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Tendinopathy

Evidence-Based Approaches to Tendinopathy Treatment: What the LiteratureSupports

Tendinopathy is a common yet challenging condition affecting athletes, active
individuals, and those with repetitive strain injuries. At Elevated Medicine, we prioritize
evidence-based, regenerative approaches to help patients recover and regain optimal
longterm function. As research evolves, it’s crucial to understand which treatments are
supported by recent literature and which may offer more temporary benefits. Let’s
explore the latest findings on various treatment options, including NSAIDs,
corticosteroids, platelet-rich plasma (PRP), autologous blood injections, prolotherapy,
and extracorporeal shockwave therapy (ESWT).

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs are often a first-line treatment for tendinopathy, as they help reduce pain and
decrease the inflammatory response. However, there appears to be sufficient evidence
to suggest that NSAIDs negatively impact the enthesis, which is the attachment of a
tendon, ligament, joint capsule, or fascia to bone. This is significantly influenced by the
type of NSAID used and duration of therapy. There is also literature that suggests
NSAIDs may negatively impact tenocyte differentiation and proliferation. Tenocytes are
responsible for maintaining the structural integrity and function of tendons by secreting
components that make up the highly organized, dense, fibrous tissue. For patients who
have tried a course of NSAIDs without improvement or would prefer to avoid NSAIDs
and are looking for solutions, the regenerative therapies discussed below may offer
better outcomes.

Corticosteroid Injections

Corticosteroids have been widely used for tendinopathy due to their powerful anti-
inflammatory effects. However, multiple studies indicate that while they may provide
short-term pain relief, they often lead to worse long-term outcomes. There is a hight rate
of reoccurrence with corticosteroid injections ranging from 54-72% when referencing the
studies below. They have also been shown to weaken tendon structure, contribute to
further degeneration, and in rare cases cause tendon rupture. Their use should be
carefully considered after weighing the risks and benefits based on the patient’s
individual risk factors, type of injury, age, and activity level.

Platelet-Rich Plasma (PRP)

PRP therapy has gained significant traction as a regenerative treatment for
tendinopathy with minimal complications and adverse outcomes. PRP is derived from a
patient’s own blood by separating the plasma from the red blood cells and concentrating
it in a centrifuge. If done properly, this process yields a high concentration of platelets,
which contain growth factors that are thought to promote tissue repair and healing. The
recent literature supports PRP as a promising alternative for certain injuries, with
multiple studies demonstrating its efficacy in reducing pain, improving tendon function
and strength through a regenerative process. This therapy is particularly beneficial in

chronic tendinopathies such as lateral epicondylitis (tennis elbow) and patellar
tendinopathy. However, there is still some variability in outcomes most likely due to the
lack of standardization of PRP preparation, concentration of platelets, and precision of
injection. Regardless, this therapy remains one of the most promising non-surgical
options available. At Elevated Medicine, we ensure the highest quality PRP processing
kits, yielding consistent and high doses of platelets. These are precisely placed into the
injury via ultrasound guidance for the best chance at optimal, long-lasting results.

Autologous Blood Injections

Autologous blood injections (ABI) involve injecting a patient’s own whole blood directly
into the affected tendon to stimulate healing. Like PRP, ABI introduces growth factors
that may aid in tendon repair, though PRP is often considered more potent due to its
higher concentration of platelets. Some studies suggest ABI may be effective in treating
tendinopathy, but PRP generally demonstrates superior results. Nevertheless, ABI
remains a viable option, particularly when PRP is not readily available or cost-
prohibitive.

Prolotherapy

Prolotherapy involves injecting an irritant solution, often dextrose-based, into the
affected tendon to stimulate the body’s natural healing response. Emerging research
supports its use in tendinopathy by promoting collagen deposition and tissue repair.
While not as extensively studied as PRP, prolotherapy has shown promise, particularly
in chronic cases where conventional treatments have failed. This approach may be
particularly beneficial when combined with other regenerative therapies.

Extracorporeal Shockwave Therapy (ESWT)

ESWT has gained recognition as an effective, non-invasive treatment for tendinopathy.
By delivering high-energy shockwaves to the affected tendon, it is thought ESWT
stimulates blood flow, collagen production, and tissue regeneration. Research supports
its efficacy in reducing pain and improving function in patients with chronic
tendinopathies such as plantar fasciitis, achilles tendinopathy, and lateral epicondylitis.
ESWT is particularly beneficial when used in combination with other regenerative
treatments, such as PRP or physical therapy, to enhance recovery. At Elevated
Medicine, this is often performed in conjunction with other regenerative techniques as
part of a comprehensive, multimodal approach.

The Elevated Medicine Approach: An Individualized Multimodal Regenerative Strategy

At Elevated Medicine, we take a comprehensive, patient-centered approach to
tendinopathy treatment. Rather than relying solely on temporary pain relief strategies,
we focus on regenerative therapies that address the root cause of tendon degeneration.
PRP, ABI, prolotherapy, and ESWT have all shown promise in restoring tendon health

and function, and we carefully tailor treatment plans based on the latest scientific
evidence and each patient’s unique needs.
If you’re struggling with chronic tendon pain and are looking for an effective, science-
backed approach to healing, schedule a consultation with Elevated Medicine today. We
look forward to working together to restore your movement, function, and quality of life.

NSAID References:

  1. Fede C, Albertin G, Petrelli L, et al. Altered tensile strain induces inflammation-like
    response in tenocytes. J Appl Physiol (1985).* 2018;124(5):1353-1360.
    doi:10.1152/japplphysiol.00281.2017. Available from:
    [https://journals.physiology.org/doi/full/10.1152/japplphysiol.00281.2017](https://journals.
    physiology.org/doi/full/10.1152/japplphysiol.00281.2017)
  2. Dakin SG, Newton J, Martinez FO, et al. Chronic inflammation is a feature of Achilles
    tendinopathy and rupture. Br J Sports Med.* 2018;52(6):359-367. doi:10.1136/bjsports-
    2017-098161. Available from:
    [https://pubmed.ncbi.nlm.nih.gov/33719579/](https://pubmed.ncbi.nlm.nih.gov/33719579
    /)
  3. Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing
    the response to loading. Br J Sports Med.* 2010;48(21):1553-1559.
    doi:10.1136/bjsports-2013-092656. Available from:
    https://bjsm.bmj.com/content/48/21/1553
  4. Soslowsky Laboratory. Effects of NSAIDs on Tendon Healing. University of
    Pennsylvania Orthopedic Research Laboratory. Available from:
    [https://www.med.upenn.edu/orl/soslowskylab/nsaid.html](https://www.med.upenn.edu/o
    rl/soslowskylab/nsaid.html)
  5. Andersson G, Forsgren S, Scott A, Gaida JE, Stjernberg T, Danielson P. Tenocyte
    hypercellularity and vascular proliferation in a rat model of Achilles tendinopathy:
    Contralateral changes and the role of NGF. J Rehabil Med. 2011;43(6):526-533.
    doi:10.2340/16501977-1800. Available from:
    https://www.medicaljournals.se/jrm/content/html/10.2340/16501977- 1800

Corticosteroid References:

  1. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilization with movement and exercise,
    corticosteroid injection, or wait and see for tennis elbow: randomized trial. BMJ. 2006;333(7575):939.
    doi:10.1136/bmj.38961.584653.AE. Available from:
    https://www.bmj.com/content/333/7575/939
  2. Coombes BK, Bisset L, Vicenzino B. Corticosteroid injections for the treatment of lateral epicondylitis: a
    systematic review and meta-analysis. Am J Sports Med. 2010;38(12):2553-2565.
    doi:10.1177/0363546510378106. Available from:
    [https://scholars.uthscsa.edu/en/publications/corticosteroid-injections-for-the-treatment-of-lateral-
    epicondyli](https://scholars.uthscsa.edu/en/publications/corticosteroid-injections-for-the-treatment-of-
    lateral-epicondyli)
  3. Kamel SI, Rosas HG, Gorbachova T. Local and Systemic Side Effects of Corticosteroid Injections for
    Musculoskeletal Indications. AJR Am J Roentgenol. 2024;222(3):e2330458. doi:10.2214/AJR.23.30458.
    Available from:
    [https://www.ajronline.org/doi/10.2214/AJR.23.30458](https://www.ajronline.org/doi/10.2214/AJR.23.3045
    8)
  4. Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the
    horizon. Clin Orthop Relat Res.* 2008;466(7):1539-1554. doi:10.1007/s11999-008-0260-1. Available
    from: https://pubmed.ncbi.nlm.nih.gov/23385272/
  5. Scott A, Squier K, Alfredson H, et al. ICON 2019: International Scientific Tendinopathy Symposium
    Consensus: There are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi
    study of healthcare professionals and patients. Br J Sports Med. 2020;54(8):444-451.
    doi:10.1136/bjsports-2019-100884. Available from:
    https://pubmed.ncbi.nlm.nih.gov/27469590/

Platelet-Rich Plasma (PRP) References:

  1. Effectiveness of Lateral Elbow Tendinopathy Treatment Depends on the Content of Biologically Active
    Compounds in Autologous Platelet-Rich Plasma. J Clin Med. 2022;11(13):3687. Available from:
    https://pmc.ncbi.nlm.nih.gov/articles/PMC9267331/
  2. Platelet-Rich Plasma Injection in Non-Operative Treatment of Partial-Thickness Rotator Cuff Tears: A
    Systematic Review and Meta-Analysis. J Rehabil Med. 2022;54:1434. Available from:
    https://pmc.ncbi.nlm.nih.gov/articles/PMC9495266/
  3. Effectiveness of Lateral Elbow Tendinopathy Treatment Depends on the Content of Biologically Active
    Compounds in Autologous Platelet-Rich Plasma. J Clin Med. 2022;11(13):3687. Available from:
    https://pmc.ncbi.nlm.nih.gov/articles/PMC9267331/
  4. Platelet-Rich Plasma Injection in Non-Operative Treatment of Partial-Thickness Rotator Cuff Tears: A
    Systematic Review and Meta-Analysis. J Rehabil Med. 2022;54:1434. Available from:
    https://pmc.ncbi.nlm.nih.gov/articles/PMC9495266/
  5. Effectiveness of Lateral Elbow Tendinopathy Treatment Depends on the Content of Biologically Active
    Compounds in Autologous Platelet-Rich Plasma. J Clin Med. 2022;11(13):3687. Available from:
    https://pmc.ncbi.nlm.nih.gov/articles/PMC9267331/
  6. Platelet-Rich Plasma Injection in Non-Operative Treatment of Partial-Thickness Rotator Cuff Tears: A
    Systematic Review and Meta-Analysis. J Rehabil Med. 2022;54:1434. Available from:
    https://pmc.ncbi.nlm.nih.gov/articles/PMC9495266/

Autologous Blood Injection References:

  1. Rees JD, Stride M, Scott A. Tendons–time to revisit inflammation. Br Med Bull. 2010;95(1):63-94.
    doi:10.1093/bmb/ldq035. Available from: https://academic.oup.com/bmb/article- abstract/95/1/63/269316
  2. Barnett J, Bernacki MN, Kainer JL, Smith HN, Zaharoff AM, Subramanian SK. The effects of
    regenerative injection therapy compared to corticosteroids for the treatment of lateral epicondylitis: a
    systematic review and meta-analysis. Arch Physiother. 2019;9:12. doi:10.1186/s40945-019-0063-6.
    Available from: https://pubmed.ncbi.nlm.nih.gov/30899764/
  3. Vander Doelen T, Jelley W. Non-surgical treatment of patellar tendinopathy: a systematic review of
    randomized controlled trials. J Sci Med Sport. 2020;23(2):118-124. doi:10.1016/j.jsams.2019.09.008.
    Available from: https://pubmed.ncbi.nlm.nih.gov/31754461/

Prolotherapy References:

  1. Sanderson LM, Bryant A. Effectiveness and safety of prolotherapy injections for management of lower
    limb tendinopathy and fasciopathy: a systematic review. J Foot Ankle Res. 2015;8(1):57.
    doi:10.1186/s13047-015-0114-5. Available from:
    https://pubmed.ncbi.nlm.nih.gov/26500703/
  2. 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;9:139-159.
    doi:10.4137/CMAMD.S39160. Available from:
    https://pubmed.ncbi.nlm.nih.gov/27429562/

Extracorporeal Shockwave Therapy (ESWT) References:

  1. Miettinen J, Järvinen T, Kallio J, et al. Effectiveness of extracorporeal shock wave therapy on chronic
    musculoskeletal disorders: A systematic review and meta-analysis of randomized controlled trials. Pain
    Physician. 2018;21(4):305-316. Available from:
    [https://pmc.ncbi.nlm.nih.gov/articles/PMC9382436/?utm]( https://pmc.ncbi.nlm.nih.gov/articles/PMC93824
    36/? )
  2. Elgendy MH, Elhakeem A, Fares A, et al. The effect of extracorporeal shock-wave therapy on pain in
    patients with various tendinopathies: a systematic review and meta-analysis of randomized controlled
    trials. BMC Sports Sci Med Rehabil. 2024;16(1):84. doi:10.1186/s13102-024-00884-8.
  3. Elgendy MH, Elhakeem A, Fares A, et al. The effect of extracorporeal shock-wave therapy on pain in
    patients with various tendinopathies: a systematic review and meta-analysis of randomized controlled
    trials. BMC Sports Sci Med Rehabil. 2024;16(1):84. doi:10.1186/s13102-024-00884-8. Available from:
    https://bmcsportsscimedrehabil.biomedcentral.com/articles/10.1186/s13102-024-00884- 8?utm_
  4. Doherty TJ, Berryman R, Jackson JL, et al. Extracorporeal shock wave therapy in veterinary medicine:
    a comprehensive review. Front Vet Sci. 2022;9:851894. doi:10.3389/fvets.2022.851894. Available from:
    [https://www.frontiersin.org/journals/veterinary-
    science/articles/10.3389/fvets.2022.851894/full?utm](https://www.frontiersin.org/journals/veterinary-
    science/articles/10.3389/fvets.2022.851894/full?utm)
  5. Guy’s and St Thomas’ NHS Foundation Trust. Extracorporeal shockwave therapy for Achilles
    tendinopathy and plantar fasciitis. Available from: [https://www.guysandstthomas.nhs.uk/health-
    information/extracorporeal-shockwave-therapy-achilles-tendinopathy-and-plantar-
    fasciitis](https://www.guysandstthomas.nhs.uk/health-information/extracorporeal-shockwave-therapy-
    achilles-tendinopathy-and-plantar-fasciitis)