The best treatment for most tendonitis is a rehab program consisting of strengthening exercises. The key to getting tendons better is to do exercise and be patient. However, some cases that are stubborn need a bit more help. In these cases, we use shockwave or GTN patches. However, even with these treatments, some people struggle to get back to sport. We often use a tendon injection for these difficult cases. So, what are the options for a tendon injection and how do you choose?
What are the options for a tendon injection?
We use different injections for difficult 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 which is the best option?
What is the evidence for injections in tendonitis?
According to a recent paper, we are a little clearer on the positives and negatives of a tendon injection for tendonitis.
Firstly, evidence suggests that a cortisone injection provides short-term pain relief for most tendonitis. However, there are questions about long-term benefits. For example, we know that a cortisone injection for tennis elbow improves pain after 6 weeks but makes you worse at 3 months. In addition, there is some evidence that cortisone can weaken tendons and increase the risk of rupture. A study found an increased risk of Achilles tendon rupture with multiple systemic or local cortisone injections.
Overall, while we still use cortisone for some tendons such as the shoulder and hamstring tendonitis, we need to be cautious with cortisone.
Are there other tendon injection options?
There are other options for a tendon injection for difficult cases.
Platelet-rich plasma (PRP) injections are a popular choice for tendonitis. Some suggest that PRP regenerates collagen in tendons. While PRP has shown effectiveness in arthritis, there is less evidence in tendonitis. Studies on PRP have shown good results in tennis elbow, plantar fasciitis and hip tendonitis. However, there is no evidence that PRP is effective for other tendons such as Achilles tendonitis, Jumper’s knee, and shoulder tendonitis.
We use sclerosant injections such as dextrose (which is a type of sugar) and polidocanol for some cases. We know that tendonitis causes growth of abnormal blood vessels. Small amounts of sclerosant are injected to destroy these blood vessels and reduce pain. There is evidence for the use of these sclerosant injections in Achilles tendonitis and tennis elbow. Nevertheless, studies results are mixed and not all are positive.
A specific type of injection called high volume injection showed early promise in some studies. However, more recent higher-level studies (randomised studies) show less promising results. It is thought that many of the positive short-term results after high volume are due to use of cortisone used rather than the high volume effect.
In addition, we use needle tenotomy in some cases. We needle the tendon with a small dose of local anaesthetic. In general, we think that repeated needling of a tendon stimulates bleeding and a healing response. Similar to other injections, we have some evidence that needling is more effective overall than other injections. Moreover, tenotomy is safe and easily performed with a small amount of local anaesthetic.
What about stem cells for tendonitis?
While there is one study showing the effectiveness of stem cells in patellar tendonitis, this therapy is very expensive. Also, there is doubt as to whether this treatment is better than other treatments such as PRP or needle tenotomy.
Finally, we perform tendon scraping for some cases of Achilles and patellar tendonitis. By using a needle with a special blade, we scrap the tendon to destroy pain-generating nerves. Early results are promising for difficult tendon cases. However, this procedure should only be used for tendon cases that have failed simple treatments.
Where does that leave patients in their decision on a tendon injection?
Given that there are no clear favourites for injections in tendonitis, the decision on when and what to inject is a shared decision between patient and doctor. However, irrespective of the decision, it is important to understand that we should use injections together with exercise to improve outcomes.
Final word from Sportdoctorlondon
Tendon injections should not be treated lightly. Generally, we should only perform injections in difficult cases that have failed rehab and non-invasive treatments such as GTN or shockwave. You would speak to an expert to decide on the best option for you.
However, in general, we would recommend the following injections for specific tendons:
Other tendon information: