Tendonitis

1. Overview

Tendonitis (tendinitis) is inflammation of the thick fibrous cords that attach muscles to bones [1]. These tendons, when inflamed, cause pain, tenderness, and swelling in the affected area. The condition occurs from repetitive movements, sudden injuries, or excessive strain over time.

Tendonitis is widespread, affecting millions globally. Lower extremity tendinopathies have a prevalence of 11.83 per 1,000 registered patients and an incidence rate of 10.52 per 1,000 patients annually [2]. Specific forms vary by activity: patellar tendinopathy affects 45% of volleyball players and 32% of basketball players [3], while Achilles tendinopathy occurs in 52% of elite runners versus 6% of the general population [4]. Lateral epicondylitis affects 4-7 per 1,000 people over their lifetime [3].

Quick Facts About Tendonitis:

• Prevalence: Affects all ages; rates vary by tendon location and activity level
• Demographics: More common in adults over 40 as tendons lose flexibility [1]
• Duration: Most cases resolve within 3-6 months with proper treatment [3]
• Impact: Can significantly limit daily activities, work, and sports
• Progressive Nature: May lead to chronic tendinopathy or rupture without treatment
• Recovery Potential: Symptoms managed effectively with appropriate treatment

Tendonitis most commonly affects shoulders, elbows, wrists, knees, and heels [1]. While there is no single cure, combining rest, physical therapy, activity modification, and medical interventions effectively manages symptoms and restores function in most cases.

2. Symptoms & Red Flags

Common Symptoms

Tendonitis symptoms typically develop gradually and worsen with activity. The characteristic symptom is pain where tendon attaches to bone, often described as a dull ache intensifying with movement [1].

Pain and Discomfort: Pain localizes to the affected tendon, becoming more pronounced when moving the joint or muscle. It may start as mild discomfort but can progress to constant pain interfering with daily tasks.

Tenderness: The area around the inflamed tendon becomes tender when pressed, helping providers identify the exact location [1].

Stiffness: Affected joints feel stiff, particularly in the morning or after inactivity. Moving through full range of motion becomes difficult and painful.

Swelling: Mild to moderate swelling may occur. The skin may appear puffy or feel warm [1].

Crackling Sensation: Some experience grating, crackling, or popping (crepitus) when moving the affected joint [5].

Weakness: The affected limb may feel weak, often resulting from pain inhibition rather than actual muscle damage.

Calcium Deposits: In chronic cases, calcium deposits may form, appearing as firm bumps that can cause intense pain [5].

Red Flag Symptoms

Seek immediate medical attention if you experience:

• Sudden, severe pain with popping or snapping sensation, indicating possible tendon tear or rupture requiring urgent evaluation [1]
• Complete inability to move the affected joint or limb
• Visible deformity or rapid swelling after injury
• Intense pain with fever, chills, or spreading redness, suggesting infection requiring immediate treatment [6]
• Signs of reduced blood flow including numbness, tingling, or coolness
• Symptoms worsening despite rest and over-the-counter pain management

These red flags require prompt evaluation to rule out serious complications like complete rupture, infection, or nerve compression [6].

Symptom Patterns

Tendonitis symptoms typically worsen with activity and improve with rest. Morning stiffness is common, often improving as the day progresses. Pain increases during and after activity, then gradually subsides during rest.

3. Causes & Risk Factors

Primary Causes

Tendonitis involves microscopic damage to tendon fibers occurring faster than the body can repair them [3]. This creates a failed healing cascade where inflammation develops but repetitive stress prevents complete healing.

Repetitive Motion: The most common cause is performing the same movement repeatedly, gradually damaging tendon fibers and overwhelming natural repair mechanisms [1]. Activities like throwing, typing, or painting create cumulative microtrauma.

Sudden Injury: Excessive force or awkward movement can cause acute tendon strain. Sudden injuries from lifting heavy objects or rapid sports movements can trigger acute tendonitis [6].

Biomechanical Factors: Incorrect movement patterns, poor posture, or improper technique place abnormal stress on tendons [1].

Age-Related Degeneration: Tendons naturally lose elasticity with aging. Cellular changes and decreased blood supply impair the tendon's ability to withstand stress and heal [7].

Non-Modifiable Risk Factors

Age: Risk increases significantly after age 40 as tendons become less flexible [1][5]. Older adults experience decreased elasticity and impaired healing.

Genetics: Genetic factors influence tendon structure and healing capacity. Some inherit tendons with different collagen compositions predisposing them to tendinopathy [3].

Modifiable Risk Factors

Occupational Factors: Jobs requiring repetitive motions, awkward positions, or overhead reaching significantly increase risk [1]. Gardeners, carpenters, laborers, and musicians face elevated risk [8].

Sports Activities: Athletes in activities involving repetitive movements—tennis, golf, baseball, running—face higher rates. Poor training practices including sudden intensity increases and insufficient recovery elevate risk [1].

Obesity: Excess weight increases mechanical load on weight-bearing tendons. Studies indicate obesity increases risk and worsens symptoms while slowing healing [9].

Medical Conditions: Diabetes mellitus alters collagen structure and impairs healing [7]. Rheumatoid arthritis creates an environment conducive to tendon inflammation [6].

Medications: Fluoroquinolone antibiotics (ciprofloxacin, levofloxacin) are associated with increased risk and rupture, particularly in patients over 60 or taking corticosteroids [10][11]. Corticosteroids and statins may also weaken tendons [5][7].

Prevention Strategies

• Gradual progression in activity intensity and duration
• Proper technique for work tasks and sports
• Regular stretching, especially after exercise [1]
• Strengthening exercises to support tendons
• Ergonomic modifications and appropriate equipment
• Cross-training to avoid repetitive stress
• Adequate rest between intense activities

##4. Diagnosis & Tests

Diagnosis Process

Diagnosing tendonitis relies primarily on clinical evaluation. Healthcare providers take a medical history, asking about symptom onset, activity patterns, and pain characteristics [1]. Understanding symptom development provides crucial diagnostic clues.

Physical examination involves palpating the affected area to locate tenderness and assess swelling [1]. The provider moves the joint through range of motion, noting limitations or crepitus. Special tests stress specific tendons to identify which structure is inflamed [5].

Most cases are diagnosed based on history and physical examination alone [12]. Additional testing may be ordered when diagnosis is uncertain or complications are suspected.

Common Tests & Imaging

X-rays: While X-rays cannot visualize tendons directly, they help rule out arthritis, bone spurs, or fractures [6][12]. In chronic tendonitis, X-rays may reveal calcium deposits.

Ultrasound Imaging: High-resolution ultrasound shows tendon thickening, tears, fluid accumulation, and neovascularization [13]. It offers dynamic imaging advantages, though accuracy depends on operator expertise.

MRI: MRI provides detailed soft tissue images, revealing inflammation, degeneration, or tears. MRI is useful when surgery is considered or diagnosis remains unclear [13].

Laboratory Tests: Blood tests aren't necessary for diagnosing tendonitis but may be ordered if inflammatory arthritis is suspected [13].

What to Expect

The diagnostic process typically occurs in one or two visits. For straightforward cases, diagnosis is often made during the initial visit. If imaging is needed, results are usually available within days.

5. Treatment Options

Treatment focuses on reducing pain, decreasing inflammation, promoting healing, and preventing recurrence. Most patients respond well to conservative management, though effectiveness varies [14]. A stepwise approach begins with least invasive options.

Lifestyle Modifications & Self-Care

Rest and Activity Modification: Temporarily reducing or modifying activities that stress the affected tendon is the cornerstone of treatment [1]. This doesn't mean complete rest but rather avoiding movements provoking pain.

Ice Therapy: Applying ice for 15-20 minutes several times daily helps reduce inflammation and pain [12], most effective in the acute phase.

Ergonomic Adjustments: Modifying workspaces, equipment, and techniques reduces tendon stress and supports recovery [1].

Physical & Occupational Therapy

Physical therapy is crucial with strong evidence supporting effectiveness [14]. Therapists develop individualized programs incorporating stretching, strengthening, and functional exercises.

Eccentric Strengthening: Eccentric exercises—where muscles lengthen under load—show particular effectiveness. For Achilles and patellar tendonitis, 12-week programs produce significant improvement, with 82% reporting improved pain [15].

Medications

NSAIDs: Oral NSAIDs like ibuprofen offer short-term relief (7-14 days) for acute tendonitis [16]. However, long-term effectiveness evidence is limited, and some research suggests NSAIDs might impair healing [7][14]. Topical formulations provide alternatives with fewer side effects.

Acetaminophen: For patients intolerant to NSAIDs, acetaminophen provides pain relief without anti-inflammatory effects.

Advanced Treatments

Corticosteroid Injections: Evidence suggests they provide short-term relief (up to 6 weeks) but no long-term benefit beyond 6 months [17]. Studies show injections may result in worse long-term outcomes [14]. Current guidelines recommend cautious use with imaging guidance [17].

Glyceryl Trinitrate Patches: Transdermal nitric oxide patches represent a promising option. Three randomized trials showed patients using patches (1.25 mg/24 hours) for 6 months experienced significant pain reduction and improved function [18]. The most common side effect is headaches.

Extracorporeal Shock Wave Therapy (ESWT): Evidence for effectiveness is strongest for calcific shoulder tendonitis [19]. For non-calcific conditions, results are inconsistent.

Other Options: Platelet-rich plasma (PRP) and sclerotherapy show preliminary promise but require further validation [20][21].

Surgical Options

Surgery is reserved for patients failing 6-12 months of comprehensive conservative treatment [14]. Approaches involve removing damaged tissue, eliminating bone spurs, or repairing tears.

For Achilles tendonitis, surgical debridement shows 67-87% success rates [22]. Shoulder surgery demonstrates results comparable to supervised exercise programs [23]. Recovery typically requires 3-6 months. Surgical outcomes are generally good but not guaranteed, with 15-30% failure rates [22].

6. Massage Therapy for Tendonitis

How Massage May Help Tendonitis

Massage therapy offers potential benefits by addressing specific pathophysiological changes in affected tendons. Unlike generic relaxation, massage for tendonitis targets unique biomechanical alterations.

Mechanism of Action: Tendonitis involves inflammation, degenerative changes, increased muscle tension, and myofascial trigger points [3][7]. Massage helps by reducing excessive muscle tension placing abnormal loads on irritated tendons. In Achilles tendonitis, tight calf muscles (gastrocnemius and soleus) increase tensile stress on the Achilles tendon. Massage directed at these muscles can reduce mechanical overload [24]. In rotator cuff tendonitis, addressing hypertonicity in deltoid, supraspinatus, infraspinatus, and surrounding shoulder muscles may decrease forces transmitted through inflamed tendons.

Specific Muscles by Condition:

• Achilles Tendonitis: Gastrocnemius, soleus, plantaris
• Patellar Tendonitis: Quadriceps (vastus medialis/lateralis), hamstrings
• Rotator Cuff Tendonitis: Supraspinatus, infraspinatus, subscapularis, teres minor, deltoid
• Tennis Elbow: Wrist extensors (extensor carpi radialis brevis/longus)
• Golfer's Elbow: Wrist flexors and pronators

Massage may improve local blood flow to tendons with naturally limited vascular supply. Enhanced circulation supports nutrient delivery and inflammatory byproduct removal. Manual techniques breaking up adhesions may restore normal tendon gliding.

Research Evidence

Scientific evidence shows mixed but generally supportive results. A systematic review found deep transverse friction massage didn't demonstrate clear superiority over other physical therapy modalities [25], indicating massage performs comparably to other conservative treatments.

A meta-analysis showed deep transverse frictional massage combined with conventional therapy produced statistically significant improvements in pain and function [26]. Patients receiving massage as adjunct to standard treatment had better results than standard treatment alone.

For Achilles tendonitis, a randomized trial comparing pressure massage to eccentric exercise found massage produced similar pain reduction and functional improvement [27]. At 6-month follow-up, both groups showed comparable outcomes.

Research on shoulder tendonitis indicates massage demonstrates effectiveness in improving shoulder pain [28].

Typical Treatment Protocols:

• Frequency: 1-3 times per week
• Duration: 6-12 weeks for chronic cases
• Session length: 30-60 minutes focusing on affected areas
• Combination with exercise therapy appears more effective than massage alone

Recommended Approaches

For Acute Flare-Ups (First 2-4 Weeks): During acute inflammatory phase, massage should be gentle, focusing on surrounding muscles rather than directly on inflamed tendon. Light effleurage and lymphatic drainage techniques help reduce swelling. Sessions should be brief (20-30 minutes) with minimal pressure. Ice application after massage may enhance anti-inflammatory effects.

For Chronic Management (After 4-6 Weeks): Once acute inflammation subsides, more intensive techniques become appropriate. Treatment can directly address the affected tendon with progressively deeper pressure. Sessions typically last 45-60 minutes, occurring 1-2 times weekly. Emphasis shifts to restoring tissue mobility, breaking up adhesions, releasing trigger points, and normalizing muscle tension patterns.

Types of Massage

Deep Tissue Massage: Uses sustained pressure and slow strokes to reach deeper muscle layers. For tendonitis, deep tissue work targets muscles attaching to or surrounding the affected tendon. By releasing chronic tension and adhesions, this approach may reduce mechanical stress on inflamed tendons.

Myofascial Release: Addresses restrictions in fascia surrounding muscles and tendons. Practitioners apply gentle, sustained pressure to fascial restrictions. Particularly valuable for addressing compensation patterns and movement restrictions [26].

Deep Transverse Friction Massage: Involves applying pressure perpendicular to tendon fibers. Theory suggests this breaks up adhesions and stimulates healing. Research shows mixed results [25]. When used, should be brief (5-10 minutes) and applied only after acute inflammation resolves.

What to Expect & Contraindications

During sessions, patients typically experience a combination of relief and therapeutic discomfort. The therapist will assess posture, movement patterns, and tender areas before beginning.

Contraindications—When to Avoid Massage:

• Acute tendonitis with severe inflammation
• Complete tendon rupture (requires medical treatment)
• Local infection or open wounds near affected area
• Recent corticosteroid injection (wait 2-3 weeks)
• Suspected tendon calcification causing intense pain
• Taking anticoagulant medications (requires medical clearance)

Important Reminder: Massage therapy should complement, not replace, comprehensive medical treatment. Work with a licensed massage therapist experienced in musculoskeletal conditions. Best outcomes occur when massage is integrated into a complete plan including rest, activity modification, and therapeutic exercises.

7. Related Therapies & Complementary Approaches

Several complementary therapies may support conventional treatment as part of comprehensive care but shouldn't replace medical treatment.

Acupuncture: Traditional acupuncture involves inserting thin needles to modulate pain and promote healing. Some studies suggest acupuncture may provide short-term pain relief for lateral epicondylitis and shoulder tendonitis [29]. Proposed mechanisms include pain modulation, endorphin release, and improved blood flow. Sessions typically occur 1-2 times weekly for 6-8 weeks.

Chiropractic Care: May address tendonitis by treating biomechanical dysfunctions contributing to abnormal tendon loading. Treatment includes joint mobilization, soft tissue techniques, and rehabilitation exercises.

Heat and Cold Therapy: Alternating applications may provide symptomatic relief. Cold therapy reduces inflammation during acute flares, while heat before activities can improve tissue flexibility.

TENS Devices: Deliver low-voltage electrical currents to modulate pain perception. Some patients find TENS helpful, though evidence is mixed.

Important Reminder: These approaches should supplement rather than replace evidence-based treatments. Effectiveness varies between individuals. Always inform all healthcare providers about complementary therapies you're using. Consult your primary provider before starting complementary therapies.

8. Self-Care & Daily Management

Effective self-care plays a crucial role in managing tendonitis and preventing recurrence.

Daily Habits:

• Practice proper posture to distribute forces evenly
• Take regular breaks every 20-30 minutes during repetitive activities
• Warm up 5-10 minutes before work tasks or exercise
• Use proper body mechanics for lifting and tool-handling
• Pace activities, alternating between demanding and lighter tasks
• Maintain general fitness through regular low-impact exercise
• Stay hydrated to support tissue health

Heat & Cold Application:

Cold Therapy (First 48-72 Hours or During Flares): Apply ice packs for 15-20 minutes every 2-3 hours [12]. Always place a thin cloth between ice and skin. Most beneficial during acute inflammation or after activities provoking symptoms.

Heat Therapy (Chronic Phase): Once acute inflammation resolves, heat application before activities can improve tissue flexibility. Apply warm compresses for 15-20 minutes or take a warm shower.

Exercise & Movement:

Complete rest often worsens tendonitis by causing stiffness. Continue modified activities that don't provoke significant pain. Gentle range-of-motion exercises help maintain joint mobility. Perform home exercises recommended by your physical therapist consistently.

Stress Management:

Chronic pain creates stress, and stress amplifies pain perception:

• Practice relaxation techniques: deep breathing or meditation
• Maintain social connections for emotional resilience
• Set realistic expectations; understand healing takes time

9. When to See a Doctor

Initial Care

Seek medical evaluation when you notice persistent tendon pain lasting more than a few days or interfering with daily activities. While minor soreness after unusual activity may resolve with rest, pain continuing despite self-care warrants professional assessment. Early evaluation can prevent acute tendonitis from progressing to chronic tendinopathy.

Follow-Up Care

Return to your healthcare provider if:

• Symptoms persist beyond 4-6 weeks despite rest and over-the-counter pain management
• Pain worsens progressively rather than gradually improving
• New symptoms develop (swelling, redness, warmth, fever) suggesting infection
• Function declines significantly
• Symptoms recur repeatedly after apparent resolution
• You experience adverse reactions to treatments

Specialist Referral

Your primary physician may refer you to specialists:

Orthopedic Surgeons: Specialize in musculoskeletal conditions and perform surgical procedures when conservative treatments fail. Referral appropriate for persistent symptoms after 3-6 months of care or when imaging reveals significant damage.

Sports Medicine Physicians: Focus on activity-related injuries and provide specialized protocols including advanced injection therapies.

Rheumatologists: Evaluate patients when inflammatory arthritis or systemic diseases may underlie tendon symptoms.

Preparing for Your Appointment

• Document symptoms: keep a pain diary noting when symptoms occur and triggering activities
• List all medications and supplements
• Prepare questions beforehand
• Bring relevant records: imaging reports or treatment summaries

10. Related Conditions

People with tendonitis may also experience these related musculoskeletal conditions covered in our guide collection:

Rotator Cuff Injury: Chronic shoulder tendonitis, if untreated, may progress to partial or complete rotator cuff tears. Degenerative changes weaken tendon structure over time, increasing vulnerability to tearing with minimal trauma [1]. See our Rotator Cuff Comprehensive Medical Guide.

Frozen Shoulder: Shoulder tendonitis can lead to adhesive capsulitis (frozen shoulder) if left untreated, particularly when pain causes prolonged immobilization. Both conditions share similar risk factors including diabetes and prolonged shoulder immobility. See our Frozen Shoulder Comprehensive Guide.

Tennis Elbow: A specific form of tendonitis affecting the lateral epicondyle, caused by repetitive wrist and arm motions. Shares similar pathophysiology with other tendinopathies but requires specific treatment approaches. See our Tennis Elbow Comprehensive Guide.

Carpal Tunnel Syndrome: People with wrist tendonitis (particularly flexor tendons) sometimes develop carpal tunnel syndrome—compression of the median nerve. Both can result from similar repetitive hand and wrist movements. See our Carpal Tunnel Syndrome Comprehensive Medical Guide.

Arthritis: Chronic tendonitis can increase stress on adjacent joints, potentially contributing to osteoarthritis development. Additionally, inflammatory arthritis conditions like rheumatoid arthritis can cause tendonitis as part of broader disease processes. See our Arthritis Comprehensive Guide.

Fibromyalgia: Individuals with widespread musculoskeletal pain from fibromyalgia may develop localized tendonitis more readily. Chronic pain sensitization can amplify tendonitis symptoms. See our Fibromyalgia Comprehensive Medical Guide.

If your symptoms don't fit typical tendonitis patterns, involve multiple body areas, or don't respond to standard treatments, discuss these related conditions with your healthcare provider. Accurate diagnosis ensures appropriate treatment.

References