Tendinopathy injections and treatments

Katherine L. Worsnick, MPAS, PA-C  and Ross Hauser MD

What is Tendinopathy? Tendinopathy is general diagnosis to describe a patient’s pain caused by damage around or in a tendon. Other diagnosis that fall under the Tendinopathy umbrella are tendinitis, which is pain from and inflammation of the tendon area.

This is usually the result of an acute or new injury. Tendinosis is pain from a tendon that has no swelling or inflammation. This is a chronic condition usually brought on ill-treated, non-healing tendinitis.

The typical treatment regime for tendonitis, such as knee tendonitis, rotator cuff tendonitis or patellar tendonitis, includes the RICE protocol, non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy and cortisone injections. Other options include cryotherapy and massage. But again, they may provide pain relief. However, if truly a weakened and/or injured tendons and ligaments is the issue, these are only a temporary fix.

Joint Instability and a comprehensive treatment plan for your tendinopathy

When a patient comes to Caring Medical with joint problems related to sports or active lifestyle, they will likely describe their elbow, knee, shoulder or achilles problem as having tendonitis.  If the problem has gone on for some time, as explained above, the problem turns into chronic tendinosis, pain from a tendon that has no swelling or inflammation

Whether tendinitis or tendinosis, the tendon needs to be repaired and made stronger so the athlete can return to their sport. The treatment to get the tendon stronger is Prolotherapy. We perform Prolotherapy injections where the weakened tendon attaches to the bone.

Many times a patient will come in and their tendon problem has become part of a larger problem, joint instability.

Joint instability is where not only the tendon of the joint is weakened, but the ligaments as well. This causes the whole elbow, shoulder, or knee joint to become unstable.  This instability, or hypermobility in the joint can contribute and worsen the degenerative wear impacting the tendons. Treating the tendons themselves will not stabilze the joint.

Because joint ligament injury is going to put additional strain on the tendon, we treat the ligaments also. Comprehensive Prolotherapy treats all the structures in the joint that are not of sufficient strength to stabilize the joint and move the joint through the pain free range of motion

Research: Prolotherapy injections for tendon tears

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, tendon cells. Published in the journal Clinical orthopaedics and related research, what the team was looking for was how did Prolotherapy change the immune system’s to the tendon injury

  1. Prolotherapy injections changed the cellular metabolic activity to a healing, regenerative environment in the tendon cells
  2. 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 that coordinates the beginning and ending of these three cycles of healing and injury repair process.
  3. 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.
  4. 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.

Tendinosis vs Tendonitis

Here is what the researchers had to say about Prolotherapy:

Proliferative therapy, or prolotherapy, is a controversial treatment method for many connective tissue injuries and disorders. It involves the injection of a proliferant, or irritant solution, into the site of injury, which causes small-scale cell death. This therapeutic trauma is theorized to initiate the body’s wound-healing cascade, perhaps leading to tissue repair.

In this study the goal was to evaluate the immediate effects of two common proliferants (dextrose and P2G, a combination of phenol, glucose, and glycerin) on the cellular response of human tenocytes, and begin to explicate the mechanisms with which each proliferant functions.

Testing on human hamstring and achilles tendon cells, the researchers were able to suggest that Prolotherapy, more so with the P2G solution, did stimulate an inflammatory response in tenocytes through various healing mechanisms including  gene expression analysis confirming that Prolotherapy treatment led to the upregulation of key proinflammatory markers including interleukin-8 and cyclooxygenase-2 (healing factors) and downregulation of the matrix marker collagen type I (degenerative factor).(1)

PRP Prolotherapy and Stem Cell Prolotherapy

Knee Prolotherapy TreatmentPlatelet Rich Plasma therapy (PRP) can be added to the traditional Prolotherapy solution to expedite the process, in specific cases. Whether alone, or with PRP, Prolotherapy causes the body to repair these structures by stimulating a mild, inflammatory response that triggers a natural wound healing cascade. The tendons get stronger and thicker because the body deposits new collagen. The tendon will become strong enough to be able to perform normally again.

Doctors at university medical centers in South Korea looked at the survival and reparative functions of stem cells in tendon injuries. Writing in the American Journal of Sports Medicine the doctors looked at rat tendons implanted with human adipose (fat) stem cells.

In a comparison study, they found that tendons treated with stem cells showed better gross morphological (tissue forming) and biomechanical recovery than those in the fibrin (a protein essential for blood clotting) and sham (no treatment) groups. Also, the expression of both human-specific collagen type I and tenascin-C (healing protein factors) was significantly higher in the cell group than in the other 2 groups.

In their conclusion the doctors stated the clinical relevance of their study that in tendon injury, stem cells can enhance tendon healing by secreting their own protein and have potential as a therapeutic option in human tendinopathy.(2)

Above we discuss Prolotherapy and its  ability to change the cellular metabolic activity to a healing, reproductive environment in the tendon cells. In the study on stem cells cited above, we also see that stem cells introduced into a tendon injury bring their own proteins to repair damage.

Stem cells also have the ability to heal through the Paracrine Mechanisms.

Chinese and Japanese researchers have combined to publish their research in the journal Current stem cell research and therapy(3) In it they suggest that while the functional healing of injured tendons is still a great challenge in orthopedics, stem cells with their ability to self-renew and differentiate into a variety of cell types, including tenocytes gives rise to the chance of improved healing of injured tendons and even tissue-engineered tendons.

Recently, more and more works have shown that the paracrine mechanisms of MSCs also play a critical role in driving the tendon repair process. Briefly the paracrine mechanisms is the stem cells ability through cell signalling to change a diseased joint environment into a healing joint environment. For a more detailed and fascinating discussion on this healing phenomena please see my articles on:

Also see articles on treatments for specific tendon problems.

Do you have a question about tendon damage and repair? You can get help and information from our Caring Medical staff.

1 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]

2 Lee SY, Kwon B, Lee K, Son YH, Chung SG. Therapeutic Mechanisms of Human Adipose-Derived Mesenchymal Stem Cells in a Rat Tendon Injury Model. Am J Sports Med. 2017 May;45(6):1429-1439. [Google Scholar]

3. Zhang B, Luo Q, Halim A, Ju Y, Morita Y, Song G. Directed Differentiation and Paracrine Mechanisms of Mesenchymal Stem Cells: Potential Implications for Tendon Repair and Regeneration. Current Stem Cell Research & Therapy. 2017 Aug 1;12(6):447-54. [Google Scholar]

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