How are tendon overuse injuries treated?

Photo of a man holding a cool pack on his elbow (PantherMedia / daisy-daisy) If you have a tendon overuse injury, the first thing to do is to rest the tendon so the damaged tissue can recover. After that, physical therapy exercises are usually done to help the tendon gradually get used to withstanding strain again.

Some people use painkillers to relieve the symptoms. Other treatments include cooling the area, ultrasound therapy and massages. But these approaches haven’t been proven to help: Some haven't been studied at all, or research on a treatment has looked at the effects on only some tendons, so it’s not clear whether they would help when used on other tendons in the body.

It is best to talk to your doctor about which treatment approach would be suitable for you. In Germany, treatments that are prescribed by a doctor (e.g. physical therapy) are usually paid for by statutory health insurers. Most of the options mentioned above are low-risk treatments. Injections or surgery, on the other hand, are associated with a higher risk of side effects and complications. So these options are only considered if the symptoms don't improve over the long term despite resting the tendon and trying out low-risk treatments.

First rest...

If you continue to put too much strain on the affected tendon, the tissue can't recover properly. The continuing strain can lead to more damage, making the tendon more prone to injuries. It may even become partially or completely torn (tendon rupture).

So the most important thing to do at first is to go easy on the tendon. You will need to know exactly which movements place stress on the affected tendon. For instance, the tendons in the knee have to withstand a lot of strain when you climb stairs, and the Achilles tendon is mainly used during movements that involve the calf (lower leg) muscles. Experts recommend avoiding activities that stress the injured tendon for about three weeks. But that doesn't mean you should keep the affected arm or leg still: It is still possible to move them, as long as the movements don’t put strain on the tendon. If that doesn’t work, though, or if the symptoms don’t improve, the affected part of the body is sometimes “taped” (using special elastic therapeutic tape) or put in a splint or brace. Splints and braces are worn for about three weeks, depending on the location and severity of the symptoms.

...then do exercises

Once the symptoms have improved, you can gradually start putting more stress on the tendon again. Physical therapy exercises can help here, particularly certain stretching and strengthening exercises.

The exercises may hurt a little, but the pain should only occur while stretching and not be any worse after doing the exercises than they were before. So it’s important to have the physical therapist show you how to do the exercises properly. She or he can also let you know immediately if you are doing them wrong. Once you have learned how to do the exercises, you can do them at home or at work too.

Depending on which tendon is affected, various exercises can be done:

  • If it is the Achilles tendon, for example, you can stand on the bottom step of the stairs (facing the stairs) with your heels sticking out over the edge of the step a little. Then you slowly lower your heels. After that, you tense your calf muscles a little, bring your feet back up into the starting position, and repeat.


Illustration: Exercises for Achilles tendonExercises for Achilles tendon


The physical therapist will tell you how often the exercise should be repeated. In the first week of treatment, for instance, 10 times a day is enough. Then you can try to gradually increase to doing it 3 x 15 times each day – with a short break of about one and a half minutes between the sets of 15. You should then stretch your Achilles tendon in this way twice a day for three months.

  • If the patellar (kneecap) tendon is affected, similar exercises are suitable. These are often special modified squats. Exercises for sore tendons in the elbow aim to stretch and strengthen the muscles in the forearm. You will find instructions on how to do these exercises in our information on tennis elbow. The physical therapist will usually do a combination of different exercises with you. Exercise machines and weights are sometimes used too.

Short-term use of painkillers

Painkillers such as NSAIDs (non-steroidal anti-inflammatory drugs) can be used to relieve the pain. They are usually well tolerated but can have side effects such as nausea or stomach pain. If they aren’t prescribed by a doctor, they shouldn't be used for longer than a few days.

These medications are also available in the form of creams or gels. They are applied to the affected area to relieve the pain.

What other treatments are offered?

People who have a tendon overuse injury are sometimes offered other treatments too: For instance, some people have treatments based on physical stimuli during the resting phase or exercise phase. If the symptoms persist for a long time, injections or surgery might be considered too. But there are no good-quality studies on these treatments. So it’s not clear whether they help, are only effective in certain tendons, or don’t work at all. In Germany, the costs of these treatments aren’t always covered by statutory health insurers.

Treatments based on physical stimuli

Various other treatment approaches use physical stimuli such as heat, cold, electricity, pressure or sound.

  • Applying heat or cold: The affected tendon can be cooled using cold packs, for instance. This can relieve the pain – just like with acute sprains and strains. Although the area is often cooled in acute cases, some people find that heat works better in longer-lasting (chronic) cases.
  • Electric current: Sometimes an approach known as iontophoresis is used. This involves attaching electrodes to the skin and passing a mild electric current through the skin in a water bath. The electric current isn’t dangerous. If anything, you might feel a slight tingling sensation. A pain-reducing medication is applied between the skin and the electrodes beforehand – often in the form of a cream. The electric current improves the absorption of the medication, allowing it to move deeper into the skin and reach the sore tissue. There are also other forms of electrotherapy, such as EMS (electrical muscle stimulation) and TENS (transcutaneous electrical nerve stimulation). These approaches aim to help relieve the pain without medication. Sometimes treatment with an electric current is combined with acupuncture (electroacupuncture).
  • Ultrasound and shock wave therapy: The aim of ultrasound therapy is to break apart tendon tissue that has become stuck together. Like in the treatment of kidney and ureteral stones, sound waves are sometimes used to break up things like calcium deposits too. This approach is known as “extracorporeal shockwave therapy” (ESWT). ESWT can be given in one or several sessions and is considered to be a low-risk treatment. The shock waves can be painful, though.
  • Massage: When treating tendon problems, a type of massage known as deep friction massage is commonly used. Here the physical therapist pushes into the tendon tissue with the tips of their fingers in order to break up adhesions (stuck-together tissue). That can be unpleasant or even painful at the time.

Possible treatments for long-lasting pain

People who have tendon problems need to be patient because it takes more than just a few days for them to get better. The symptoms sometimes last longer than 3 to 6 months or keep returning despite resting the tendon and having physical therapy and treatments based on physical stimuli. If that happens, injections or surgery can be considered.

  • Treatment with injections: This involves injecting medication into the affected area around the tendon. Steroids and local anesthetics are commonly used for this purpose. But other substances are sometimes injected too, such as hyaluronic acid or glucose. It is also possible to inject a combination of different medications. Some people have platelet-rich plasma injected into the sore area. This is made out of their own blood and contains a high concentration of blood platelets. Treatment with injections can cause side effects such as pain, swelling and tissue damage. It can also lead to an inflammation where the needle is inserted. The inserted needle can damage a blood vessel or nerve too. Allergic reactions to the injected substance can occur as well.
  • Surgery: Tendon overuse injuries are only rarely operated on. The surgery involves removing damaged tissue and calcium deposits, as well as breaking apart tissue that is stuck together. Other procedures are sometimes done too. For instance, the muscle that is attached to the tendon might be extended (made longer) or tendon tissue from a different area may be sewn onto the affected tissue. There are many different surgical techniques for the Achilles tendon alone, ranging from open surgery to procedures that are done through small cuts in the skin using an endoscope (a long, thin tube that has a light and camera at one end). Known as “minimally invasive procedures,” these techniques are considered to be more gentle and less likely to lead to complications such as infections, bleeding and damage to muscles, nerves or blood vessels.