eMedicine Specialties > Emergency Medicine > Rheumatology
Tendonitis: Treatment & Medication
Updated: Mar 31, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
The goal of treatment is to reduce pain and to return to activity.
Treatments of tendinopathy are listed below.
- Rest or decrease activity level. No clear recommendations are available for the duration of rest; however, patients should restrict activities that cause pain.
- Ice is recommended for the first 24-48 hours.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in relieving tendinopathy pain. However, because the vast majority of tendinopathies are not inflammatory, whether NSAIDs are more effective than other analgesics is unclear.
- Splinting and/or immobilization; sling for rotator cuff tendonitis
- Strengthening and stretching exercises can be performed once the pain has subsided. Eccentric strength training can be effective in treating tendinopathies.
- Low-intensity pulsed ultrasound was shown to be no more effective than placebo in the treatment of patellar tendinopathy.2
- Peritendinous lidocaine/corticosteroid injection
- Consider this injection for patients with tendonitis in whom conservative therapy with rest, immobilization, and anti-inflammatory agents has failed.
- The efficacy of locally injected steroids is debated.
- Never inject into the Achilles tendon because cases of Achilles tendon rupture have been reported following a single injection of corticosteroid.
- Avoid repetitive corticosteroid injections in any site, as well as injection directly into a tendon, because of the risk of tendon rupture.
Consultations
An ED consultation is rarely necessary for tendonitis.
Medication
The goals of pharmacotherapy are to control pain and decrease inflammation.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents are used for the relief of mild to moderate pain. Although the effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen usually is the drug of choice (DOC) for initial therapy. Other options include naproxen and indomethacin.
Ibuprofen (Motrin, Advil, Ibuprin, Nuprin)
Usually DOC for treatment of mild to moderate pain if no contraindications are present.
Inhibits inflammatory reactions and pain, probably by decreasing activity of the enzyme cyclooxygenase, which results in inhibition of prostaglandin synthesis.
Adult
400 mg PO q4-6h, 600 mg PO q6h, or 800 mg PO q8h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid; start at lower end of dosing range and titrate upward; not to exceed 2.4 g/d
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; cross-sensitivity to other NSAIDs may occur; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Naprosyn, Aleve)
For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which results in decrease of prostaglandin synthesis.
Adult
200-250 mg PO q6-8h or 500 mg PO bid; not to exceed 1.25 g/d; may increase to 1.5 g/d for limited periods
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Indomethacin (Indocin, Indochron E-R)
Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis.
Adult
25-50 mg PO bid/tid
75 mg SR PO bid; not to exceed 200 mg/d
Pediatric
1-2 mg/kg/d PO divided bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; GI bleeding or renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia)
Corticosteroids
These agents have both anti-inflammatory (glucocorticoid) and salt-retaining (mineralocorticoid) properties. Glucocorticoids have profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.
Dexamethasone acetate (Decadron, AK-Dex, Alba-Dex, Dexone)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. Dosage varies with degree of inflammation and size of affected area.
Adult
4-16 mg intralesionally (0.5-1 mL) mixed with equal or double volume of 1% local anesthetic (ie, lidocaine)
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; decreases effect of salicylates and vaccines used for immunization
Documented hypersensitivity; active bacterial or fungal infection
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, PUD, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use
Methylprednisolone acetate (Solu-Medrol, Depo-Medrol, Medrol)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Use 0.5-1 mL (40 mg/mL) mixed with equal or double volume of 1% local anesthetic (ie, lidocaine). Dosage varies with degree of inflammation and size of affected area.
Adult
Tendon sheath inflammation: 4-30 mg intralesionally
Pediatric
Not established
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, PUD, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use
Hydrocortisone acetate (Solu-Cortef, Cortef)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Use 0.5-1 mL (25 or 50 mg/mL) mixed with equal or double volume of 1% local anesthetic (ie, lidocaine). Dosage varies with degree of inflammation and size of affected area.
Adult
5-12.5 mg intralesionally
Pediatric
Not established
Corticosteroid clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific ulcerative colitis, diabetes, and myasthenia gravis
More on Tendonitis |
| Overview: Tendonitis |
| Differential Diagnoses & Workup: Tendonitis |
 Treatment & Medication: Tendonitis |
| Follow-up: Tendonitis |
| References |
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References
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Warden SJ, Metcalf BR, Kiss ZS, Cook JL, Purdam CR, Bennell KL, et al. Low-intensity pulsed ultrasound for chronic patellar tendinopathy: a randomized, double-blind, placebo-controlled trial. Rheumatology (Oxford). Apr 2008;47(4):467-71. [Medline].
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Further Reading
Keywords
tendonitis, pain at tendinous insertions, lateral epicondylitis, tennis elbow, medial epicondylitis, calcific tendinitis, rotator cuff tendonitis, patellar tendonitis, popliteus tendonitis, iliotibial band syndrome, shinsplints, Achilles tendonitis, supraspinatus tendonitis, bicipital tendonitis, Yergason test, Speed test, Renne test, tendonopathy, tendinopathy, tendinitis
