The most effective treatment for most tendonitis is a rehabilitation program that includes strengthening exercises. The key to improving tendons is to engage in exercise and be patient. However, some stubborn cases need a bit more help. In these cases, we use shockwave or GTN patches. However, even with these treatments, some struggle to return to sports. We often use a tendon sheath injection for these complex cases. What are the options for a tendon injection, and how do you choose the best one?

What are the options for a tendon injection?

We use different injections for challenging tendonitis. Traditionally, we have used cortisone injections. Each year, we perform over 500000 cortisone injections for arthritis and tendonitis. Cortisone is a good pain reliever, but there are problems with cortisone, including nasty side effects such as tendon weakening and rupture. Other options include high-volume stripping, sclerosants, platelet-rich plasma, hyaluronic acid, needle tenotomy, and tendon scraping. So, how do you choose the best tendon injection option?

What is the evidence for a tendon injection?

According to a recent paper co-authored by Dr Masci, we are more aware of the positives and negatives of a tendon injection for tendonitis. This paper summarises the evidence for tendon injections in tendonitis. 

Cortisone injections for tendonitis 

Evidence suggests that a cortisone injection provides short-term pain relief for most cases of tendonitis. However, there are questions about long-term benefits. For example, a cortisone injection for tennis elbow improves pain after six weeks but worsens it at three months. Additionally, there is some evidence that cortisone can weaken tendons and increase the risk of tendon rupture. For example, a study found an increased risk of Achilles tendon rupture with multiple systemic or local cortisone injections. 

Overall, while we still use cortisone for certain tendons, such as those affected by rotator cuff tendonitis and hamstring tendonitis, we must exercise caution with its use.

When injecting cortisone for tendonitis, it is essential to use ultrasound guidance to direct the injection around the affected tendon. Tendon sheath injections are preferred, as inadvertent injection of corticosteroids into the tendon may cause damage and further weaken the tendon. Tendon sheath injections can only be performed with the use of ultrasound. 

Do steroid injections weaken tendons? 

Yes. We think so. A recent study found that the mechanical properties of tendons were reduced for a few weeks after a steroid injection. However, we don’t know whether this change continues for months or years after a cortisone shot. Additionally, the same study found increased collagen disorganisation and necrosis after a cortisone injection. 

Are there other tendon injection options?

There are alternative options for tendon injections in complex cases.

PRP injection for tendonitis

Platelet-rich plasma (PRP) injections are a popular choice for tendonitis. Some suggest that PRP regenerates collagen in tendons.

PRP is obtained from whole blood, which is centrifuged to separate the plasma from the red cells. Blood plasma contains a high concentration of platelets and growth factors. When plasma is injected into tendons, the platelet growth factors are released, leading to tendon regeneration. 

While PRP is effective in treating arthritis, there is less evidence to support its use in tendonitis. Studies on PRP have shown promising results in the following tendons: 

However, no evidence exists that PRP is effective for other tendons, such as Achilles tendonitis or Jumper’s knee. A recent study on all high-level studies for Achilles tendonitis found no difference between a placebo injection and the actual treatment. 

Glucose injections for tendonitis 

For some cases, we use sclerosant injections such as dextrose (a type of sugar) and polidocanol.

We know that tendonitis causes the growth of abnormal blood vessels. Therefore, small amounts of sclerosant are injected to destroy these blood vessels and reduce pain. Evidence suggests the use of these sclerosant injections for Achilles tendonitis and tennis elbow. Nevertheless, the results of the studies are mixed, and not all are positive.

High-volume saline injection for tendonitis 

A specific type of injection for Achilles and patellar tendinitis, known as high-volume injection, has shown early promise in some studies. It is a tendon sheath injection. However, more recent higher-level studies (randomised studies) show less promising results. It is believed that the positive short-term results following high-volume treatment are attributed to cortisone rather than the high-volume effect. 

Percutaneous needle tenotomy for tendonitis

In some cases, we use needle tenotomy for tendonitis. We needle the tendon with a small dose of local anaesthetic. Repeated dry needling of tendonitis generally stimulates bleeding and healing. Like other injections, there is some evidence that needle tenotomy for tendonitis is more effective than other treatments. Moreover, dry needling for tendonitis is a safe and easily performed procedure, typically involving a small amount of local anaesthesia.

Hyaluronic acid for tendonitis 

Hyaluronic acid is a naturally occurring substance found in ligaments and joints. We usually use it to treat osteoarthritis. However, more recently, we have started using it for tendonitis. 

One of the more common uses of hyaluronic acid is in the treatment of plantar fasciitis-associated Achilles tendonitis. In these cases, the minor plantaris tendon rubs against the inside of the Achilles tendon, causing friction and pain. We inject hyaluronic acid between the plantaris and Achilles tendons to separate the two tendons and prevent friction. Thus, it is a tendon sheath injection. 

What about stem cells for tendonitis? 

While one study demonstrates the effectiveness of stem cells in treating patellar tendonitis, this therapy is costly. Additionally, there is doubt about whether this treatment is superior to other options, such as PRP or needle tenotomy.

ultrasound picture de quervains tenosynovitis injection

Tendon scraping for tendonitis

Finally, we perform tendon scraping for some cases of Achilles and patellar tendonitis. Using a needle with a special blade, we scrape the tendon to destroy pain-generating nerves. Early results are promising for complex tendon cases. However, tendon scraping should only be used for patients who have failed simple treatments.

Tenex procedure for tendonitis

The Tenex procedure is a new and innovative treatment for tendonitis. It uses ultrasonic energy to remove damaged tendon tissue while preserving the healthy part. Unlike surgery, it is minimally invasive and performed with local anaesthetic. Thus, it replaces the need for more invasive and riskier surgery. It is a good option for upper and lower limb tendonitis that has not responded to other treatments. 

Where does that leave patients when deciding on a tendon injection?

Given that there are no clear favourites for tendonitis injections, the patient and the doctor share the decision on when and what to inject. However, regardless of the decision, we must recognise that using injections and exercise can improve outcomes.

Other frequently asked questions about tendon injections:

Is a cortisone shot for patellar tendonitis a good option?

We don’t think so. Cortisone shots for patellar tendonitis can be done with or without ultrasound. 

A study on patellar tendonitis compared a cortisone shot to exercise and shockwave therapy. It found that patients who received a cortisone shot performed worse at 3-6 months than those who received other treatments. We suggest avoiding a cortisone shot for patellar tendonitis.

Can a cortisone shot help bursitis? 

Yes. Generally, bursitis forms secondary to tendonitis. For example, trochanteric bursitis in the hip is often secondary to hip tendonitis. A cortisone shot can reduce pain from bursitis, but it should always be combined with physical therapy to strengthen the hip tendons. 

Will a cortisone shot help a torn ligament? 

Generally, ligament tearing leads to initial inflammation and swelling, followed by a healing process. Typically, we don’t inject cortisone into a torn ligament, as we suspect that it may impair proper healing. 

Final Word from Sportdoctorlondon about a Tendon Sheath Injection

A Tendon injection should not be treated lightly. Generally, we should only perform injections in challenging cases that have failed rehab and non-invasive treatments such as GTN or shockwave. You would speak with an expert to determine the best option.

However, we would recommend the following injections for specific tendons:

Other tendon information:

Dr Masci is a specialist sports doctor in London. 

He specialises in muscle, tendon and joint injuries.

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