Dr. Khan et al provided an excellent summary and analysis of current treatments for tendinosis in part 4.1 of the article “Histopathology of Common Tendinopathies” in Sports Med June;27(6):393-408, 1999.  Another great list of treatments with references to research articles for their efficacy can be found in full text form at Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon from Clin Orthop Relat Res. Jul 2008; 466(7): 1539–1554. I've included a similar list of treatments here, with some more recent additions (I will try to keep this updated).
Ideally, tendinosis treatments would focus on promoting better healing of collagen and breaking the cycle of failed healing. Unfortunately, healing from tendinosis usually requires some time no matter what treatments you try, but you can increase your odds of success with the right approach. Physical therapy is probably the most useful and important treatment if you can find a good therapist in your area.
Please note that tendinosis.org does not endorse any particular 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 so you can choose what's best for you. Note: The numbers in brackets after some sentences on this page are references found on the References page.
A note about diagnosis: Diagnosis of tendinosis is usually made through consideration of medical history and symptoms, physical exam, and imaging using MRI or ultrasound. New software for ultrasound interpretation has recently been developed that should aid in diagnosis and treatment of tendinosis by more accurately pinpointing areas to treat and providing the ability to track treatment efficacy with ultrasound over time. For more information about this new patented diagnostic tool, see the echoMetrix website and this information sheet. Some statistics comparing the accuracy of standard ultrasound vs MRI in diagnosis of tendinosis/tendinopathy can be found in a summary of the 2012 second International Scientific Tendinopathy Symposium (ISTS) in Vancouver (this article also summarizes current treatments).
By the time you feel pain from tendinosis, your injury has been gradually building for many weeks. Remember that tendons heal slowly. 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 exercises, but when you are ready your physical therapist can create a gradual strengthening program for you. Loading from the proper exercises can help to stimulate healing.
If you feel impatient with your injury, you might try to join a support group for RSI, whether it is a local group in your community or an online group. 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.
- Physical Therapy Exercises
Gentle 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. The term “mechanotherapy” has been coined to describe the way loading through exercise can stimulate repair and remodeling in tendon. You can read a paper by Dr. Khan about mechanotherapy and listen to a podcast interview with him on this topic.
Some studies have shown that eccentric exercise is especially helpful for tendinosis. [50, 51, 52, 53, 54] 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 with exercises that involve no resistance from weights or elastic bands and then gradually add resistance as you gain strength.
- 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 nothing has really been definitive. The best you can do is just try some of these treatments 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.
Using ice packs, or cryotherapy, is one of the most common modalities 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 (as long as you take care not to get "ice burn" from too much ice).
Non-steroidal anti-inflammatories would not be expected to help tendinosis since it is an injury of chronic degeneration, not inflammation. Studies show that NSAIDs can actually impede the healing process, which is the last thing needed with tendinosis.  Long-term use of NSAIDs for tendinosis is not a good idea, though they can possibly be helpful in the initial phase. For more information, see “Histopathology of Common Tendinopathies” (part 4.1) and The Tendinitis Myth.
The opening paragraph for The Tendinitis Myth abstract is, “Tendinitis such as that of the Achilles, lateral elbow, and rotator cuff tendons is a common presentation to family practitioners and various medical specialists. Most currently practising general practitioners were taught, and many still believe, that patients who present with overuse tendinitis have a largely inflammatory condition and will benefit from anti-inflammatory medication. Unfortunately this dogma is deeply entrenched. Ten of 11 readily available sports medicine texts specifically recommend non-steroidal anti-inflammatory drugs for treating painful conditions like Achilles and patellar tendinitis despite the lack of a biological rationale or clinical evidence for this approach. Instead of adhering to the myths above, physicians should acknowledge that painful overuse tendon conditions have a non-inflammatory pathology.” This article was written in 2002 and yet doctors still prescribe NSAIDs routinely as the primary treatment for tendinosis.
- 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 very helpful if you 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).
- 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. If you’re having trouble with your wrists/forearms/elbows from using a computer, you might try dictation software and/or a pen tablet (Wacom is one pen tablet company whose products I have used).
- Nutritional Supplements
Not much scientific research has been done to investigate the effects of specific nutritional supplements on the healing of tendinosis. Basic good nutrition is advisable though because it gives your body the best chance to heal.
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. 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).
Other supplements that claim to help heal tendons and ligaments contain the amino acids glycine, lysine, and proline. This idea seems logical 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 tenocyte 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 tendinosis-specific supplement that can somehow induce the injured cells in tendinosis to make normal collagen, but for now we don't know of anything. Your best bet is to eat a healthy plant-based diet with plenty of fruits, vegetables, good fats, protein, whole grains, and antioxidants and with minimal amounts of trans fats, saturated fats, and simple carbohydrates. For more information about healthy nutrition, see sites such as Forks Over Knives, NutritionFacts.org, UC Davis Integrative Medicine Program’s Guide For Plant-Based Eating, and DrWeil.com. Improvements from good diet take time to notice, so don't expect immediate results.
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, and eating an ant-inflammatory diet has been found to be good for your general health. The following are some of the supplements that have been found to be anti-inflammatory in arthritis patients: ginger, tumeric, and fish oil. For information on how to use these supplements and how to eat an anti-inflammatory diet, see the four links in the paragraph above (and those sites contain links to other nutrition sites as well).
- Bodywork and Soft Tissue Mobilization
Physical therapists sometimes perform friction massage and soft tissue mobilization. Many kinds of alternative medicine practitioners perform bodywork such as Feldenkrais and Alexander Technique. Some practitioners also try to help with your posture and body mechanics. Studies with rats have shown that soft tissue mobilization can increase fibroblast activity and speed healing. [48, 49]
Physical therapists usually say that although massage can cause mild discomfort, it 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. Sometimes a mild flare-up can lead to improvement later, and sometimes not. Proceed cautiously until you learn how your own soft tissue reacts to various hands-on procedures.
A number of practitioners offer aggressive hands-on techniques to manually break up adhesions and stimulate healing by promoting tissue remodeling. Some approaches are more formalized with names and acronyms and are taught to practitioners following certain protocols. One approach is called Augmented Soft Tissue Mobilization or ASTM. These treatment programs are more likely to help people who have a specific injury to one location rather than someone with a propensity for chronic tendon trouble in multiple areas. Be sure you are a good candidate for this type of treatment before trying it. The idea of “breaking up adhesions” has been questioned, as summarized in this blog post by a sports medicine physiotherapist.
- Low Intensity Laser Therapy
Laser Therapy has been used to treat chronic soft tissue injuries for years, and it is now being offered at some clinics. One maker of these devices is Bio Flex. It is something you can look into in your area. The Bio Flex website has a section that gives links to studies into the treatment's effectiveness.
Prolotherapy involves injections that are intended to provoke irritation and then promote healing. The injections often cause flare-ups and things can get worse before they get better; the injections are meant to be irritating as a way of promoting a healing response. Some people have emailed to tell me prolotherapy cured them when nothing else did, and other people have said it made them worse and they wished they hadn't tried it. I think the results vary greatly depending on what is in the injection and how much training and experience the practitioner has, but it does have some risk. It is different from but sometimes confused with platelet-rich plasma therapy, described below.
- Platelet-Rich Plasma Therapy
Platelet-rich plasma therapy (PRP) involves processing some of your own blood to concentrate the platelets and then re-injecting that blood back into your injury site in hopes that it may help with healing. This treatment has been successful for some athletes and has received some press. You can read more about it at the Blood Cure blog and website. PRP may be more effective when combined with stem cell therapy, but not enough research has been done yet to know for sure. Recent research has called into question whether PRP is at all useful, and the answer isn’t yet known.
- Stem Cell Injections, Fibroblast/Tenocyte Injections, and Growth Factor Enhancement
These treatments are not mainstream yet and are covered in detail on the Future Treatments page. They are being offered in a few places such as The Institute of Regenerative and Molecular Orthopaedics in Florida, Regenexx in Colorado, and through Ortho Cell in Australia. Initial studies have shown promise for injecting tenocyte-like cells in elbows and knees with tendinosis. [55,56] A more recent study followed up on eight patients who had undergone stem cell therapy for patellar tendinopathy five years prior; seven of the eight had good results and were still happy with the procedure after five years.  Time is needed before we’ll know the rate of good results with these therapies, but they appear promising.
An Ortho Cell study
published in the December 2013 American Journal of Sports Medicine found that autologous tenocyte therapy was helpful in the treatment of lateral epicondylitis.  If you live in Australia, you can look for a clinic that works with Ortho Cell to offer autologous tenocyte treatment; you would have an initial appointment during which a tendon biopsy would be collected and sent to Ortho Cell for processing, and then later you would return for an injection of the tenocyte cells that had been isolated and grown from your biopsy (they biopsy from an uninjured tendon).
Another company to watch is the Canada-based Replicel, which has scheduled a clinical trial to begin in Sept 2014 for their new autologous cell therapy treatment for tendinosis. They will be injecting Achilles tendinosis injuries with fibroblasts collected from the dermal sheath of patients’ hair follicles. Replicel reports that these fibroblasts derived from hair follicles produce five times more Type I collagen than skin-derived fibroblasts.
Some companies that are offering mesenchymal stem cells are trying them for many diverse medical and cosmetic conditions without much research behind the treatment. It is good to see Ortho Cell and Replicel conducting their fibroblast and tenocyte research specifically for tendinosis. The Replicel tenocyte method has the added benefit of not requiring a tendon biopsy from a healthy tendon.
A study in the Sept 2014 International Orthopaedics reported that mesenchymal stem cells improved tendon healing following rotator cuff repair. The study was presented at the American Academy of Orthopaedic Surgeons 2015 Annual Meeting. After 6 months, 100% of the stem cell treated patients had healed compared to 67% of the non-treated controls. After 10 years, 87% of the stem cell treated repairs were still intact vs 40% of the controls.
- Glyceryl Trinitrate Patches for Nitric Oxide Therapy
Nitirc oxide, or NO, is produced by enzymes called nitric oxide synthases, or NOS. Researchers found that the three NOS isoforms are up-regulated following tendon injury and that inhibiting NOS activity with oral drugs reduces the cross-sectional area and failure load of healing Achilles tendon in rats.[28,29,30] These studies implied that NO might help healing in tendons.
Several studies have shown promise for the use of topical glyceryl trinitrate (GTN) patches directly over the painful region of tendinosis. [58, 60, 61, 62, 63] The patches are not FDA approved for tendinosis, but they are sometimes used this way as an off-label application of the patches. You can check with your doctor or physical therapist if you want to try them. The main potential side effect with this therapy has been possible headaches in some patients.
- Cortisone Injections
Cortisone injections can sometimes temporarily lessen the pain of tendinosis, but they don't help the injury heal, with the possible exception of cases where they reduce pain just long enough to get someone able to tolerate PT exercises that stimulate healing. Cortisone injections have been shown to cause adverse effects on the tissue in the area of the injection if repeated injections are given. 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 cortisone is becoming regarded as an outdated treatment for tendinosis.
A 2014 paper summarized the role of cortisone in tendinopathies this way, “Overall it is clear that the local administration of glucocorticoid has significant negative effects on tendon cells in vitro, including reduced cell viability, cell proliferation and collagen synthesis. There is increased collagen disorganisation and necrosis as shown by in vivo studies. The mechanical properties of tendon are also significantly reduced. This review supports the emerging clinical evidence that shows significant long-term harms to tendon tissue and cells associated with glucocorticoid injections.”
Another paper gives one possible mechanism for how cortisone has damaging effects on tendons.
Surgery has been 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 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.
When surgery is indicated, some new methods are being employed, such as the Tenex Health TX method (formally known as FAST ) for removing damaged tissue. This technique is minimally invasive (done in a procedure room in under 20 minutes) and has a much quicker recovery time than traditional surgery. This new surgical approach may make surgery a good option for many more people. A video of an actual procedure along with more explanation is available on The Doctors, and patient information and testimonial videos are available on the Tenex website.
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Tendon Research News:
University of Glasgow: Scientific breakthrough unlocks potential novel tendon therapy
”Tendinopathy is essentially the result of an imbalance between collagen type-1 and type-3 and we have discovered the molecular cause. This breakthrough has allowed us to find a way to alter the levels of collagen type-3 in tendons, with the ultimate aim to get patients with tendon injuries better quicker."
Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case-controlled study
“This study showed that significant improvement in healing outcomes could be achieved by the use of BMC (bone marrow concentrate) containing MSC (mesenchymal stem cells) as an adjunct therapy in standard of care rotator cuff repair. Furthermore, our study showed a substantial improvement in the level of tendon integrity present at the ten-year milestone between the MSC-treated group and the control patients.”
Treatment of Lateral Epicondylosis Using Allogeneic Adipose-Derived Mesenchymal Stem Cells: A Pilot Study
“This pilot study on the safety and efficacy of allo-MSC injection for treating chronic LE demonstrated that the intervention was safe and efficacious in improving pain, performance, and anatomical defects for more than a 52-week follow-up period. This is the first clinical study using allogeneic MSCs to treat chronic tendinopathy.”
Cell Therapy Ltd announces positive Phase II clinical trial results of Tendoncel ™, a first-in-class topical regenerative medicine for severe tendon injury
“Patients using the non-invasive Tendoncel ™ topical gel for 21 days experienced a clinically relevant and statistically significant improvement in their tendon injury. Reporting an average improvement of 70% on the DASH disability scale and 74% improvement on the PRTEE scale, Tendoncel’s results exceed those expected of injectable treatments and have the advantage of painless topical application.”
Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair
“Mechanotransduction is the physiological process where cells sense and respond to mechanical loads. This paper reclaims the term “mechanotherapy” and presents the current scientific knowledge underpinning how load may be used therapeutically to stimulate tissue repair and remodelling in tendon, muscle, cartilage and bone.”