Tendinitis

Also indexed as: Tendonitis

Tendinitis is a condition where a tendon or the connective tissue that surrounds the tendon becomes inflamed. This is often due to overuse (e.g., repetitive work activities), acute injury, or excessive exercise. People who are at higher risk of developing tendinitis include athletes, manual laborers, and computer keyboard users. Occasionally, tendinitis may be due to diseases that affect the whole body, such as rheumatoid arthritis or gout.

The most common sites of tendinitis are the shoulder, elbow, forearm, thumb, hip, hamstring muscles (in the back of the upper leg), and Achilles tendon (behind the ankle).1

Checklist for Tendinitis

Rating Nutritional Supplements Herbs
3Stars DMSO (topical)  
2Stars Bromelain
Proteolytic enzymes		  
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

What are the symptoms of tendinitis? People with tendinitis may have symptoms, which appear after injury or overuse, including swelling, redness, tenderness, and sharp pain in the affected area, which is worsened with movement or pressure.

How is it treated? Conventional treatment may include non-steroidal anti-inflammatory drugs (e.g., aspirin, ibuprofen, naproxen), salicylate analgesics, and local injections of steroids (e.g., dexamethasone, methylprednisolone, hydrocortisone), anesthetics (e.g., lidocaine), immobilization, and controlled physical therapy.

Lifestyle changes that may be helpful: Many people suffer from tendinitis as a result of their work environment. Studies have shown that tendinitis of the wrist, hands, and fingers are often caused by repetitive work and physical stress.2 3 4 Physical changes to the work environment, such as setting up the work station so that the body is in a balanced, untwisted position, minimizing the need to use excessive force, avoiding overuse of any one joint, changing positions frequently, and allowing for rest periods, have all been shown to diminish symptoms of lower arm tendinitis.5 One study of computer workers with arm and wrist tendinitis found that using an ergonomic keyboard versus a standard keyboard reduced the severity of pain and improved hand function after six months of use.6

Nutritional supplements that may be helpful: DMSO, or dimethyl sulfoxide, has a long history as a topical anti-inflammatory agent. One double-blind trial used a 10% DMSO gel topically on patients with tendinitis of the elbow and shoulder and found that it significantly reduced pain and inflammation in each joint.7 Other preliminary8 9 and double-blind10 11 trials found DMSO to be effective in treating tendinitis, but one double-blind trial found no difference between the effects of a 70% DMSO solution and a 5% DMSO placebo solution.12 Certain precautions must be taken when applying DMSO, and it should only be used under the guidance of a qualified healthcare professional.

Alternative healthcare practitioners frequently recommend proteolytic enzymes for various minor injuries. Research demonstrates that these enzymes are well absorbed when taken by mouth,13 14 and preliminary15 16 17 18 and double-blind19 20 21 22 trials have shown their effectiveness for reducing pain and swelling associated with various injuries and for speeding up the healing process. Unfortunately, many of these studies did not specifically identify the patients’ injury, so it is unclear whether the positive results included improvements in tendinitis.

Bromelain, a proteolytic enzyme, is an anti-inflammatory agent and for this reason is helpful in healing minor injuries, particularly sprains and strains, muscle injuries, and the pain, swelling, and tenderness that accompany sports injuries.23 24 25

Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions.

Other integrative approaches that may be helpful: Acupuncture may be helpful for treating tendinitis. A controlled trial compared acupuncture to sham (fake) acupuncture in people with shoulder tendinitis and found that acupuncture treatment produced significantly higher scores on a combined measurement of pain, ability to perform daily activities, ability to move shoulder without pain, and strength.26 This study also reported that the beneficial effects of acupuncture continued for at least three months following treatment. Another controlled study found traditional “deep” acupuncture more effective than superficial acupuncture for tennis elbow immediately after a series of ten treatments, but at 3 to 12 months’ follow up, both treatment groups had improved similarly.27 A third controlled study found no benefit from ten treatments of laser acupuncture for tennis elbow.28

Certain treatments used by physicians and other healthcare practitioners have been shown to be effective for tendinitis. In a controlled trial, patients with tendinitis of the shoulder received 24 treatments over six weeks of either ultrasound or a sham treatment.29 Ultrasound resulted in considerable improvement in pain level and overall quality of life, but many of the patients had their original symptoms return after nine months. The use of ultrasound for tennis elbow has not been validated, according to a systematic review of controlled studies.30 One controlled trial compared the effects of ultrasound alone to ultrasound plus a topical steroid medication (a process known as phonophoresis, where ultrasound is used to drive a substance into the skin).31 Both of these treatments were given three times per week for three weeks and both produced similar reductions in pain and tenderness.

Preliminary studies have suggested that daily use of TENS (transcutaneous electrical nerve stimulation) for one to two weeks reduces or eliminates pain in patients with tendinitis.32 33 Controlled studies are needed to confirm these findings.

References:

1. Berkow PK, Fletcher AJ, Beers MH (eds). The Merck Manual of diagnosis and therapy, 16th Ed. Rahway, NJ: Merck Research Laboratories, 1992;1367–8.

2. Latko WA. Armstrong TJ, Franzblau A, et al. Cross-sectional study of the relationship between repetitive work and the prevalence of upper limb musculoskeletal disorders. Am J Ind Med 1999;36:248–59.

3. Piligian G, Herbert R, Hearns M, et al. Evaluation and management of chronic work-related musculoskeletal disorders of the distal upper extremity. Am J Ind Med 2000;37:75–93.

4. Stock SR. Workplace ergonomic factors and the development of musculoskeletal disorders of the neck and upper limbs: a meta-analysis. Am J Ind Med 1991;19:87–107.

5. Piligian G, Herbert R, Hearns M, et al. Evaluation and management of chronic work-related musculoskeletal disorders of the distal upper extremity. Am J Ind Med, 2000;37:75–93.

6. Tittiranonda P, Rempel D, Armstrong T, Burastero S. Effect of four computer keyboards in computer users with upper extremity musculoskeletal disorders. Am J Ind Med 1999;35:647–61.

7. Kneer W, Kuhnau S, Bias P, et al. Dimethylsulfoxide (DMSO) gel in treatment of acute tendopathies. A multicenter, placebo-controlled, randomized study. Fortschritte Med 1994;112:142–6 [in German].

8. Lockie LM, Norcross BM. A clinical study on the effects of dimethyl sulfoxide in 103 patients with acute and chronic musculoskeletal injuries and inflammations. Ann N Y Acad Sci 1967;141:599–602.

9. Steinberg A. The employment of dimethyl sulfoxide as an antiinflammatory agent and steroid-transporter in diversified clinical diseases. Ann N Y Acad Sci 1967;141:532–50.

10. Brown JH, Wood DC, Jacob SW. Current status of dimethyl sulfoxide (DMSO). A double blind evaluation of its therapeutic value in acute strains, sprains, bursitis and tendonitis. Bull Soc Int Chir 1972;31:561–6.

11. Brown JH. A double blind study-DMSO for acute injuries and inflammations compared to accepted standard therapy. Curr Ther Res Clin Exp 1971;13:536–40.

12. Percy EC, Carson JD. The use of DMSO in tennis elbow and rotator cuff tendonitis: a double-blind study. Med Sci Sports Exerc 1981;13:215–9.

13. Miller JM. The absorption of proteolytic enzymes from the gastrointestinal tract. Clin Med 1968;75:35–42 [review].

14. Castell JV, Friedrich G, Kuhn CS, et al. Intestinal absorption of undegraded proteins in men: presence of bromelain in plasma after oral intake. Am J Physiol 1997;273:G139–46.

15. Cirelli MG. Five years’ experience with bromelains in therapy of edema and inflammation in postoperative tissue reaction, skin infections and trauma. Clin Med 1967;74:55–9.

16. Trickett P. Proteolytic enzymes in treatment of athletic injuries. Appl Ther 1964;6:647–52.

17. Sweeny FJ. Treatment of athletic injuries with an oral proteolytic enzyme. Med Times 1963:91:765.

18. Boyne PS, Medhurst H. Oral anti-inflammatory enzyme therapy in injuries in professional footballers. Practitioner 1967;198:543–6.

19. Deitrick RE. Oral proteolytic enzymes in the treatment of athletic injuries: A double-blind study. Pennsylvania Med J 1965;Oct:35–7.

20. Holt HT. Carica papaya as ancillary therapy for athletic injuries. Curr Ther Res 1969;11:621–4.

21. Rathgeber WF. The use of proteolytic enzymes (Chymoral) in sporting injuries. S Afr Med J 1971;45:181–3.

22. Buck JE, Phillips N. Trial of Chymoral in professional footballers. Br J Clin Pract 1970;24:375–7.

23. Seligman B. Bromelain: an anti-inflammatory agent. Angiology 1962;13:508–10.

24. Cirelli MG. Treatment of inflammation and edema with bromelain. Delaware Med J 1962;34:159–67.

25. Masson M. Bromelain in the treatment of blunt injuries to the musculoskeletal system. A case observation study by an orthopedic surgeon in private practice. Fortschr Med 1995;113:303–6.

26. Kleinhenz J, Streitberger K, Windeler J, et al. Randomised clinical trial comparing the effects of acupuncture and a newly designed placebo needle in rotator cuff tendinitis. Pain 1999;83:235–41.

27. Haker E, Lundeberg T. Acupuncture treatment in epicondylalgia: a comparative study of two acupuncture techniques. Clin J Pain 1990;6:221–6.

28. Haker E, Lundeberg T. Laser treatment applied to acupuncture points in lateral humeral epicondylalgia. A double-blind study. Pain 1990;43:243–7.

29. Ebenbichler GR, Erdogmus CB, Resch KL, et al. Ultrasound therapy for calcific tendonitis of the shoulder. N Engl J Med 1999;340:1533–8.

30. van der Windt DA, van der Heijden GJ, van den Berg SG, et al. Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain 1999;81:257–71.

31. Klaiman MD, Shrader JA, Danoff JV, et al. Phonophoresis versus ultrasound in the treatment of common musculoskeletal conditions. Med Sci Sports Exerc 1998;30:1349–55.

32. Kaada B. Treatment of peritendinitis calcarea of the shoulder by transcutaneous nerve stimulation. Acupunct Electrother Res 1984;9:115–25.

33. Saveriano G, Lionetti P, Maiolo F, Battisti E. Our experience in the use of a new objective pain measuring system in rheumarthropatic subjects treated with transcutaneous electroanalgesia and ultrasound. Minerva Med 1986;77:745–52 [in Italian].