Tendinopathy Treatment - What Works?

Cortisone Injections, Shockwave Therapy, Dry Needling. What works?

Pain from tendinopathy can be frustrating and debilitating, it can affect your day-to-day life, including your sleep.  Simple movements including sitting, walking, running, climbing the stairs, or reaching overhead can become difficult and painful.  It is understandable people suffering from tendon pain will eventually investigate a ‘quick fix’. The truth about tendinopathy (the broader term now used for tendinitis and tendinosis); is it often takes months to heal, and there is NO ‘quick fix’.

The current best practice management for tendinopathy pathologies is load management, along with a targeted exercise program, but what about these other popular options? How well do they work and when should you seek them out, if at all?

Cortisone Injections
Cortisone is a corticosteroid used to reduce inflammation and reduce pain.  Cortisone injections should be a last resort when treating tendon pathologies; the negatives far outweigh any benefit.  Corticosteroid injections have been shown to provide some short-term pain relief in some patients (up to 2 months). There is no clear evidence of medium to long-term benefit, with studies showing they may be worse than other treatments, and may cause long-term damage and degeneration to the tendon tissue and cells. (Mohamadi et al. 2017).  There is no benefit of having multiple injections; any pain relief initially experienced lessens over time with sensitisation occurring. 

It is recommended you give the proven treatments (load management, exercises, and education) a good go before thinking about cortisone injections.

Shockwave Therapy
Shockwave therapy is a safe but often painful treatment that is commonly used to treat tendon pain.  The shockwaves are thought to increase blood flow and metabolic activity around the area of pain.  Studies into the effectiveness of this treatment have been conflicting.  The most encouraging evidence is in its treatment of plantar heel pain.  It’s thought it possibly works by diffuse noxious inhibitory control – a change in pain due to the significant pain it causes during the treatment (10-15sec bursts). This may not sound appealing, but there have been positive results for many people in clinical use.  It may be used successfully with an exercise-based rehab program to assist with short-term pain relief. 

What about massage, dry needling and taping?
There is some evidence that myofascial dry needling may help as a short-term pain modulator.  A study conducted by Brennan (2015) on gluteal tendinopathy showed dry needling to be as effective as steroid injection over 6 weeks.  Considering the long-term implications of steroid injections, dry needling may be a better option.

 Massage of the tendon is not beneficial and may aggravate it.  Massage of the surrounding muscles may be beneficial and worth trying.  There is little evidence proving its effectiveness but the few studies available show it may be helpful for reduction in pain when used with exercise and load management.

Where to from here?

First line treatment – Load management (exercise modification), exercise program and education
Second line treatment (can be used alongside the above) – taping, shockwave therapy, massage, dry needling
Third line treatment (when the above has made no progress) – Injections and surgery