Diagnosis and Management of Common Tendinopathies

Abstract

Purpose of Review

Tendinopathy is a common cause of musculoskeletal morbidity, resulting in frequent visits to primary care providers, orthopedists, and urgent care clinics. Six common regions of tendinopathy are discussed in this article, including up to date findings in their clinical history and exam findings, special testing, imaging, and treatment. Recent findings: Point of care musculoskeletal ultrasound has gained popularity as a tool in the diagnosis of various tendinopathies. Advanced interventions, including extracorporeal shockwave therapy (ESWT) and injections modalities such as platelet rich plasma (PRP) are becoming more common in the treatment of tendinopathy; however, the evidence for these interventions is mixed with most providing some short-term relief in symptoms but no long-term improvement in outcomes.

Recent Findings

Point of care musculoskeletal ultrasound has gained popularity as a tool in the diagnosis of various tendinopathies. Advanced interventions, including extracorporeal shockwave therapy (ESWT) and injections modalities such as platelet rich plasma (PRP) are becoming more common in the treatment of tendinopathy; however, the evidence for these interventions is mixed with most providing some short-term relief in symptoms but no long-term improvement in outcomes.

Summary

The diagnosis of tendinopathy often remains a clinical diagnosis with the mainstay of treatment remaining activity modification, physical therapy, and anti-inflammatories for acute pain control. Recovery time is widely variable between patients and conditions.

Introduction

Tendinopathy is identified by pain, impaired function, and histological changes in tendons. It is seen in the general population and athletes alike. Changes in tendon structure including disorganized collagen, increased ground substance, and neovascularization are typically seen, rather than simply isolated inflammation typically seen in other reactive musculoskeletal injuries. These are common maladies that clinicians from many specialties encounter in their practice and should understand to provide optimal care to patients. Tendinopathies can be diagnosed with a targeted history, exam, and imaging if needed. While tendinopathies share common histological and pathologic features, the various anatomic regions demonstrate nuanced historical presentations, examination findings, and treatment strategies. This article will provide an overview of the diagnosis, evaluation, and treatment of common tendinopathies across a spectrum of anatomic locations.

Rotator Cuff Tendinopathy

Overview

Rotator cuff injuries can be acute or chronic. Acute injuries are often associated with trauma and can result in tears or tendonitis, which is inflammation of the tendon. Chronic injury or overuse results in tendinopathy. Tendinopathy can be associated with or contribute to partial thickness and full thickness tears as well as impingement syndrome. Calcific tendinitis is a subset of rotator cuff tendinopathy where calcium deposits can be seen in the tendon [1]. Tendinopathy most commonly affects the supraspinatus tendon, but infraspinatus, teres minor, and subscapularis can also be the cause, which will change the clinical presentation.

History

The typical presentation includes anterolateral shoulder pain worse with active range of motion. The patient will often describe the pain as dull, diffuse, or achy [2]. Specific painful maneuvers depend on which rotator cuff muscle is involved. Risk factors for developing rotator cuff tendinopathy include age > 50, history of diabetes mellitus, and history of repetitive use of shoulder above 90 degrees or overhead athletic activity [3].

Exam

Patients may have decreased active range of motion (ROM), but normal passive ROM. If reduced passive and active ROMs are equivalent this favors adhesive capsulitis. There will be pain with resisted internal (subscapularis) or external rotation (infraspinatus) but strength will be preserved. Special tests that may be positive include Jobe’s test (supraspinatus), lift off test (subscapularis), or Hornblower’s test (teres minor), depending on which specific muscles of the rotator cuff have pathology [1, 2].

Imaging

While the physical exam is invaluable, Grashey view on x-ray can be very useful to look for bony abnormalities of the acromion, calcification of tendons, and joint space narrowing [2]. Magnetic resonance imaging (MRI) and ultrasound (US) are useful to look for partial thickness and full thickness tears, with near equal sensitivity and specificity [4]. Fatty degeneration can also be seen on T1 MRI.

Treatment

Rotator cuff tendinopathy treatment includes activity modification and non-steroidal anti-inflammatories (NSAIDs) for analgesia and inflammation [5]. Physical therapy with emphasis on eccentric loading is the primary rehabilitative measure. Corticosteroid injections are helpful for short term pain management, but do not show any benefit for long term pain relief without physical therapy. Physical therapy does show improved quality of life in long term reassessments [6]. Platelet rich plasma (PRP) in recent systematic reviews has shown improved pain scores at 6–12 weeks, but no difference in long term outcomes [7, 8]. Shockwave therapy is a newer modality that has shown benefit in select populations, with improved pain and shoulder function, but shows no improvement in shoulder ROM [9]. Surgery may be warranted in cases refractory to the above therapies, as well as those with large full thickness tears. Surgical options include open or arthroscopic rotator cuff repair, acromioplasty, decompression, or debridement. Calcific tendinitis has shown improvement with both non-operative (shockwave and ultrasound guided needling) as well as operative management. Operative management shows superior results, but given statistically favorable results of non-operative treatments and lower costs and risk profile, it is recommended to trial these first [10].

Medial Epicondylopathy (Golfer’s Elbow)

Overview

The medial epicondyle of the humerus is the attachment point for five muscles of the forearm: the flexor digitorum superficialis, flexor carpi ulnaris, palmaris longus, flexor carpi radialis, and pronator teres. It is a common site of pain in athletes or laborers who perform repetitive wrist flexion activities. Golfers, baseball pitchers, and bowlers are often seen with this condition due to the nature of their respective sports [11].

History

Typical presentation includes medial sided elbow pain that is exacerbated by wrist flexion or pronation. The pain will often radiate into the proximal forearm.

Exam

Tenderness is often present just distal to the medial epicondyle with swelling. There is pain with resisted flexion of the wrist, passive extension of the wrist, and pronation of the forearm. Sometimes there is decreased grip strength compared to the opposite side.

Imaging

Imaging is typically not necessary for diagnosis but can be used in settings when the diagnosis is unclear or when the patient is not responding to conservative treatments. US can be cost effective and may show areas of tendon thickening with hypoechoic or anechoic areas. A recent study showed 95.2% sensitivity and 92% specificity in diagnosing tendinopathy with US [4]. T2-weighted sequences on non-contrast MRI will show high signal intensity at the common flexor tendon as well as peritendinous edema.

Treatment

Activity modification with reduction of exacerbating activity is the mainstay of treatment. Formal physical therapy with emphasis on eccentric loading is the primary rehabilitative measure [12]. A counterforce brace with the compression pad positioned just distal to the medial epicondyle may be beneficial. PRP and shockwave therapy have shown benefit in select populations, particularly cases refractory to therapy alone [13, 14]. Caution should be used with steroid injections due to increased risk of tendon rupture [15]. Surgery may be warranted in cases refractory to the above therapies.

Lateral Epicondylopathy (Tennis Elbow)

Overview

The lateral epicondyle of the humerus is the attachment point for the common wrist extensor tendon. Lateral epicondylopathy is seen frequently in racquet sports that require repetitive wrist extension. Additionally, the repetitive resisted supination experienced by laborers who use manual screwdrivers can lead to tendinopathy [16]. It is significantly more common than medial epicondylopathy.

History

The typical presentation includes lateral sided elbow pain that is exacerbated with wrist extension. This is often preceded by repetitive gripping with wrist extension, such as in those who work in manual labor or in tennis players.

Exam

Tenderness to palpation is often present just distal to the lateral epicondyle. There is pain with resisted wrist extension (Cozen Test), passive wrist flexion (Mill’s Test), and supination of the forearm. However, strength is intact.

Imaging

Again, imaging can be reserved for cases with diagnostic uncertainty or failure to improve with conservative measures. US findings are similar to medial epicondylopathy with hypoechoic or anechoic areas, tendon thickening, or increased vascularity [4]. On MRI the tendon may show increased signal.

Treatment

Activity modification with reduction of exacerbating activity is the mainstay of treatment. Formal physical therapy with emphasis on eccentric loading is the primary rehabilitative measure. Steroid injections have shown worse long-term outcomes compared to physical therapy [12]. Counterforce braces with the compression pad positioned just distal to the lateral epicondyle may be beneficial. PRP has shown to be beneficial in patients refractory to conservative treatments, though research is limited [16, 17]. Shockwave may also provide benefit in tennis elbow by increasing cellular permeability and blood flow near the tendon, accelerating the healing process [18]. Surgery may be warranted in cases refractory to the above therapies.

Gluteal Tendinopathy

Overview

Gluteal tendinopathy is a common cause of lower extremity pain and is a significant contributor leading to greater trochanteric pain syndrome. The gluteus medius and minimus assist in abduction and stabilization of the hip. Their tendons insert on the greater trochanter of the femur. This is the site where most patients will describe their pain. It is most commonly seen in females ages 40–70 [19].

History

The typical presentation includes lateral hip pain. Patients often mentioning pain is worsened with lying on the affected side and with weight bearing activity.

Exam

Tenderness to palpation over the greater trochanter is usually present. There is pain with resisted hip abduction. Frequently patients will have a positive Trendelenburg sign, demonstrating weak hip stabilizers. FADER-R (Flexion Adduction, External Rotation with isometric Resistance against internal rotation) can help to distinguish the gluteal tendons as the culprit from other lateral hip pathologies [20].

Imaging

US may show areas of tendon thickening with hypoechogenicity. MRI findings include increased signal on T1 weighted images and normal appearance on T2 weighted appearances [19].

Treatment

Activity modification with reduction in exacerbating activity is important. Formal physical therapy with emphasis on gluteal strengthening is the mainstay of treatment, and results in greater patient satisfaction compared to a corticosteroid injection at 12 months with no accompanying physical therapy [19]. NSAIDs may be used for analgesia and treatment of inflammation. For persistent cases, ESWT, corticosteroid injection, or PRP injection may provide benefits; however, steroid injections only have short term benefits and do not provide long term benefit [20, 21]. Additionally, repetitive steroid injections may lead to long morbidity from tendon damage/rupture.

Extensor Mechanism of the Knee (Jumper’s Knee) – Quadriceps Tendinopathy or Patellar Tendinopathy

Overview

Knee extensor complex tendinopathy accounts for about 10% of all clinical knee concern diagnoses and is especially common in the active population [22]. It is exacerbated by activities which load the knee, including jumping, squatting, or ascending/descending stairs. It is most often seen in athletes whose sports require frequent jumping, such as basketball and volleyball. Risk factors for developing patellar tendinopathy include being male, higher BMI, increased number of training hours, and tall height [23].

History

For quadriceps tendinopathy, typical presentation includes pain just superior to the patella, exacerbated by activities that load the knee in flexion, including ascending/descending stairs, squats, and jumping. For patellar tendinopathy, pain is most common at the proximal patellar tendon, though pain can be present anywhere along the tendon. Pain usually starts insidiously and only presents at the end of activity but progresses to pain throughout exercise if left untreated [23].

Exam

There is tenderness to palpation at the affected portion of the tendon. Knee flexion is often limited due to pain. Pain is reproduced with resisted knee extension and/or maximal quadriceps stretching.

Imaging

US shows areas of hypoechogenicity with tendon thickening, and physicians can identify areas of neovascularization using the Doppler setting [23]. MRI will also demonstrate areas of thickened tendon with increased signal intensity as well as being able to identify partial tears on T2 weighted images.

Treatment

Activity modification should be focused on reduction in knee extension activities that exacerbate pain. Formal physical therapy with emphasis on eccentric exercises such as the decline eccentric squat are first line. In addition to eccentric exercises, heavy slow resistance (HSR) and progressive tendon loading exercises have shown strong benefits in return of knee function and strength and can be added as an adjunct to eccentric therapy [24]. Steroid injections into the tendon, though beneficial in the short term, are not superior to other treatments in the long term and carry a high chance of adverse effects including tendon rupture, atrophy, and decreased tendon strength [23]. Several studies have shown PRP to be beneficial in chronic cases of patellar tendinopathy [23]. ESWT has not been shown to be beneficial when applied in-season of sport, but is effective during the off-season [24].

Achilles Tendinopathy

Overview

The Achilles tendon is the largest tendon in the body. It has a limited blood supply, receiving blood via longitudinal arteries, with the poorest supply in the 2 to 6 cm above the tendon insertion into the calcaneus [25]. Achilles tendinopathy is divided into insertional and non-insertional (also called mid-substance or midportion), which is more common, with some differences in treatments. Histologic changes include increased thickness, loss of normal collagen, and increased proteoglycans [26].

History

Runners and jumpers are more likely to develop Achilles tendinopathy, and a recent increase in intensity or duration of activity increases development risk. Other risk factors include being high BMI, being male, recent steroid or fluroquinolone use within the previous 8 days, and presence of Haglund’s deformity (a bony growth from the calcaneus at the Achilles insertion). 30% of presentations are bilateral. Pain is usually present with running or jumping and patients are pain free at rest. Patients can have localized swelling. Athletes may notice a decrease in performance before noticing pain [26].

Exam

Tenderness to palpation over the Achilles tendon and subjective report of pain is the most sensitive finding. The arc sign and Royal London Hospital test, where the Achilles tendon is palpated during dorsiflexion and plantarflexion for the presence of nodules or swelling, are less sensitive but more specific. The location of tenderness is useful for distinguishing insertional vs. non-insertional [26].

Imaging

As with other tendinopathies, imaging is usually not necessary for diagnosis. MRI may show areas of tendon thickening with increased signal. US can show increased thickness, hypoechogenicity, calcifications, and retro-calcaneal bursitis. Using the Doppler setting on ultrasound, neovascularity may be present in chronic cases. Haglund’s deformity, which is a risk factor for developing the disease, can be evaluated as well. Partial and full-thickness tears can also be seen and are graded on the Kuwada classification system (Grade I-IV) [27].

• Grade I- Partial rupture, < 50%.

• Grade II- Complete rupture, gap < 3 cm.

• Grade III- Complete rupture, gap 3–6 cm.

• Grade IV- Complete rupture Gap > 6 cm.

Treatment

Traditional treatments have involved conservative measures such as ice, rest, and NSAIDs as well as weight loss and appropriate shoes [25]. Rehabilitation is focused around eccentric strengthening. The most common rehabilitation protocol for Achilles tendinopathy is the Alfredson protocol, but there is a lack of evidence to prove its superiority to other strength programs [28]. Both insertional and non-insertional Achilles tendinopathy are initially approached with the same conservative measures, with evidence of improved pain and functional outcomes with eccentric exercises [29–31]. However non-insertional tendinopathy has much better results than insertional tendinopathy with a strength program, and many insertional tendinopathies progress to surgical management [32]. PRP has shown maximal efficacy and pain scores at 6–12 weeks, but no statistical difference is observed in long term outcomes [33]. Many studies have shown ESWT has positive trends for pain and function but these trends have not been statistically significant [34, 35]. Acupuncture has also shown improved short-term pain but no improved long-term outcomes [29]. Topical nitroglycerin patches have been used for decades based on pharmacodynamic understanding of local vasodilation, but studies have shown no statistically significant evidence that it improves outcomes in pain or recovery time [36]. Side effects, headache being the most common, should be considered when prescribing this. Dextrose prolotherapy, like PRP, shows early improvements in pain and function, but fails to show significant difference in long term (12 month) outcomes [28]. Heel lifts can help with pain and function at 12 weeks in those with mid-substance tendinopathy [37]. Surgical options for refractory mid-substance tendinopathy include percutaneous longitudinal tenotomy, gastrocnemius recession, tendon debridement, and Flexor Hallucis Longus (FHL) autograft tendon transfer. In cases of refractory insertional tendinopathy, options include Haglund’s deformity resection, tendon debridement with reconstruction via suture anchors, autograft reconstruction, and retrocalcaneal bursectomy [28].

Discussion

While tendinopathies share common pathological features, clinical presentations and management strategies differ by anatomical site. Exercise-based rehabilitation remains the cornerstone of treatment across all types, especially protocols emphasizing eccentric or HSR exercises. Adjuncts such as injections and shockwave therapy may offer additional benefits in select cases. Caution should always be taken when giving corticosteroid injections as there is an increased risk of tendon rupture [15]. Imaging is primarily reserved for diagnostic uncertainty or treatment-resistant cases.

Common themes of rest/activity modification, physical therapy, NSAIDs if safe, and a variety of injectable options tend to be sufficient for treatment. If there is insufficient benefit from these, surgery may be necessary.

Conclusion

Tendinopathies are common and often debilitating. Table 1 provides a concise review of common exacerbating activities of the six common tendinopathies discussed. Accurate diagnosis through patient history, clinical examination, and selective imaging guides effective treatment. Evidence supports conservative management using tailored loading programs, with adjunct modalities playing a role in specific cases. Understanding the nuances of each tendinopathy ensures optimal patient outcomes.

Table 1.

Demonstrates common activities that May elicit pain which should Raise the examiner’s index of suspicion for tendinopathy

Historical Clues for Common Tendinopathies by Anatomic Region
Shoulder	Elbow	Hip	Knee	Ankle
Rotator Cuff	Medial Epicondyle (Golfer’s Elbow)	Gluteal Tendons	Quadriceps Tendon	Achilles Tendon
• Reaching	• Wrist flexion	• Lying on affected side	• Jumping	• Running
• Lifting	• Wrist pronation	• Walking/running uphill	• Squats	• Jumping
• Overhead activity	• Repetitive gripping	• Sitting cross-legged	• Ascending/descending stairs	• Long distance walking
	Lateral Epicondyle (Tennis Elbow)		Patellar Tendon
	• Wrist extension		• Jumping
	• Wrist supination		• Squats
	• Repetitive gripping		• Ascending/descending stairs

The views expressed are those of the authors and do not necessarily reflect the official policy or position of the U.S. Air Force, Uniformed Services University of the Health Sciences, U.S. Department of Defense, or U.S. government.

Key References

• Tendinopathy in Sport, by Ackermann P and Renström P.

  • This article was provided a review on several decades’ progress in treating tendinopathy, with excellent information on physiologic adaptations leading to tendinopathic changes, to the transition from surgery-focused to conservative measures-focused treatments.

• Platelet-rich plasma and corticosteroid injection for tendinopathy: a systematic review and meta-analysis, by Ye Z, et al.

  • This article was an excellent review in the evidence surrounding platelet-rich plasma (PRP), which is gaining significant popularity in musculoskeletal medicine.

• The beneficial effects of eccentric exercise in the management of lateral elbow tendinopathy: a systematic review and meta-analysis, by Yoon SY, et al.

  • This article, while focused primarily on lateral elbow tendinopathy, provided a valuable review of studies through the years focused on best-practice rehab protocols for tendinopathy. It clarified how and why eccentric therapy is valuable for tendinopathy treatment and reviewed the evidence indicating why it is emphasized in most rehabilitation protocols.

Author Contributions

JM, HH, JB, and SG wrote the main manuscript. JM and JB prepared Table 1. All authors reviewed the manuscript.

Funding

No author received funding.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Human and Animal Rights Informed Consent

This article does not contain and studies with human or animal subjects performed by any of the authors.

Competing Interests

The authors declare no competing interests.