Current Treatments

Dr. Khan et al have provided an excellent summary and analysis of current treatments for tendinosis in part 4.1 of the article Histopathology of Common Tendinopathies.[18] I've included a similar list of treatments here (with a few additions); you can read my comments to get a patient's perspective and see his article for further medical information.

Ideally, tendinosis treatments would focus on promoting better healing of collagen and breaking the cycle of failed healing. Unfortunately, the treatments that are currently available don't speed the healing process very much. Physical therapy is probably the most useful treatment if you can find a really good therapist. Perhaps we'll have better treatments in the future; see Future Treatments for details.

Because we don't have a current treatment for tendinosis that dramatically speeds healing, the market is ripe for people who promote various "miracle cures" such as exercise programs, exercise devices, braces, relaxation aides, topical creams, pills, and more. Some of these items can be helpful, but their promoters often make claims that can't be fulfilled. For example, people often claim that their products will cure you in just a week, even if you've had symptoms for years. If you really have a tendinosis injury, the damage to your collagen can't possibly heal in a week. Don't expect miracles. You can heal, and some of these products might help, but the healing will take time because your body needs to create new collagen to repair the injury.

Please note that tendinosis.org does not endorse any particlar product, treatment, or website. Tendinosis.org is strictly a site to provide information about tendinosis and to encourage research into the etiology and treatment of tendinosis. The information in this section is intended to help you learn about treatments that are currently available.

Note: The numbers in brackets after some sentences on this page are references found on the References page.

1. Rest
   By the time you feel pain from tendinosis, your injury has been gradually building for many weeks. Remember that tendons heal slowly. Dr. Khan's article says tendons require over 100 days to make new collagen. 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 any strengthening exercises, but when you are ready your physical therapist can create a gentle stretching and strengthening program for you.
   
   If you feel impatient with your injury, join a support group for RSI, either a local group in your community or an online group. (See RSI Groups and Links .) 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.

2. Physical Therapy Exercises
   Gentle stretching and strengthening exercises can help heal tendinosis, 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 speeds the healing process. Find a physical therapist who has a lot of experience with tendinosis, and make sure he/she is willing to go as slowly as your body requires.
   
   Some studies have shown that eccentric exercise is especially helpful for tendinosis. 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 or sports medicine doctor about trying eccentric exercises as part of your strengthening program.

   You can find examples of physical therapy exercises in many places on the web. You probably shouldn't design your own PT program just from online information, but these sites will give you a few ideas to try. 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. Your therapist will probably start you out with exercises that don't involve resistance (weights or elastic bands) and then gradually add resistance as you gain strength.

   For some example physical therapy exercises, see the "Rehabiliation" and "Strengthening Exercises" sections on the Personal Health page of The Physician and Sports Medicine. Each of these categories has a list of articles that give illustrated examples of exercises for many areas of the body (legs, arms, back, shoulders). Also see the Physical Therapy Corner page of the Nicholas Institute of Sports Medicine and Athletic Trauma website. The site gives in-depth discussions of many common injuries and illustrated examples of rehabilitative exercises. For a discussion of strengthening exercises for patellar tendinosis, see the section "Strengthening: Putting Theory into Practice" of Overuse Tendinosis, Not Tendinitis, Part 2: Applying the New Approach to Patellar Tendinopathy. For short video clips of some physical therapy exercises (some with elastic band resistance), see the www.ussportsmed.com website. You can easily find more websites with PT exercises by typing "physical therapy exercises" and your injury type or body part into a search engine.

   To learn stretching exercises designed specifically for RSI injuries of the upper body, try Sharon Butler's book "Conquering Carpal Tunnel Syndrome And Other Repetitive Strain Injuries." For a list of more books on RSI, see The RSI Page.

3. Physical Therapy Modalities
   Physical therapy modalities include things like heat, cold, ultrasound, electrical stimulation, and laser treatment. Not enough research has been done on these modalities to prove that they can help tendinosis heal faster or better. A few studies have found some positive effects, but the evidence is very skimpy at this point. The best you can do is just try some of these things if your physical therapist suggests them and see if they seem to help you. If heat or cold treatments are helpful, you can do them at home for yourself.

4. Sonocur Shockwave Therapy
   Sonocur shockwave therapy is a new treatment for tendinosis. As of July 2002, the FDA approved it as a treatment for lateral epicondylitis (tennis elbow), but it is also being used for tendinosis in other areas of the body such as the shoulder, knee, and heel. The Sonocur machine is an "extracorporeal ultrasound device" that delivers sound waves to a very focused area of the tendon. It seems to be most effective for people who have pain located in a smaller, specific area rather than pain in a large, diffuse region.

   Most patients receive the treatment once a week for three weeks. Each treatment lasts 8 to 10 minutes. Sonocur is combined with other standard treatments for tendinosis, such as ice and physical therapy. The Sonocur literature says that full effects of the treatment can take 6 to 12 weeks to emerge.

   FDA approval for Sonocur came after completion of a clinical trial in the U.S. that began in 2000. The double-blind trial studied 114 patients with chronic tennis elbow. All the patients had been injured for at least one year and had failed to respond to conventional treatments. After 12 weeks, 64% of the treated patients had at least a 50% decrease in pain. The treatment seemed to help decrease pain and increase function. The study did not find any serious side-effects, but you might want to consult a Sonocur expert before trying it if you flare up easily.

   You can get more information about Sonocur treatment on the www.sonorex.com website. They also have a "therapy center locator" that can help you find a doctor nearest you that offers Sonocur therapy.

   The research so far does not show whether Sonocur stimulates collagen healing or whether it works more as a pain-killer. More research is needed to determine exactly why it seems to help some people. Sonocur is an interesting new treatment that might be worth looking into if you've not had luck with conventional treatments, but you might wait until we know more about it. A single clinical trial isn't a lot to go on. With time, we'll have more statistics about its effectiveness.

5. Ice
   Using ice packs, or cryotherapy, is a common treatment for tendinosis. Many physical therapists suggest that you use ice following your exercises or whenever you need some pain reduction during the day. Don't use it just prior to your exercises. It's hard to say if ice has any long-term beneficial effect on tendinosis, but it can be an excellent form of pain control that has no negative side effects (as long as you take care not to get "ice burn" from too much ice).

6. NSAIDs
   Non-steroidal anti-inflammatories would not be expected to help tendinosis since it is an injury of chronic degeneration, not inflammation. Studies show that some NSAIDs actually impede the healing process, which is the last thing needed with tendinosis.[17] Long-term use of NSAIDs for tendinosis is probably not a good idea. For more information, see the online articles Histopathology of Common Tendinopathies (part 4.1) and The Tendinitis Myth.[18,44]

7. Cortisone Injections
   Cortisone injections have been shown to cause adverse effects on the tissue in the area of the injection if repeated injections are given. Because tendinosis is a chronic injury that can't be cured with a cortisone injection, this treatment has limited use. You are probably better off avoiding cortisone injections since they can harm the tissue and slow collagen synthesis. Like NSAIDs, cortisone's main beneficial effect is to reduce inflammation, and tendinosis is not an inflammatory condition.
   
   Cortisone injections can temporarily lessen the pain of tendinosis, but they don't help the injury heal. Doctors used to think that cortisone reduced the pain by reducing inflammation, but now that doctors have discovered tendinosis is not an inflammatory injury, they think cortisone reduces pain by reducing or blocking other irritating biochemical substances that occur as part of the injury process. NSAIDs could relieve pain through the same mechanism. See Overuse Tendon Injuries: Where Does The Pain Come From? for more information.[42]

8. Braces, Supports, 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. Sometimes carpal tunnel syndrome patients like to sleep with wrist braces to avoid getting into 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 helpful if you really 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).

9. Technique Correction and Ergonomic Correction
   Using the correct technique when playing sports can be very helpful in improving tendinosis. Poor biomechanics can definitely make your injury worse. Make sure you talk with a qualified coach to help you improve your technique. Also, make sure your equipment fits you properly.
   
   Correcting ergonomic problems can be very helpful in healing workplace tendinosis. Ergonomic improvements are a better prevention than cure for tendinosis, but better late than never. You can find lots of information on ergonomics on the web; try your favorite search engine or check the links on the RSI Groups and Links page.

10. Nutritional Supplements
    Not much scientific research has been done to investigate the effects of nutritional supplements on the healing of tendinosis. Basic good nutrition is probably advisable, but we don't know yet whether any particular supplement can help.
    
    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.
    
    Although glucosamine sulfate and chondroitin sulfate can be very helpful for osteoarthritis, they are not likely to help tendinosis. Based on the comments I've seen online, most people who have tried glucosamine for tendinosis haven't noticed any improvement. This is not surprising because tendinosis and osteoarthritis are quite different. Osteoarthritis causes a decrease in collagen, proteoglycans, and glycosaminoglycans (GAGs) in cartilage. Tendinosis 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 help build proteoglycans; since the levels of GAGs and proteoglycans are already abnormally high in tendinosis, 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]
    
    Other supplements that claim to help heal tendons and ligaments contain the amino acids glycine, lysine, and proline. This idea isn't bad since those three amino acids are very abundant in tendon and ligament collagen. However, the problem again is that merely throwing more collagen ingredients at the injured fibrocyte cells probably won't change their behavior of making abnormal collagen. You should be sure to get enough protein in your diet so you're not outright deficient in amino acids, but there's no evidence to suggest that extra amino acids can cure tendinosis.
    
    Maybe someday we'll find a supplement that can somehow induce the injured cells in tendinosis to make normal collagen, but for now we don't know of anything that can do it. Your best bet is to eat a healthy diet with plenty of fruits, vegetables, good fats, protein, whole grains, and antioxidants and with minimal amounts of trans fats and saturated fats. For more information about healthy nutrition, see www.drweil.com and www.wholehealthmd.com.

    Although we don't know of a supplement that can help the collagen in tendinosis injuries heal, we do know of some supplements that can help inflammation. Tendinosis is not an inflammatory injury, but if you have an acute sprain/strain or an acute flare-up involving inflammation, some of these supplements might help. Because many of these supplements take a little time to work, they are not always effective as temporary treatments for acute flare-ups (you need something more fast-acting). Still, some people find these supplements are useful for sprains and back injury flare-ups, so they might be worth trying when you think you have acute inflammation. The following are some of the supplements that have been found to be anti-inflammatory in arthritis patients: ginger, tumeric, boswellia, bromelain, and fish oil. For information on how to use these supplements, see www.drweil.com.

11. Bodywork
    Physical therapists do massage, and many kinds of alternative medicine practitioners do bodywork such as Feldenkrais, Hellerwork, and Alexander Technique. Although we don't know if any of these treatments can help produce better collagen in the tendinosis injury, many people find that bodywork can help them loosen up and feel better. Many practitioners try to help you with your posture and body mechanics, and some do hands-on soft tissue work. Check with support groups to find out more information about the various approaches.

    Be careful not to let someone convince you that the treatment must be painful to be effective -- you could make your injury worse. Physical therapists say that some kinds of massage can cause mild discomfort but shouldn't cause intense pain. You'll need to learn how your own body reacts; some people can have massage that causes discomfort at the time but they feel fine later, while other people can have that same level of discomfort during massage lead to a painful flare-up that lasts a week. Proceed cautiously until you learn how your own soft tissue reacts to various hands-on procedures.

12. Surgery
    Surgery is a last resort for tendinosis. 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 very 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. Don't view surgery as a magic solution; it's possible that in many cases more benefit comes from the rehabilitation following the surgery than from the surgery itself. And many people on the sorehand discussion list have said surgery made them much worse. You can search for information about surgery results in the sorehand archives (for more information about sorehand, see RSI Groups and Links ).