Tendinitis and Tendinopathy

What is Tendinitis and Tendinopathy?

Tendinopathy is a painful problem of a tendon, characterized by pain, loss of function and reduced exercise tolerance.^[1] The terms are often mixed up. Tendinitis means inflammatory changes in the tendon, tendinosis means degeneration from overuse, and tendinopathy is the umbrella term for both.^[2]

Common symptoms

Pain in the tendon that comes on with loading is the main symptom. The most common sites are the rotator cuff in the shoulder, the inner and outer elbow, the patellar tendon below the kneecap, the gluteal tendons at the hip and the Achilles tendon.^[1]

• Pain or tenderness during or after activity
• Stiffness, often worst first thing in the morning or after rest
• Swelling or thickening of the tendon
• Loss of strength and less tolerance for exercise^[1]

Causes and risk factors

Tendinopathy is thought to develop when micro-injuries occur faster than the tendon can repair them.^[2] Under the microscope, the tendon shows disorganized collagen fibers, extra small blood vessels and nerve endings, and changes in immune cells and inflammatory chemicals.^[1] Repetitive overload from sport or work is the usual trigger, and age and poor biomechanics add to the risk.^{[1, 2]}

How it is diagnosed and treated conventionally

Diagnosis rests mostly on your symptoms and a physical exam. Pain-provoking tests and imaging are used in some cases.^[1] Treatment centers on exercise and loading programs, with other options such as therapeutic modalities and surgery, though how well each works is still uncertain.^[1]

For tennis elbow, a meta-analysis of 30 trials found exercise better than passive treatments, though the effect was small and the certainty low.^[3] A meta-analysis of 27 trials found platelet-rich plasma injections gave better mid-term pain relief than corticosteroid injections in tendinopathy, with long-term results still unclear.^[4]

Why Tendinitis and Tendinopathy calls for a whole-person approach

Tendon pain rarely comes from a single cause. The load on the tendon, the tendon's own repair capacity, and how the nervous system processes pain all play a part.^[1]

Care that supports comfort and recovery while you rebuild tendon capacity through exercise is therefore a reasonable addition.

Load and overuse

Overload is the main driver. Because tendons repair slowly, more load than the tendon can recover from keeps the cycle of micro-injury going.^[2] Exercise is the backbone of rehabilitation.^[3]

Tendon structure and healing

Chronic tendon problems involve disorganized collagen and a failed healing response, not only inflammation.^{[1, 2]} This is why long-standing tendon pain often responds slowly.

Nerve ingrowth and pain sensitivity

Tendinopathic tendon shows increased small nerve fibers and blood vessels, which may help explain why it hurts with loading.^[1]

Inflammatory signaling

Inflammatory mediators and immune cells are increased in tendinopathy.^[1] Laboratory research suggests acupuncture may influence similar inflammatory pathways in pain, although this is mostly animal work.^[5]

Acupuncture for Tendinitis and Tendinopathy

What the research shows

The evidence is limited and mixed, and most of it concerns tennis elbow. A 2024 meta-analysis of 17 trials (979 people) found that dry needling, a related needling technique, improved short-term pain, function and grip strength in tennis elbow.^[6] A narrative review of needling for tendinopathy at several sites called the early evidence promising but noted very different techniques and a need for sham-controlled trials.^[7]

Results for acupuncture itself are mixed. A trial of 45 people with chronic tennis elbow found real acupuncture better than sham acupuncture for pain and arm function at two weeks. By two months the pain difference was no longer significant.^[8] An umbrella review of 40 meta-analyses, however, concluded that acupuncture was ineffective for tennis elbow, and a network meta-analysis found no treatment clearly better than placebo for short-term pain.^{[9, 10]}

Elsewhere, a trial of 64 people with chronic Achilles tendinopathy found acupuncture improved symptom scores more than eccentric exercise alone.^[11] A trial of 68 people with de Quervain tenosynovitis found less pain after two weeks of acupuncture than with waiting, though a waitlist group does not control for expectation.^[12] In another trial, electroacupuncture added to massage and injection therapy delayed relapse in tennis elbow.^[13]

How acupuncture may work

Researchers propose that acupuncture and electroacupuncture ease pain by activating the body's opioid and other signaling systems and by lowering inflammatory chemicals in tissue and the spinal cord.^{[5, 14]} Needling in tendon may also prompt a local healing response.^[7] These are proposed explanations drawn largely from laboratory work, not settled facts about tendon pain in people.

What treatment involves

Treatment uses fine, sterile, single-use needles placed near the painful tendon and at points elsewhere on the body, usually left in place for about 20 to 40 minutes. A course is several visits, and we reassess progress along the way. Trials have used from 5 to 10 sessions over several weeks.^{[8, 12]}

Serious problems are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, pain or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[15] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Tendinitis and Tendinopathy

The Ayurvedic view

Ayurveda does not have a single condition that matches tendinopathy. Tendon, ligament and joint pain is traditionally linked to aggravated Vata, with stiffness, dryness and pain on movement, and sometimes to Pitta when heat and inflammation are present. These are traditional categories, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine that favor warm, regular meals and steady rest
• Warm herbal oil massage and local heat near the affected tendon
• Herbs traditionally used for pain and inflammation, such as turmeric and Boswellia
• Local herbal preparations applied to the skin, including transdermal medication therapy

Panchakarma is not appropriate during pregnancy, acute illness or frailty, and heat or oil is not suitable on a fresh, swollen tendon injury until a clinician has assessed it.

What the research shows

No clinical trials of Ayurvedic treatment for tendinopathy were found in PubMed, so the evidence is none. The closest research concerns turmeric and Boswellia, which appear in studies of supplements for tendon problems; these are covered under herbal medicine below.^[16] Some Ayurvedic products also carry safety concerns. About one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[17] Any Ayurvedic herb should come from a tested source and be prescribed individually.

Herbal medicine for Tendinitis and Tendinopathy

Herbs and formulas that have been studied

Research on herbs in tendon disorders is mostly on nutritional supplements. A scoping review of 16 studies found compounds including collagen peptides, omega-3 fatty acids and a turmeric and Boswellia combination, along with several multi-ingredient blends.^[16] A systematic review of nutraceuticals for tendinopathy also considered curcumin and boswellic acid.^[18]

What the research shows

The evidence is limited and of low quality. The scoping review suggested some supplements may be useful alongside exercise, but noted a lack of studies. The systematic review of 46 articles found encouraging laboratory results that clinical studies had not fully confirmed, with poor methods, many products combining several ingredients, and no basis for firm recommendations.^{[16, 18]} No trials of Chinese herbal formulas for tendinopathy itself turned up in this search.

Safety and herb-drug interactions

Herbs can interact with medicines. Case reports describe bleeding when warfarin was combined with herbs including dang gui, dan shen, ginger, ginseng and Boswellia.^{[19, 20]} Interactions between supplements and drugs have not been well studied in tendon disorders.^[18] Tell us about all medicines you take, including blood thinners and anti-inflammatory painkillers.

Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, have liver or kidney disease, or have surgery planned.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine often describes tendon pain as stagnation of qi and blood in the channels around the joint, sometimes with cold or dampness. Researchers studying acupuncture look at features that loosely parallel this: local inflammatory signaling, nerve pathways that carry pain, and the body's own opioids.^{[5, 14]}

Ayurveda's aggravated Vata describes stiffness and pain on movement. Modern research describes tendon disorganization, nerve ingrowth and altered healing.^[1] No study has shown that a dosha or pattern of qi corresponds to a specific change in tendon tissue.

How this care fits with your medical care

Integrative care for tendon pain is complementary. Keep your physician, physical therapist or sports medicine specialist, and do not stop or change prescribed medicines, injections or your rehabilitation program without their advice. Exercise is a core part of treatment, although in tennis elbow the certainty of the evidence for it is low.^[3] We do not diagnose the cause of tendon pain, so new or worsening pain should be medically evaluated.

Please bring your diagnosis, imaging reports, your rehabilitation plan, a full list of medicines and supplements, and details of any recent injections or surgery.

When to seek urgent medical care

Some tendon symptoms point to a rupture or another serious problem rather than tendinopathy.^[2]

• A sudden pop or snap with immediate weakness or inability to use the limb
• A visible gap, bulge or deformity along the tendon
• A hot, red, swollen joint or tendon with fever
• Numbness, tingling or a cold, pale hand or foot
• Severe pain after a fall or injury
• Pain at night or at rest that keeps getting worse

If any of these occur, call 911 or go to the nearest emergency department.