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Injections for Tendons: What’s good, and what’s not?

Tendon pain is one of the most frustrating conditions to treat: it is persistent, pervasive and sometimes seems unresponsive to any treatment. While the best treatment for tendinopathy is not to get it in the first place (through regular, consistent loading rather than ‘weekend warrior’ activities), once established it is a common reason to present for treatment.

Many years of good research has shown that exercise is the best treatment for most tendon pain.1 Some tendons however do not respond to this approach, or are too painful to start exercising. Surgery is a last resort unless a tendon is completely torn. That leaves a lot of tendons stuck in the middle.

This was the focus of a recent seminar titled “Injection Therapy in Tendinopathy: Art and Science.”

The traditional approach to these tendons is to get an injection of steroid (“cortisone”) into the tendon. This generally makes a tendon feel better for a short period of time, but studies have consistently shown that this doesn’t improve tendon pain or function compared to placebo at 6, 12 or 24 months.2 A recent study of plantar fasciitis followed over 15 years in fact showed that those injected with cortisone actually do worse.3

Injection of whole blood, or of blood fractions produced in the rooms (Platelet Rich Plasma/PRP, or autologous conditioned serum/ACS) have become commonly used in the last 10 years. The effectiveness of these treatments is still unclear, with some studies showing clear benefits compared to steroid injections, and some finding no difference. 4,5
That has been our experience over many years- blood injections are sometimes just the thing to get a tendon responding to a rehabilitation program.

What seems clear is that any injection therapy needs to be performed under appropriate imaging guidance. Steroid around a tendon is sometimes very effective, but steroid INTO a tendon probably damages it further. A blood or PRP injection into a tendon might work, but only if it is actually in the damaged part of the tendon. Having used ultrasound guidance in the rooms for several years now, it has become just part of our assessment and treatment program.

It is also apparent that any tendon injection needs to be followed up with the appropriate exercise program for the tendon. That will vary from person to person, and from tendon to tendon. While our treatment options have expanded, optimal treatment for tendons is still a blend of the science and the art.

1. Rio E, Kidgell D, Purdam C et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med 2015; 49:1277-1283
2. Coombes B, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010; 376:1751-1767
3. Hansen L, Krogh T, Ellingsen T et al. Long-term prognosis of plantar fasciitis: A 5- to 15-year follow-up study of 174 patients with ultrasound examination. Ortho J Sports Med 2018; 6(3): 1-9
4. Fitzpatrick J, Bulsara MK, O’Donnell J, Zheng MH. Leucocyte-rich platelet-rich plasma treatment of gluteus medius and minimus tendinopathy: A double-blind, randomized controlled trial with 2-year follow-up. Am J Sports Med 2019; 47(5): 1130-1137
5. Scott A, LaPrade RF, Harmon KG et al. Platelet-rich plasma for patellar tendinopathy: A randomized controlled trial of leukocyte-rich PRP or leukocyte-poor PRP vs saline. Am J Sports Med 2019: doi: 10.1177/0363546519837954