Tendinopathy refers to tendon problems that are accompanied by pain or swelling. Tendons are the bands of fibrous connective tissue that attach your muscles to your bones. When you contract or relax a muscle, tendons transfer the force from the muscle to the bone to facilitate movement. Tendons are composed of bundles of collagen fibres arranged in a rope-like structure. The flexibility and strength of collagen makes tendons highly impact resistant.

Tendinopathy is common in the general population, and especially those partaking in sports and physical activity. Tendinopathies are usually caused by overuse or strain of the tendon, resulting in symptoms that include:

• pain or tenderness
• stiffness or difficulty moving the joint
• a grating sensation when moving the joint

The most common form of tendinopathy is tendinosis – a chronic injury that occurs gradually due to degeneration of the collagen fibres in the tendon. This damage gets repaired imperfectly, resulting in a build-up of scar tissue due to the disrupted tendon structure. On the other hand, tendinitis refers to acute tendon injuries that appear quickly, characterised by inflammation of the tendon.

It’s important to distinguish between chronic or acute tendinopathy, as this can affect the choice of treatment. Your doctor should be able to detect this using an ultrasound.

A multidisclipinary approach is considered the optimal approach for treatment, utilising physical therapies and pharmacological treatment.¹ Conservative treatment for acute or chronic tendinopathy, such as tendinosis, typically relies on rest, anti-inflammatory drugs, and physiotherapy.

Pharmacological treatment of tendinopathy, using oral non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroid injection, should be used with caution. Such treatment only provides temporary relief, doesn’t address the underlying cause of pain, and can have negative effects on the healing process. Corticosteroid injections in particular are problematic due to an increased risk of tendon rupture and the alteration of tendon structure.² Equally, oral NSAIDs are inappropriate for long term use due to the risk of adverse events such as gastrointestinal bleeding, kidney injury, heart attack and stroke.³

The most effective therapies are those that promote a regenerative response in the tendon. Physical therapies (including exercise and shockwave therapy) and hyaluronic acid treatment have all been shown to have beneficial effects. Exercise therapy — specifically, eccentric exercise with simultaneous lengthening and contraction of the muscle — is considered the gold standard for tendinopathy treatment, and is especially effective for managing Achilles and patellar (knee) tendinopathies.1 This form of exercise stimulates tendon remodelling^,4,5 reorganisation, and healing.⁶ Shock wave therapy, another form of physical therapy, has seen a rise in popularity for tendinopathy treatment in recent years. It has been shown to facilitate tendon remodelling by increasing new cell turnover⁷ and promoting processes that help to clear damaged tissue.⁸

Hyaluronic acid injection into or around the tendon is an effective complementary approach to physical therapy and can accelerate recovery. Hyaluronic acid injection has demonstrated anti-inflammatory activity in animal and cell models, along with positive effects on new cell turnover and collagen deposition.⁹ These processes are essential for the regeneration of healthy tissue.

• When combined with physical therapy, hyaluronic acid injection can accelerate recovery by 12 days, compared with physical therapy alone.¹⁰
• Hyaluronic acid injection is more effective and less painful than shockwave therapy.¹¹
• Hyaluronic acid injection is suitable for all tendinopathies but has been proven to be particularly effective for rotator cuff (shoulder) tendinopathy,¹⁰ Achilles tendinopathy,¹¹ and tennis elbow.¹¹

HA can be injected into or around the affected tendon, once a week, for a total of 1 to 3 injections. The treatment is most effective when the injection is guided by ultrasound, and should only be administered by a physician experienced and trained in peritendinous or intrasheath injection.

Hyaluronic acid injection is well-tolerated due to the structure of the molecule matching the naturally occurring hyaluronic acid that is produced by the human body. Tendinopathy treatment with hyaluronic acid has been demonstrated to be safe, with mild pain following injection reported as the most common side effect.¹⁰