Tendinitis

Signs and Symptoms

• Swelling
• Tenderness
• Pain that gets worse when you move the affected limb
• Warmth and redness
• A crackling sound, called crepitus

What Causes It?

Tendinitis can happen because of:

• Overuse, undertraining, or poor technique in sports
• Repetitive movement in some jobs, such as typing
• Falling
• Lifting or carrying heavy objects
• Extreme or repeated injury

Your risk for tendinitis may be higher if you have any of the following health issues:

• Overweight, due to increased pressure on tendons, ligaments, and bones
• Inflammatory conditions, such as Reiter syndrome or ankylosing spondylitis
• Autoimmune disorders, such as type 1 diabetes
• Certain infections

What to Expect at Your Doctor's Office

Your doctor will give you a physical examination and may take x-rays and other diagnostic tests.

Treatment Options

Your doctor may prescribe pain relievers or steroid injections. Treatment also may include ice, rest, or keeping the area still, such as with a sling. Massage, strengthening exercises, or physical therapy may help. Some studies show that high energy shock wave therapy improves symptoms and pain associated with tendinitis. If you have severe tendinitis that is not healing from other treatments, you may need surgery.

Drug Therapies

• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs such as ibuprofen (Advil, Motrin) and naproxen (Aleve), reduce pain and inflammation. There are also prescription NSAIDs. NSAIDs may increase the risk of stomach bleeding.
• Lidocaine or corticosteroid injections into the tendon. These cannot be used for weight-bearing tendons because of the risk of rupture.
• Colchicine. For calcific tendinitis, when calcium builds up in the joint.

Complementary and Alternative Therapies

• Ice, especially right after the injury.
• Rest.
• Massage.
• Immobilizing the affected limb (slings, splints).
• Flexibility and strengthening exercises after the inflammation goes down.
• Physical therapy, such as range-of-motion exercises.
• Ultrasonography. High-frequency sound used to heat an area and increase circulation
• Transcutaneous electrical nerve stimulation (TENS). Electricity used to help relieve pain.

• Bromelain. This enzyme that comes from pineapples reduces inflammation. Bromelain may increase the risk of bleeding, so people who take anticoagulants (blood thinners), such as warfarin (Coumadin), clopidogrel (Plavix), and aspirin should not take bromelain without first talking to their doctors. People with stomach ulcers should avoid bromelain. If taken with antibiotics, bromelain may increase the levels of antibiotic in the body, which could be dangerous. Turmeric is sometimes combined with bromelain because it makes the effects of bromelain stronger.
• Vitamin C. To aid in healing, increase immune function, and reduce inflammation. Vitamin C supplements may interact with other medications, including chemotherapy drugs, estrogen, warfarin (Coumadin), and others.
• Calcium and magnesium. To aid healing of connective tissues and muscles. If you have any underlying medical conditions, especially heart conditions, such as high or low blood pressure, COPD, or others, you should not take calcium or magnesium supplements without your doctor's supervision.
• Vitamin A. For immune function and healing. DO NOT use if you are or may become pregnant. Vitamin A interacts with a number of medications, including some that are available over the counter. Some of these interactions can be dangerous. Ask your doctor before taking vitamin A.
• Vitamin E and essential fatty acids, such as fish oil or evening primrose oil to reduce inflammation. Vitamin E may interact with a number of medications. Vitamin E, fish oil, and evening primrose oil may increase the risk of bleeding. If you take blood thinners, ask your doctor before taking any of these supplements.

Herbs help strengthen and tone the body's systems. As with any therapy, you should work with your doctor to diagnose your problem before starting treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. (5 g) herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day. You may use tinctures alone or in combination as noted.

Tell your doctor if you are pregnant or nursing before using any herbal products.

• Turmeric (Curcuma longa). For pain and inflammation. Turmeric is sometimes combined with bromelain, because it makes the effects of bromelain stronger. Turmeric may increase the risk of bleeding, so people who take anticoagulants (blood thinners), such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin should not take turmeric without first talking to their doctors.
• Willow bark (Salix alba). To relieve pain. Willow acts similar to aspirin. DO NOT take white willow if you are also taking aspirin or blood-thinning medications. DO NOT take willow bark products if you are allergic to aspirin or salicylates. Willow should not be given to children under the age of 18.
• Licorice (Glycyrrhiza glabra). To reduce inflammation. DO NOT take licorice if you have high blood pressure, edema, or heart failure; hormone-sensitive cancers such as breast, prostate, ovarian, or uterine cancer; diabetes; kidney disease; liver disease; or if you are taking corticosteroids prescribed by your doctor. Licorice interacts with a number of medications. So to be safe, ask your doctor before taking licorice if you take any other medications.

The following herbs may also help reduce inflammation, although they have not been tested for tendinitis.

• Cat's claw (Uncaria tomentosa). Has been used traditionally for pain relief. DO NOT take cat's claw if you take medicine for high blood pressure or blood-thinning medications. Cat's claw may stimulate the immune system, and might interact with drugs taken to suppress the immune system, or be inappropriate for people with autoimmune disorders. Cat's claw may also lower blood pressure, so if you take medication for high blood pressure you run the risk of your blood pressure dropping too low.
• Devil's claw (Harpagophytum procumbens). Has been used traditionally to relieve pain. Devil's claw may increase the risk of bleeding, especially if you also take blood thinners, such as warfarin (Coumadin). It can interact with diabetes medications and other drugs. It can have negative effects on people with heart problems, such as high blood pressure or low blood pressure. DO NOT take Devil's claw if you have gallstones. Talk to your doctor before taking it.
• Boswellia (Boswellia serrata). Boswellia may increase the risk of bleeding, so tell your doctor before taking it if you also take blood-thinning medication.

Homeopathic remedies for tendinitis include creams or gels. Arnica cream by itself, or in combination with Calendula officinalis, Hamamelis virginiana, Aconitum napellus, and Belladonna, applied 3 to 6 times a day, speeds healing and reduces discomfort. For acute (sudden) injuries, always start with Arnica.

Orally, the dose is usually 3 to 5 pellets of a 12X - 30C remedy every 1 to 4 hours until the symptoms improve.

• Bryonia. For pains that are worse with the slightest motion or when jarred. The pain feels worse with cold and better with heat.
• Phytolacca. For tendinitis where the pain is focused at the insertion of the tendons and feels worse with heat.
• Rhus toxicodendron. For tendinitis that is worse in the morning.
• Rhododendron. For tendinitis that gets worse with barometric changes.

Many naturally-oriented doctors use injectable homeopathic medications, including Traumeel, which has shown promise in reducing inflammation in some studies.

• Orthotics or heel lifts and shoe correction, for Achilles tendinitis.
• Elbow strap and small (2 lb.) weights, for tennis elbow.
• Contrast hydrotherapy, or alternating hot and cold applications. After the first 24 to 48 hours, soak affected part for 3 minutes in hot water, then 30 seconds in cold water.
• Castor oil pack. Apply oil to a clean, soft cloth, cover in plastic wrap, and apply to the affected area. Place a heat source over the pack, and let sit for 30 to 60 minutes.

The National Institutes of Health has reported that acupuncture may help treat tennis elbow. In addition, two studies looking at the effect of acupuncture on tendinitis found that acupuncture provides better pain relief than placebo.

Acupuncturists say that people with tendinitis frequently have a primary deficiency in the liver meridian, with a relative excess in the gallbladder meridian. In addition to needling treatment on the liver meridian and the supporting kidney meridian, treatments using moxibustion, a technique in which the herb mugwort is burned over specific acupuncture points may also be included. Needling and moxibustion may also be directly applied to painful areas and related sore points.

A technique known as balance method acupuncture may be effective in treating many musculoskeletal problems, including tendinitis.

Although no well-designed studies have looked at chiropractic care for treating tendinitis, chiropractors commonly treat this condition with ultrasound, electrical muscle stimulation, manual trigger point therapy (applying firm pressure by hand on a trigger point for several seconds and then stretching the muscle afterward), and massage. People with stiff joints may also receive joint manipulation.

Following Up

Tendinitis often has 3 stages:

1. A dull ache following activity, which improves with rest
2. Pain with minor movements (such as dressing)
3. Constant pain

Special Considerations

Tendinitis often comes back, particularly for athletes and people whose work requires repetitive motions.

Supporting Research

Albert JD, Meadeb J, Guggenbuhl P, et al. High-energy extracorporeal shock-wave therapy for cacifying tendinitis of the rotator cuff: a randomized trial. J Bone Joint Surg Br. 2007;89(3):335-341.

Cacchio A, Paoloni M, Barile A, et al. Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study. Phys Ther. 2006;86(5):672-682.

Fray C, Zamora J. The effects of obesity on orthopaedic foot and ankle pathology. Foot Ankle Int. 2007;28(9):996-999.

Fredberg U, Stengaard-Pedersen K. Chronic tendinopathy tissue pathology, pain mechanisms, and etiology with a special focus on inflammation. Scand J Med Sci Sports. 2008;18(1):3-15.

Gelineck J, Salomonsen M, Hviid C. Retropharyngeal tendinitis: radiographic and magnetic resonance imaging findings. Acta Radiol. 2006;47(8):806-809.

Gobel H, Heinze A, Ingwersen M, et al. Effects of Harpagophytum procumbens LI 174 (devil's claw) on sensory, motor und vascular muscle reagibility in the treatment of unspecific back pain. Schmerz. 2001;15:10-18.

Harvie P, Pollard TC, Carr AJ. Calcific tendinitis: natural history and association with endocrine disorders. J Shoulder Elbow Surg. 2007;16(2):169-173.

Kimmatkar N, Thawani V, Hingorani L, et al. Efficacy and tolerability of Boswellia serrata extract in treatment of osteoarthritis of knee -- a randomized double blind, placebo controlled trial. Phytomedicine. 2003;10:3-7.

Lathia AT, Jung SM, Chen LX. Efficacy of acupuncture as a treatment for chronic shoulder pain. J Altern Complement Med. 2009;15(6):613-618.

Rahman MH, Khan SZ, Ramiz MS. Effect of therapeutic ultrasound on calcific supraspinatus tendinitis. Mymensingh Med J. 2007;16(1):33-35.

Skjong C, Meininger A, Ho S. Tendiopathy Treatment: Where is the Evidence? Clin Sports Med. 2012;31(2):329-350.

Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med. 2009 Sep;37(9):1855-1867.

Zubler C, Mengiardi B, Schmid MR, Holder J, Jost B, Pfirrmann CW. MR arthrography in calcific tendinitis of the shoulder: diagnostic performance and pitfalls. Eur Radiol. 2007;17(6)1603-1610.