Tendinitis and Tendinosis treatments – Injections for Chronic Tendinopathy
Ross Hauser, MD , Danielle R. Steilen-Matias, MMS, PA-C
Tendinitis and Tendinosis treatments – Injections for Chronic Tendinopathy
You went to your follow up visit with your orthopedist. You were told that you have Tendinopathy or “Tendon problems.” This came as no surprise to you. You know something is wrong. The pain may be in your shoulder, your wrist, your hamstrings, where there is a tendon there is the chance for Tendinitis and Tendinosis.
When the swelling goes away, that does not mean your tendon has healed
You have pain and sometimes you can barely move. Some of you may be curious as to why your joint swelling went away. You initially thought this was a good thing and that your tendon was healing. Now you are finding out pain without swelling is not such a good thing and you have progressed to “tendinosis.” You are anxious to get something positive done but this is now turning into a long-term, “I have to live with this problem.”
In this article, we will talk and guide you to information and research on various treatment options for various tendinopathies.
Tendinosis, the long-term consequences of non-treatment or ineffective tendon injury
When a patient comes to Caring Medical with joint problems related to sports or active lifestyle or physically demanding job and a diagnosis of one of the various tendinopathy issues described in this article, many of them will have an advanced case. It will either be advanced tendinitis or advanced tendinosis.
- The initial wear and tear and overuse injuries to tendons usually involve a degree of inflammation. This is the Tendinitis stage. This is where your health care provider will attack your problems with anti-inflammatory medications and possibly cortisone injections.
- You continue to have pain but not inflammation. In essence, your body has given up trying to repair the tendon because your body believes, it is “too far gone.”
The medical community is in debate as to what is “true tendinitis,” and what is “true tendinosis.”
This affects your treatment, you have to pay attention and talk to your doctor
The differences between tendinitis and tendinosis are important as it helps guide treatments. Clearly, a path of anti-inflammatory treatments would have to be carefully evaluated for effectiveness in tendinosis.
Here is an example that will help you understand the confusion in the medical community and why you need to talk to your doctor about your treatment.
An example with tennis elbow, what is it? “itis” or “osis”?
- For example, you may have a diagnosis of “tennis elbow.” Tennis elbow is a common name for the more medical term “lateral epicondylitis.“
- Lateral epicondylitis means an inflammation “itis” of the side (lateral) area where the tendon attaches to the bones in the elbow. In this case the humerus, the upper arm bone and the radius, the forearm bone.
“Itis” means inflammation and to treat with anti-inflammatories.
Is inflammation good or bad?
It is this question, “Is inflammation good or bad?” that is causing confusion in the medical community. If you are reading this article with a problem of chronic tendinopathy, it is very likely that through all your doctor visits and treatments you were told that “you have to get rid of the inflammation.” You probably have a long medical history with anti-inflammatory medicines. You may have taken anti-inflammatory medicines today. Are this medications helping or hurting. You may not be sure but you may be taking anti-inflammatories because they help sometimes.
Lets look at a December 2019 study in the British Medical Bulletin, (1) it shows the confusion in the medical community as to what exactly is the role of chronic inflammation.
These are the learning points:
The role of inflammation in tendon healing is still unclear:
- “The role of inflammation in tendon healing is still unclear, though it seems to affect the overall outcome. A thorough understanding of the biochemical mediators of healing and their pathway of pain could be used to target tendinopathy and possibly guide its management.” In other words, inflammation has something to do with tendon healing. The researchers of this study, citing the collective research of many studies could not definitely say however what it is.
Exercise or physical therapy may or may not help
- “Based on the current evidence, it is difficult to establish the right threshold for a beneficial effect of exercise without raising the risk of a potential harm in human patients.”
- What the researchers found was that in animal studies, tendons benefitted from exercise because exercise increased inflammation and this increase in inflammation help accelerate healing.
- The researchers also add: “Several preclinical studies note that exercise still represents one of the best ways to positively influence tendon healing by negatively affecting the inflammatory environment. This highlights the role of early mobilization in injured tendons.”
- Let’s add a brief explanatory note: Exercise brings blood to an injury. Blood brings inflammatory cells that clean up damaged and dead cells first, then blood brings the immune cell rebuilders of damaged tissue. Healing is greatly dependent on this initial healing response after injury.
- “Negatively affecting the inflammatory environment.” What does this mean? When there is more injury than the body’s natural healing mechanism can heal, inflammation continues. This is the chronic low grade inflammation that perhaps you and many people suffer from. When this inflammation persists, or becomes chronic, the inflammation itself becomes degenerative as the corrosive elements that are initially designed to quickly dissolve and flush away dead and damaged cells continues to linger. The inflammation is buring out your joints. Here is the birth of the great controversy. You need inflammation to heal, you need to get rid of inflammation to prevent your joints from dissolving.
The conclusion of this paper sums up this controversy like this: “The overall role of inflammation remains unclear.” We are going to return to this paper later in this article.
At this point we also want to take away some notes to refer back to in this article:
- Inflammation has something to do with tendon healing. Anti-inflammatories may prevent healing.
- Exercise and physical therapy may or may not work
- Circulation and increased blood flow is beneficial to healing a tendon. Rest and immobilization should be limited or avoided if possible.
Inflammation has something to do with tendon healing. Anti-inflammatories may prevent healing.
To understand why you are having chronic tendinopathy issues despite increased anti-inflammatory dosage is to understand that your tendons are degenerating faster than your body can heal them. The question then is, are the anti-inflammatory medications accelerating the degeneration?
Understanding inflammation in healing: Chronic inflammation will continue trying to heal something it can’t.
- The body’s healing response is inflammation. Inflammation fixes injuries. Inflammation will turn on and continue staying on until the tendon is fully healed. If you have reached the point of chronic tendinopathy, your inflammation is always on because the tendon is not or cannot fully heal. Chronic inflammation will continue trying to heal something it can’t.
Research: Ibuprofen does not help tendinosis it may make it worse
You do not have to be a scientist to understand this research. Ibuprofen does not help tendinosis.
This research came from the University of Copenhagen and was published in the Journal of Applied Physiology in November 2017 (2).
Highlights of research
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat tendinopathy, but evidence for this treatment is lacking, and little is known regarding the effects of NSAIDs on the human tendinopathic tendon.
- This study investigated the effects of NSAID treatment (ibuprofen) on human tendinopathic tendon, with changes in gene expression (generally: Gene expression is your cells talking to each other or signaling each other that they need to heal something) as the primary outcome, and tendon pain, function, and blood flow as secondary outcomes.
- Noteworthy of this research: “Nonsteroidal anti-inflammatory drugs are widely used in the treatment of tendinopathy, but little is known of the effects of these drugs on tendon tissue. We find that one week of ibuprofen treatment has no effect on gene expression of collagen and related growth factors in adult human tendinopathic tendon in vivo . . . suggesting that tendinopathic cells are not responsive to ibuprofen.”
Ibuprofen does not stimulate healing in tendinosis – Ibuprofen may make your tendinopathy worse
In a May 2018 study published in the Journal of musculoskeletal disorders and treatment, (3) researchers at Rush University Medical Center offered these observations on an Achilles injury in laboratory rats:
- Post-tendon injury analgesia (pain relief) is often achieved with NSAIDs such as Ibuprofen, however there is increasing evidence that NSAID usage may interfere with the healing process.
- We have examined the effect of oral Ibuprofen, on Achilles tendon healing in rat tendinopathy.
- The rats received Ibuprofen 3 days after initial injury (acute cellular response phase – this is during the time of inflammation in response to injury) and continued for 22 days
- or started at 9 days after injury (transition to matrix regeneration phase – this is the time of repair after the initial inflammatory phase) and given for 16 days.
- Ibuprofen prevented key processes of the inflammatory response to healing. Including the processes of removing dead injured tissue and the process of rebuilding the damaged tendon. The researchers concluded that the use of Ibuprofen for pain relief during inflammatory phases of tendinopathy, might interfere with the normal processes of healing.
Our discussions with patients helping them to understand their advancing stage tendon injuries
Despite the differences in what tendinitis and tendinosis are, most patients come in for our first visit with an MRI film and report and say they have a “tendinitis.” This is probably the easier of terms for them to understand as it is a term to describe a new onset of pain. But when you look at his or her MRI and read the MRI report we find that this problem of tendinitis has been going on for some time. It has deteriorated into tendinosis. So we ask them:
- Have you continued to work out or play sports or go to work with your tendon problem?
- For the worker, they see themselves as having little choice. For the sports-minded or physical exercise enthusiast, many patients we see say yes they have. For both groups, the anti-inflammatory medication help get them through their workday or workout. Certainly putting ice on the problem are has its benefits.
In the initial phase of a tendon injury, you likely had an inflamed tendon. Ice and anti-inflammatories will help reduce the swelling and with pain, but at what cost? Long-term tendinosis and continued doctor visits.
- We find this particularity true in weightlifters. They continue on with their routines looking to increase the size of their bicep muscles for instance. Yet the entire success of their workout is dependent on a healthy bicep tendon. When the bicep tendon is hurt, they have their tendinitis treated with anti-inflammatories and cortisone injections. The exact treatments that will decrease the size of their bicep by damaging the bicep tendon. Then they will get a cortisone injection. Then they will come into our office looking for help because the cortisone “wore off,” or is no longer effective. They can no longer train. This happens all the time. Let’s briefly look at the various tendinopathies we see:
We see many people with Achilles Tendinopathy. You may be an older active person, maybe you are a sports referee or like to run. Men’s league basketball players often show up with Achilles injuries from “out of nowhere.” If it is your Achilles tendon that is the problem, please see our article: Achilles Tendinopathy and Achilles tendon partial and full thickness rupture | Surgery and non-operative treatment.
We see many people with Swimmer’s shoulder, or supraspinatus tendinopathy, or a rotator cuff tendinopathy diagnosis, they come in knowing that their shoulder hurts, there is a problem with tendons, and they are thinking that somewhere along the line someone, if they have not already, is going to eventually recommend a surgery. Surgery means extended time away from sport or work. Surgery for many, therefore, is not a realistic option. But perhaps the biggest problem is that everywhere this person has been, all the talk is about a single tendon or the rotator cuff as a single unit. It is most probable that no one sat down with this person and said to them, “to heal this tendon problem, we have to heal your whole shoulder.” If it is your Rotator Cuff and you want to learn more about your realistic options, start here: Rotator Cuff Tendinopathy
Is it your knee?
In our clinic, we see many knee problems. This is not limited to people trying to avoid a knee replacement or a meniscus surgery. Like the rotator cuff people, many of these knees have been diagnosed with a “tendinopathy,” (tendon problems); a “tendinosis,” (tendon problems without inflammation “osis.”); a “tendinitis,” (tendon problems with “inflammation or “itis.”)
- Patellar tendinitis is inflammation of the patellar tendon, which attaches the kneecap to the tibia or shinbone. The patellar tendon helps your muscles extend your knee. Patellar tendinopathy is a degeneration process of the kneecap tendon.In our article: Patellar Tendinopathy surgery and treatment options, we examine research and clinical observations of various treatments for patellar tendinopathy. We will also look at the connection between patellar tendinopathy, continuing degenerative knee ligament damage, and degenerative knee instability that makes it very difficult for a jumper to jump, a runner to run, or a worker to work without pain.
- Pes anserinus tendinitis, which involves the pes anserinus tendons that lie on the inside and just below the knee joint and prevents the lower leg from twisting outward while running.
- Popliteus tendinitis
- Semimembranous tendinitis.
Is it your elbow?
We started this conversation above. We see a lot of people with elbow problems, they have been diagnosed with “Tennis Elbow” and “Golfer’s Elbow.” A history of cortisone and physical therapy has now made their situation worse. If this sounds like this is happening to you, please see our article: Comprehensive Prolotherapy and PRP tennis elbow and elbow instability injections.
Is it your “glutes?”
The “glutes” of the hip, that is the gluteus maximus and the smaller gluteus medius, are powerful muscles of the hip and pelvic region. Connecting these powerful muscles are powerful tendons. When these tendons are damaged patients are diagnosed with a problem of hip or pelvic tendinopathy. Problems that can bring with it significant pain and disability. If this is you, you can get more information in our article Gluteus Medius Tendinopathy Injections.
When the hip joint region becomes unstable, the muscles, including the Gluteus Medius, tries to create stability by tensing, cramping, or going into spasm. When the muscle tenses, you have “pull” on the tendon. If the tendon is damaged, it will be very painful. That painful tendon starts sending signals to the hip and spine and knee and leg and ankle that it needs help taking some of the load. Suddenly you have pain messages going up and down your leg from spine to foot.
Your continued tendon problems are so challenging that an international team of researchers have published findings on treatment guidelines: Date: December 2018
This is what the surgical group: The European Society of Sports Traumatology Knee Surgery and Arthroscopy, published in their Journal of Experimental Orthopaedics.(4) December 2018. Remember above what the surgeons wrote in 1999. Here we are 19 years later.
- The treatment of painful chronic tendinopathy is challenging.
- Patients and health care providers have a choice to treat problems with multiple non-invasive (non-surgery) and tendon-invasive (surgery) methods.
- When traditional non-invasive treatments fail, the injections of platelet-rich plasma autologous blood or cortisone have become increasingly favored. However, there is little scientific evidence from human studies supporting injection treatment.
- As the last resort, open or arthroscopic surgery to the tendon, or surgery to the tendon and surrounding soft tissue are employed even though these also show varying results.
In the opening of this study, the surgeons acknowledge that helping people with tendinopathy is challenging. Non-surgical methods do not work that well, see the research they cite below of a 25% failure rate, and surgeries do not typically work that well. Cortisone is usually not supported and the surgeons question the benefit of PRP injections. Which we will discuss at length below.
So what are the treatments and what does the research say?
“The great incidence of tendon injuries as the failure rate of up to 25% (of the available conservative treatments) has made alternative biological approaches (PRP and stem cell therapy among them) “most interesting.”
The above quote is from research published in the journal BMC musculoskeletal disorders (5). A fascinating part of this research is the investigators suggesting that: “The study of the microenvironment of tendinopathy is a key factor in improving tendon healing.” What is the microenvironment of tendinopathy? INFLAMMATION
Listen to what the researchers suggest, it will give you an understanding of how to heal by getting rid of anti-inflammatory medications.
- “An alternative anti-inflammatory and immunomodulatory (suppressing the immune response, i.e., inflammation) approach that replaces the traditional anti-inflammatory modalities (i.e. NSAIDs) may provide another potential opportunity in the treatment of chronic tendinopathies.”
The research shows that even in cases of tendinosis, where it is thought that no inflammation is occurring, there is still inflammatory cellular activity. IN OTHER WORDS – your tendon is waiting for the inflammation to start up again and do its repair and there is a “skeleton crew,” of cellular communicators waiting for signals. Waiting for signals as we will see below is an important part of the tendons rebooting its healing cycle.
Rebooting the inflammatory process in tendon healing – one way to fix chronic tendinopathy
Rebooting the inflammatory process means getting blood flow and healing factors back into the damaged area. There are many treatments that can do this.
Before we get into these treatments a quick word about ice packs. Some people become “addicted” to ice because it helps numb the area and reduce pain in the short-term. Icing make pain worse in the long run. We cover this at length in our article Rest ice compression elevation | Rice Therapy and Price Therapy
Extracorporeal shock wave therapy
Some people explore Extracorporeal shock wave therapy and find this treatment effective. Shock wave therapy puts pressure on the damaged area, it is an electric massage. It does bring circulation and healing factors to the damaged tendon. We find this to be a good supportive treatment for some, but not a primary treatment as tendon damage may be more significant than the treatment can realistically help.
Physical therapy and light exercise
Movement brings circulation and healing factors to the site of injury. The careful thing of course is that the movement does not make the injury worse. We also find this to be a good supportive treatment for some, but not a primary treatment as tendon damage may be more significant than the treatment can realistically help.
The evidence that pro-inflammatory treatments work better than anti-inflammatory treatments
Below is a pro-inflammatory treatment demonstration. It is injections of detxrose Prolotherapy. This simple solution brings pro-inflammatory factors into the damaged area to stimulate healing. The research is below.
The best way in our opinion to show you how pro-inflammatory treatments heal where anti-inflammatory treatments do not heal is in the research making a direct comparison.
A multi-national team of researchers including those from Rutgers University, Virginia College of Osteopathic Medicine, and the University Regensburg Medical Centre in Germany tested the effects of Prolotherapy on tenocytes repair (tendon cells). Published in the journal Clinical orthopaedics and related research, (6) what the team was looking for was how did Prolotherapy injections change the immune system’s response to a difficult to teal tendon injury.
These are the highlights:
- Prolotherapy injections changed the cellular metabolic activity to a healing, regenerative environment in the tendon cells.
- Prolotherapy activated RNA expression. The healing phase of soft tissue injury starts spontaneously after the tendon injury. Healing occurs in three phases: inflammation, proliferation and maturation. RNA expression is the communication changes in genes (remember the gene expression from above) that coordinates the beginning and ending of these three cycles of healing and injury repair process.
- Activated Protein secretion – the process of rebuilding. For a fascinating look at this subject please see our article on Extracellular matrix in osteoarthritis and joint healing.
- Cell migration. The ability of healing cells to get to the site of an injury, and the denial of damaging inflammatory factors from reaching the same site.
In our own published research, we reported in the Clinical medicine insights. Arthritis and musculoskeletal disorders, (7) we reported that the consensus is growing regarding the effectiveness of dextrose Prolotherapy as an alternative to surgery for patients with chronic tendinopathy who have persistent pain despite appropriate rehabilitative exercise.
Platelet Rich Plasma Therapy and Prolotherapy
Platelet Rich Plasma therapy (PRP) can be added to the traditional Prolotherapy solution to expedite the process, in specific cases.
- PRP treatment re-introduces your own concentrated blood platelets into areas of chronic tendinopathy
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma.
- The procedure and preparation of therapeutic doses of growth factors consist of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.)
- In our clinics, patients are generally seen every 4-6 weeks. Typically three to six visits are necessary per area.
Below is a pro-inflammatory treatment demonstration of Prolotherapy combined with PRP treatments. This simple treatment brings pro-inflammatory factors into the damaged area to stimulate healing. The research is below.
Platelet Rich Plasma vs Cortisone. Pro-inflammatory treatments vs anti-inflammatory treatments
What we see in this research is a straight out comparison of PRP treatments with cortisone
- Patients with chronic gluteal tendinopathy achieved greater clinical improvement at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection.(8)
- PRP improved pain and function patients with chronic lateral epicondylitis (Tennis elbow), who had not had relief with cortisone injection.(9)
- Journal of clinical and diagnostic research, a 2015 study reveals PRP as a superior treatment option to cortisone in cases of tennis elbow.(10)
- Doctors in Pakistan have shown the effectiveness of platelets rich plasma versus corticosteroids or the “tennis elbow steroid injection.” The doctors looked at 102 patients in the study and divided them into two groups of 51(50%) each.
- In the patients in the cortisone group 53% improvement
- In the patients in the PRP group 82%
- Their conclusion: PRP is an effective alternative to corticosteroid in the treatment of lateral epicondylitis (tennis elbow).(11)
- International orthopaedics (2012) Compared with cortisone injections, PRP showed significant clinical benefit for patellar tendinopathy. Additionally, the PRP benefit worked best when the patient did not have a PREVIOUS CORTISONE INJECTION.(12)
The problem of lack of treatment standardization
In our 25 plus years of helping people with tendon injuries, we have found Prolotherapy and PRP treatments to be effective in helping these people’s goals of getting back to sports or work. The article you have just read is based on our years of experience in treating thousands and thousands of patients. The way we offer treatment is not how you may find this treatment offered at other clinics.
In November 2018, this very problem of lack of standardized in treatment was discussed by doctors at the University of Pittsburgh who published this paper Myths and Facts of In-Office Regenerative Procedures for Tendinopathy: Literature Review., in the American journal of physical medicine & rehabilitation. Here is what the Pittsburgh doctors had to say:
“Tendinopathy carries a large burden of musculoskeletal disorders seen in both athletes and aging population. Treatment is often challenging, and progression to chronic tendinopathy is common. . . The field of regenerative medicine has taken the forefront, and various treatments have been developed and explored including prolotherapy, platelet rich plasma (PRP), stem cells, and percutaneous ultrasonic tenotomy. However, high-quality research with standardized protocols and consistent controls for proper evaluation of treatment efficacy is currently needed.”(13)
Basically, there are many practitioners and researchers who are not sure what is the optimal standardized treatment is. In our experience, we find that the optimal standardized treatment is a comprehensive and customized treatment program based on the needs of the individual patient. Someone who runs marathons needs a customized treatment different that someone who simply wants to walk pain free. Your treatment is based on your treatment goals of resuming pain-free activity.
Do you have a question about tendon damage and repair? Get help and information from Caring Medical
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This page was updated February 23, 2021