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 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”?

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:

Exercise or physical therapy may or may not help

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.

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.

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

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:

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:

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.

Achilles tendon

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.

Shoulder, Rotator Cuff, and upper arm extremities

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.

A September 2022 paper in the Skeletal radiology (14) describes various treatments for tendinopathy in the shoulders, elbows and hands. “Upper limb injections commonly use corticosteroids and anesthetics with different reported short- and long-term results depending on the tendon treated; better results are obtained in the treatment of tenosynovitis (sliding tendons such as trigger finger and De Quervain’s tenosynovitis). Shoulder and elbow tendinopathies (anchor tendons) may also benefit from injections containing irritants or healing stimulants such as dextrose (prolotherapy) and platelet-rich plasma or by the stimulation of healing via tendon perforations (fenestration). The hyaluronic acid injection has also been used in the treatment of both tenosynovitis and tendinopathies. For tendons passing through osteofibrous tunnels (such as the carpal tunnel), an additional release may be performed. . . ”

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 tendinopathy

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.

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.

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:

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.

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

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

1 Chisari E, Rehak L, Khan WS, Maffulli N. Tendon healing in presence of chronic low-level inflammation: a systematic review. British medical bulletin. 2019 Dec 11;132(1):97-116. [Google Scholar]
2 Heinemeier KM, Øhlenschlæger TF, Mikkelsen UR, Sønder F, Schjerling P, Svensson RB, Kjaer M. Effects of anti-inflammatory (NSAID) treatment on human tendinopathic tissue. Journal of Applied Physiology. 2017 Aug 31;123(5):1397-405. [Google Scholar]
3 Bittermann A, Gao S, Rezvani S, Li J, Sikes KJ, Sandy J, Wang V, Lee S, Holmes G, Lin J, Plaas A. Oral Ibuprofen Interferes with Cellular Healing Responses in a Murine Model of Achilles Tendinopathy. Journal of musculoskeletal disorders and treatment. 2018;4(2). [Google Scholar]
4 Abat F, Alfredson H, Cucchiarini M, Madry H, Marmotti A, Mouton C, Oliveira JM, Pereira H, Peretti GM, Spang C, Stephen J. Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part II: treatment options. Journal of experimental orthopaedics. 2018 Dec 1;5(1):38. [Google Scholar]
5 Lohrer H, David S, Nauck T. Surgical treatment for achilles tendinopathy – a systematic review. BMC Musculoskelet Disord. 2016;17:207. Published 2016 May 10. doi:10.1186/s12891-016-1061-4 [Google Scholar]
6 Ekwueme EC, Mohiuddin M, Yarborough JA, Brolinson PG, Docheva D, Fernandes HA, Freeman JW. Prolotherapy Induces an Inflammatory Response in Human Tenocytes In Vitro. Clinical Orthopaedics and Related Research®. 2017 Apr 27:1-1. [Google Scholar]
7 Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain. Clin Med Insights Arthritis Musculoskelet Disord. 2016;9:139-59. Published 2016 Jul 7. doi:10.4137/CMAMD.S39160 [Google Scholar]
8 Fitzpatrick J, Bulsara MK, O’Donnell J, McCrory PR, Zheng MH. The Effectiveness of Platelet-Rich Plasma Injections in Gluteal Tendinopathy: A Randomized, Double-Blind Controlled Trial Comparing a Single Platelet-Rich Plasma Injection With a Single Corticosteroid Injection. The American Journal of Sports Medicine. 2017:0363546517745525.  [Google Scholar]
9 Massy-Westropp N, Simmonds S, Caragianis S, Potter A. Autologous blood injection and wrist immobilisation for chronic lateral epicondylitis. Adv Orthop. 2012;2012:387829. doi: 10.1155/2012/387829. Epub 2012 Dec 4.  [Google Scholar]
10 Yadav R, Kothari SY, Borah D.  Comparison of Local Injection of Platelet Rich Plasma and Corticosteroidsin the Treatment of Lateral Epicondylitis of Humerus. J Clin Diagn Res. 2015 Jul;9(7):RC05-7. doi: 10.7860/JCDR/2015/14087.6213. Epub 2015 Jul 1.  [Google Scholar]
11 Khaliq A, Khan I, Inam M, Saeed M, Khan H, Iqbal MJ. Effectiveness of platelets rich plasma versus corticosteroids in lateral epicondylitis. J Pak Med Assoc. 2015 Nov;65(11 Suppl 3):S100-4. [Google Scholar]
12 Gosens T, Den Oudsten BL, Fievez E, van ‘t Spijker P, Fievez A. Pain and activity levels before and after platelet-rich plasma injection treatment of patellar tendinopathy: a prospective cohort study and the influence of previous treatments. Int Orthop. 2012 Sep;36(9):1941-6. doi: 10.1007/s00264-012-1540-7. Epub 2012 Apr 27 [Google Scholar]
13 Neph A, Onishi K, Wang JH. Myths and Facts of In-Office Regenerative Procedures for Tendinopathy: Literature Review. American journal of physical medicine & rehabilitation. 2018 Nov. [Google Scholar]
14 Silva FD, Zorzenoni F, da Silva LN, dos Reis Teixeira Neto A, Gonzalez MT, Guimarães JB. Tendon injections–upper extremity. Skeletal Radiology. 2022 Sep 2:1-2. [Google Scholar]

This page was updated February 23, 2021



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