Tendinitis (tendon inflammation) is irritation of a tendon, the tissue that attaches muscle to bone, or of its sheath, most often from repeated strain; it causes pain that gets worse with movement [1][2]. A mild tendon injury can be treated at home and should feel better within 2 to 3 weeks [1]. For long-lasting symptoms, treatment starts with managing the load and with progressive exercise programmes [3][4]; the effect of a steroid injection is short-lived, and the evidence for shock-wave therapy and PRP is limited [5][6][7].
What is tendinitis, and how does it differ from tendinopathy?
Tendons are fibrous cords of tissue that attach muscles to bone [1][2]. Tendinitis (tendon inflammation) is inflammation or irritation of a tendon or of the sheath that covers it [2].
According to the current consensus, local pain in a tendon that comes on with tendon-loading activities is called "tendinopathy" [4]. In tendinopathy the tissue shows, alongside inflammatory cells, changes such as disorganised collagen fibres [3]. In this article the commonly used word "tendinitis" also covers tendinopathy.
Bursitis, by contrast, is inflammation of the small fluid-containing sacs (bursae) that act as cushions between bones and soft tissues; in tendinitis it is the tendon itself or its sheath that is affected [2]. The two can also occur together; bursitis is covered in a separate article in this guide [2].
What causes tendinitis?
Tendinitis is mostly the result of overuse: small stresses that repeatedly strain the tendon add up, and the tissue does not have enough time to recover [2]. The main causes are repetitive exercise such as running, jumping and throwing, sudden sharp movements, repeated movements at work or in sport, and poor posture or technique [1].
According to the Dutch guideline on Achilles tendinopathy, an external load that is too high in an athlete, or a very low capacity in an inactive person, can lead to relative overload [4]. In the Achilles tendon the problem is generally related to ageing and overuse; having had a tendinopathy in the leg before increases the risk [4]. As a preventive measure, the guideline also recommends considering avoiding fluoroquinolone antibiotics if another option is available and the clinical picture allows [4].
Where does tendinitis occur?
Overuse tendon problems most often involve the rotator cuff tendons in the shoulder, the inner and outer sides of the elbow, the patellar (kneecap) tendon in the knee, the hip (gluteal) tendons and the Achilles tendon [3]. Tendinitis of the shoulder and elbow is more common in swimming, tennis, volleyball and golf; tendinitis of the knee and ankle in football, basketball and running [2]. The topics that have a separate article in this guide are:
- Shoulder: rotator cuff problems and calcific tendinitis of the shoulder
- Elbow: tennis elbow
- Wrist and thumb: De Quervain's tenosynovitis, which affects the tendon sheath
- Achilles tendon: Achilles tendon rupture
- Pain under the heel (plantar fasciitis, heel spur) and muscle tears
What are the symptoms and how is it diagnosed?
Symptoms usually develop gradually [2]. The main ones are pain in a tendon that gets worse with movement, difficulty moving the joint, a grating or crackling sensation when the tendon moves, and swelling, sometimes with heat or redness [1]. Function and exercise tolerance may decline [3].
The diagnosis is mostly based on the symptoms and the examination; in some cases pain-provoking tests and imaging may be needed [3]. In the Achilles tendon, no additional imaging is needed when all the diagnostic criteria on examination are met; when the diagnosis is uncertain or surgery is being considered, ultrasound is the first choice [4].
What helps tendinitis? Gels and medicines
A mild tendon injury can be treated at home [1]. Your pharmacist can tell you which painkiller is suitable for you: simple painkillers can ease the pain, and an anti-inflammatory gel rubbed on the skin may also be recommended [1]. Anti-inflammatory medicines may be used in the treatment of tendinitis [2]; the Achilles tendinopathy guideline, however, asks for caution with these medicines [4].
The steps recommended for the first 2 to 3 days are [1]:
- Rest: trying not to move the tendon for 2 to 3 days
- An ice pack wrapped in a towel for up to 20 minutes every 2 to 3 hours
- Wrapping the area with an elastic bandage or using a soft brace
- Moving the area again once pain allows, so that the joint does not become stiff
- Avoiding heavy lifting, strong gripping, twisting actions and, until the tendon has recovered, sport
Exercise: loading the tendon gradually
If the pain is severe, lasts a long time or movement is limited, physiotherapy may be offered [1]. Different exercise and loading programmes are used in the management of tendinopathy; however, uncertainty remains about how effective they are [3].
The Achilles tendinopathy guideline states that in long-standing cases simply waiting brings no improvement, or only limited improvement, in the short term, and it advises active treatment, in which the load is increased step by step [4]. The recommended initial treatment has three parts [4]:
- Education: an explanation of the condition and of the expected course
- Managing the load: stopping the activities that bring on the pain, then increasing the load gradually according to the pain
- Progressive exercises that strengthen the calf muscles, for at least 12 weeks; the pace of progression is set by pain and muscle fatigue
Steroid injections, shock-wave therapy and PRP
In severe tendinitis a cortisone (steroid) injection may be offered; it may provide short-term pain relief [1]. A review of 41 randomised trials found that cortisone injections reduced pain more than other interventions in the short term, but that this effect was reversed in the intermediate and long term; tennis elbow is the example, whereas in the rotator cuff the short-term effect is not clear [5]. In the studies that reported adverse events, tendon rupture occurred in one of 991 people who received cortisone; the review stated that the response varies by site and should not be generalised [5]. The Achilles tendinopathy guideline asks for caution with cortisone injections [4]. Site-specific information is given in the relevant articles.
In Achilles tendinopathy, shock-wave therapy (ESWT) is one of the additional options that can be considered if there is no improvement after 3 months despite exercise and load management; its additional benefit is uncertain [4]. A systematic review of common conditions of the leg found low-level evidence that it may be effective in some of them; in patellar tendinopathy (knee tendinitis), however, there is moderate-level evidence of no difference between focused shock-wave therapy and placebo in the short and medium term [6].
For platelet-rich plasma (PRP), a Cochrane review concluded that there is insufficient evidence to support its use in soft tissue injuries; the quality of the evidence is very low [7]. In Achilles tendinopathy PRP was not found to be more effective than placebo [5].
How long does it take to heal, and when is surgery considered?
A mild tendon injury should feel better within 2 to 3 weeks; if there is no improvement within a few weeks, you should see a doctor [1]. In long-lasting tendinopathy recovery is slow: in the Achilles tendon it can take months or even years, and a return to full loading without symptoms is generally possible only after at least a few months of active treatment [4]. Most patients recover; nevertheless, in 23–37% symptoms may persist in the long term despite treatment [4].
If symptoms continue, the patient may be referred to an orthopaedic specialist; surgery may be recommended to remove damaged tissue or repair a ruptured tendon [1]. In Achilles tendinopathy, surgery is considered only in patients who have not recovered despite at least six months of active treatment [4].
When not to wait
If the pain started suddenly and severely during an accident or an activity, the tendon may have ruptured; a popping or snapping sound may have been heard when the pain began [1]. In the following situations seek care without waiting [1]:
- Severe pain that started suddenly
- A popping or snapping sound heard when the pain began
- You think the tendon has ruptured
- Your pain is very severe
Frequently asked questions
- What is the best medicine or cream for tendinitis?
- Your pharmacist can recommend a painkiller that suits you; simple painkillers can ease the pain, and an anti-inflammatory gel rubbed on the skin may also be recommended [1]. The Achilles tendinopathy guideline asks for caution with anti-inflammatory medicines [4].
- When does tendinitis go away?
- A mild tendon injury should feel better within 2 to 3 weeks [1]. In long-standing tendinopathy recovery can take months; a return to full loading without symptoms is generally possible only after at least a few months of active treatment [4].
- How does tendon inflammation settle?
- For the first 2 to 3 days, rest, ice wrapped in a towel and support are recommended; the joint is moved again once pain allows [1]. If symptoms continue, treatment carries on with load management and progressive strengthening exercises [4].
- What is knee tendinitis (patellar tendinitis)?
- It is an overuse problem of the kneecap tendon (patellar tendon) and is among the most common tendinopathies [3]; the tendons of the knee are affected more often in football, basketball and running [2]. There is moderate-level evidence that shock-wave therapy at this site is no different from placebo in the short and medium term [6].
This article is a general summary; diagnosis and treatment decisions are made by the doctor who examines you.
Sources
- Tendonitis. NHS (nhs.uk), 2023. nhs.uk
- Sprains, Strains and Other Soft-Tissue Injuries. American Academy of Orthopaedic Surgeons (OrthoInfo), n.d.. orthoinfo.org
- Tendinopathy. Nature Reviews Disease Primers (Millar NL, et al.), 2021. pubmed.ncbi.nlm.nih.gov
- Dutch multidisciplinary guideline on Achilles tendinopathy. British Journal of Sports Medicine (de Vos RJ, et al.), 2021. pubmed.ncbi.nlm.nih.gov
- Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. The Lancet (Coombes BK, et al.), 2010. pubmed.ncbi.nlm.nih.gov
- The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. British Journal of Sports Medicine (Korakakis V, et al.), 2018. pubmed.ncbi.nlm.nih.gov
- Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database of Systematic Reviews (Moraes VY, et al.), 2014. pubmed.ncbi.nlm.nih.gov
This article is general information and does not replace an examination or imaging. If you have symptoms, see a doctor.
More in this area
- Bursitis: what is it, what causes it? Elbow bursitis, symptoms and treatment
- Broken collarbone (clavicle fracture): sling or surgery?
- Frozen shoulder: how long does it last, and when are injections or surgery considered?
- Shoulder pain and rotator cuff problems: is surgery needed?
- Calcific tendinitis of the shoulder: why it happens and how it is treated
- Dislocated shoulder: what happens after it is put back, and is surgery needed?
- Shoulder pain: what causes it, what helps and who to see
- Tennis elbow: what do steroid injections, PRP and surgery add?