How are tendon overuse injuries treated?

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).

That is why it's important to determine which movements are possible and which ones make the problem worse. It isn't helpful to only rest or to keep the joints immobilized. Experts even recommend continuing to move, even if it hurts occasionally.

Then it's important to know exactly what is causing the strain on the affected tendon. The tendons in the knee, for instance, are subject to a lot of strain in sports like volleyball or basketball, both of which involve a lot of jumping, – and your Achilles tendon is especially strained by movements that involve your calf muscle. Tendons in the shoulder and arm are subject high levels of strain in sports like tennis.

Experts advise against more strenuous activity for a while. Sometimes a special elastic therapeutic tape bandage or an orthopedic brace (orthotic) can be used for a few weeks to reduce strain on the tendon.

If you have a tendon overuse injury, special stretching and strengthening exercises are recommended at an early stage. You can do them on your own or as part of physical therapy. These types of exercises are called “eccentric” exercises, and they are designed to strengthen your tendons and muscles, which helps to relieve the pain.

The exercises may hurt a little, but the pain should not be much worse after doing the exercises than it was before. So can be helpful to have the physical therapist show you how to do the exercises properly. The therapist 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 so that you are on your tiptoes. Then slowly lower your heels. After that, you tense your calf muscles a little, bring your feet back up into the starting position, and briefly take any weight off the affected foot. Then repeat these steps.

Your physical therapist will tell you how often the exercise should be repeated. It is often recommended to do them in three sets of 15 repetitions each. You should take a short break of about 90 seconds between sets. These exercises can be done every day or every other day. Studies suggest that if you have a tendon overuse injury, it's generally more effective to do the exercises every other day at a higher intensity than it is to do the exercises every day at a lower intensity.

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.

Pain relievers such as nonsteroidal anti-inflammatory drugs (NSAIDs) are one way to relieve symptoms. NSAIDs include, for example, acetylsalicylic acid (the drug in medicines like Aspirin), ibuprofen, and diclofenac, which can be taken in tablet form. 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.

Various other passive therapeutic approaches use physical stimuli such as heat, cold, electricity, pressure or sound. These treatments offer little to no benefit, and they are no substitute for strengthening and stretching exercises. In Germany, the costs of these treatments aren’t always covered by statutory health insurers.

• Applying heat or cold: The affected areas can be cooled using cold packs to reduce acute pain, for instance. If the pain is chronic, it can help to apply heat. But it is not clear whether that is effective.
• Electric current: This involves attaching electrodes to the skin and passing a mild electric current through the skin in a water bath. The current is harmless; at most, it might cause a slight tingling feeling. A pain-reducing medication is applied between the skin and the electrodes beforehand – often in the form of a cream. The current is intended to help the body absorb the active ingredient in the medication more effectively. This approach is called iontophoresis. There are also other forms of electrotherapy, such as EMS (electrical muscle stimulation) and TENS (transcutaneous electrical nerve stimulation).
• Ultrasound shock wave therapy: This involves directing sound waves into the body. These are intended to dissolve calcium deposits and reduce inflammation. This approach is known as “extracorporeal shockwave therapy” (ESWT). In studies it has not been shown to be very effective on its own – and it offered no benefit when used in addition to exercise therapy. 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.

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 treatment. If that happens, injections or surgery can be considered.

• Treatment with injections: This involves injecting medication into the affected area around the tendon. One option is steroids, which can provide some relief from the pain, at least in the short term. There are also local anesthetics, 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 probably ineffective. 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 (“neurosurgical clipping”): 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.