Management of Chronic Tendon Injuries

 

Am Fam Physician. 2019 Aug 1;100(3):147-157.

Journal Audio: An audio version of this article is available.

Author disclosure: No relevant financial affiliations.

Chronic tendon injuries are common athletic and occupational injuries that account for many physician visits. Tendons have a complex biology that provides a unique combination of strength, flexibility, and elasticity but also predisposes them to injury. The term tendinopathy is preferred to tendinitis because of the presence of a disordered and degenerative healing process—not inflammation—in the pathologic tendon. Insidious onset of pain and dysfunction is a common presentation for most tendinopathies, and patients typically report that a change in activity affected the use of the tendon. Diagnosis is typically based on history and physical examination findings, but radiography is an acceptable initial imaging modality. Ultrasonography and magnetic resonance imaging may be useful when the diagnosis is unclear. The mainstays of treatment are activity modification, relative rest, pain control, and protection. Early initiation of rehabilitative exercises that emphasize eccentric loading is also beneficial. Despite a lack of high-quality evidence, cryotherapy has a role in controlling pain. Nonsteroidal anti-inflammatory drugs and corticosteroids have a role in treatment despite the lack of histologic evidence of inflammation. Short-term use of these drugs reduces pain and increases range of motion, which can assist patients in completing rehabilitative exercises. Care should be taken when injecting corticosteroids into and near major load-bearing tendons because of the risk of rupture. Topical nitroglycerin, extracorporeal shock wave therapy, and platelet-rich plasma injections have varying levels of evidence in certain tendinopathies and are additional nonsurgical treatment options.

Tendon injuries account for at least 7% of physician visits in the United States.1 More than 30% of sports-related injuries involve tendons, but chronic tendinopathy can also occur via occupational or lifestyle activities and can impair work and recreational performance.13

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Corticosteroid injections near areas of tendinopathy are helpful for short-term but not long-term treatment. However, they have a small risk of tendon rupture.13,2527,29,31,49,61

A

Based on clinical review articles and systematic reviews of randomized controlled trials

With consistent use, topical nitroglycerin can reduce tendon pain associated with activity.25,42

A

Based on a systematic review and meta-analysis

Extracorporeal shock wave therapy may be beneficial for plantar fasciitis, greater trochanteric pain syndrome, and calcific rotator cuff tendinopathy that are resistant to initial treatment. It has no clear benefit for noncalcific rotator cuff tendinopathy or lateral epicondylitis.25,32,50,51

B

Based on clinical review articles and systematic reviews of lower-quality studies

Eccentric exercises are effective for treating rotator cuff tendinopathy, lateral epicondylitis, patellar tendinopathy, and midsubstance Achilles tendinopathy.1315,25,31,55,64,67,68,73,79

B

Based on clinical review articles, systematic reviews of lower-quality studies, and lower-quality randomized controlled trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Corticosteroid injections near areas of tendinopathy are helpful for short-term but not long-term treatment. However, they have a small risk of tendon rupture.13,2527,29,31,49,61

A

Based on clinical review articles and systematic reviews of randomized controlled trials

With consistent use, topical nitroglycerin can reduce tendon pain associated with activity.25,42

A

Based on a systematic review and meta-analysis

Extracorporeal shock wave therapy may be beneficial for plantar fasciitis, greater trochanteric pain syndrome, and calcific rotator cuff tendinopathy that are resistant to initial treatment. It has no clear benefit for noncalcific rotator cuff tendinopathy or lateral epicondylitis.25,32,50,51

B

Based on clinical review articles and systematic reviews of lower-quality studies

Eccentric exercises are effective for treating rotator cuff tendinopathy, lateral epicondylitis, patellar tendinopathy, and midsubstance Achilles tendinopathy.1315,25,31,55,64,67,68,73,79

B

Based on clinical review articles, systematic reviews of lower-quality studies, and lower-quality randomized controlled trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information

The Authors

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SHAWN F. KANE, MD, FAAFP, FACSM, is an associate professor of family medicine and a faculty member in the Family Medicine Residency Program at the University of North Carolina School of Medicine, Chapel Hill....

LUCIANNE H. OLEWINSKI, MD, is an assistant professor of family medicine at the University of Tennessee College of Medicine, Knoxville.

KYLE S. TAMMINGA, MD, is a third-year family medicine resident at the University of North Carolina School of Medicine.

Address correspondence to Shawn F. Kane, MD, FAAFP, FACSM, 590 Manning Dr., Chapel Hill, NC 27599 (email: shkane@email.unc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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