendinopathy, you wouldn't expect oral supplementation of glucosamine and chondroitin to help.

Some supplements are sold with the claim that they will raise growth hormone levels and therefore help heal all sorts of problems, including chronic tendon injuries. Even if these supplements could raise growth hormone levels (which is unproven), the higher growth hormone might just stimulate more abnormal collagen rather than normal collagen (since that was the effect of adding growth factors to cells from carpal tunnel syndrome patients).[1]

Some foods and supplements, such as ginger and turmeric, can help reduce inflammation. Eating an ant-inflammatory diet has been found to be good for your general health and might be especially good when you are trying to heal soft tissue injuries.

Your best bet is to maintain a healthy weight and eat a plant-based diet with plenty of antioxidant-rich whole fruits, vegetables, nuts, legumes, and grains, while eating minimal amounts of trans fats, saturated fats, and simple carbohydrates. For more information about healthy nutrition, see sites such as Forks Over Knives, NutritionFacts.org,  UC Davis Integrative Medicine Program’s Guide For Plant-Based Eating, and DrWeil.com. Improvements from good diet take time to notice, so don't expect immediate results.

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Injection Of Stem Cells, Fibroblasts, Or Tenocytes

Stem cells are progenitor cells found in embryos and also in some tissues of adults; these special cells can differentiate into cells for many different kinds of tissue such as bone, fat, cartilage, tendon, nerve, blood, brain, or muscle.  Embryonic stem cells can differentiate into more tissue types than adult stem cells, but adult cells are more available and avoid the ethical and political issues associated with the use of embryonic cells. Adult stem cells have been found in many parts of the body, including fat, bone marrow, and skin.

The mesenchymal stem cell, or MSC, can differentiate into various kinds of connective tissue. Adult bone marrow and fat are two sources for MSCs.  Researchers are exploring how to use MSCs to repair tissues such as bone, tendon, ligament, and cartilage.[47]

In several early tendon studies, researchers surgically created one-centimeter-long gap defects in rabbit tendons and then implanted composites of stem cells suspended in Type I collagen gel into the injuries.[2,3,15] In one study, MSC treated tendons were twice as strong as untreated tendons after 4, 8, and 12 weeks.[15] The treated tendons also had larger cross-sectional area and better aligned collagen fibers.

In later studies, MSCs were injected directly into the area of chronic injury rather than being injected into surgically created tendon injuries. The MSCs are healthy cells uninjured by repetitive motion that could, in theory, go to work creating new healthy collagen to slowly repair the area of failed healing.

A 2012 study followed up on eight patients who had undergone stem cell therapy for patellar tendinopathy five years prior; seven of the eight had good results and were still happy with the procedure after five years. [57]

Stem cell injections are being offered at a few clinics such as Regenexx in Colorado. Sometimes stem cell therapy is combined with plasma-rich platelet injections and growth factors to try to maximize the results.

A study in the Sept 2014 International Orthopaedics reported that mesenchymal stem cells improved tendon healing following rotator cuff repair. The study was presented at the American Academy of Orthopaedic Surgeons 2015 Annual Meeting. After 6 months, 100% of the stem cell treated patients had healed compared to 67% of the non-treated controls. After 10 years, 87% of the stem cell treated repairs were still intact vs 40% of the controls.

Rather than injecting stem cells, researchers have also tried injecting fibroblasts into areas of tendinopathy. Fibroblasts are cells in tissue, such as skin and tendon, that produce collagen and the extracellular matrix. For more on the differences between stem cells and fibroblasts, see studies such as ”Fibroblasts share mesenchymal phenotypes with stem cells, but lack their differentiation and colony-forming potential,” Biol Cell. 2011 Apr;103(4):197-208. doi: 10.1042/BC20100117.

Initial studies have shown promise for injecting dermal fibroblasts (what these studies call tenocyte-like cells) in elbows and knees with tendinopathy. [55, 56]

This type of autologous cell treatment (where the cells are collected from the same person into which they are injected) is being offered in Australia through Ortho Cell. In September/October 2013, Ortho Cell reported that a clinical study of autologous tenocyte therapy for lateral epicondylitis was successful. The study was published in the December 2013 American Journal of Sports Medicine. [59] Patients can go to clinics that work with Ortho Cell; the patient has an initial appointment during which a tendon biopsy is collected from a healthy tendon and sent to Ortho Cell for processing, and then later the patient returns for an injection of the tenocyte cells isolated and grown from the biopsy. Orthocell's treatments have only been available to clinical trial participants but are being considered for approval for wider usage.

A Canadian company, Replicel, is running clinical trials for their autologous cell therapy tendinopathy treatment called RCT-01. They inject tendinopathy injuries with fibroblasts collected from the dermal sheath of patients’ hair follicles. Replicel reports that these fibroblasts derived from hair follicles produce five times more Type I collagen than skin-derived fibroblasts and don't require biopsy from a healthy tendon to collect the cells (they are collected from the scalp instead). A Phase 1 trial of RCT-01 was successful in patients with Achilles tendinopathy who had failed earlier treatment. An information sheet about the replicel therapy can be read here.

The stem cell field has had trouble with fraudulent companies that were not offering real stem cell therapy, and even when the treatments are real, they are not well researched yet. Some of these new technologies appear promising, but use caution when pursuing these treatments.