Tendinopathy Without Cortisone: What Are the Alternatives?

Reducing pain is not the same biological process as rebuilding tendon tissue.

This distinction becomes particularly important when we look at what glucocorticoids do to tendon cells and collagen.

It is sometimes said that cortisone “dries out” a tendon.

That is not the correct scientific description.

The actual experimental findings are more specific and more useful.

A systematic review examining 50 studies of locally administered glucocorticoids found:

• reduced tendon-cell viability

• reduced tendon-cell proliferation

• reduced collagen synthesis

• increased collagen disorganisation

• increased collagen necrosis in experimental studies

• an overall significant deterioration in tendon mechanical properties

Collagen is fundamental to the strength and organisation of tendon tissue.

These biological effects point in the opposite direction from what we want when the objective is to rebuild a strong, load-tolerant tendon.

This does not mean that every cortisone injection inevitably causes clinically significant tendon damage or rupture.

It does mean that the rapid disappearance of pain should not be interpreted as evidence that the tendon itself has regenerated.

When corticosteroid exposure is repeated around a tendon, these tissue effects deserve particular consideration.

A randomized trial in patellar tendinopathy compared corticosteroid injections with eccentric exercise and heavy slow resistance training.

During the first 12 weeks, all three groups improved.

If the study had stopped there, corticosteroid treatment could have appeared successful.

But the six-month follow-up changed the picture.

The improvements achieved through eccentric exercise and heavy slow resistance were maintained.

The corticosteroid group deteriorated again.

Heavy slow resistance was also associated with increased collagen turnover.

This is an important distinction.

Cortisone reduced symptoms initially.

Progressive loading was directed towards rebuilding the capacity of the tendon, and its benefits persisted.

A randomized trial involving 204 people with gluteal tendinopathy compared education plus exercise, corticosteroid injection and a wait-and-see approach.

At eight weeks, both active treatments helped.

But education plus exercise produced better global improvement than corticosteroid injection.

At 52 weeks, education plus exercise again produced better global improvement than corticosteroid injection.

The study reinforces a recurring theme in tendinopathy care:

the fastest route to pain relief is not necessarily the best route to longer-term recovery.

Lateral elbow tendinopathy provides some of the clearest randomized evidence of the problem with relying on corticosteroid injections.

The early response can be excellent.

Patients feel better and naturally assume the problem has been solved.

But high recurrence and poorer longer-term results have repeatedly been observed.

A tendon that no longer hurts is not automatically a tendon that has regained its strength and load tolerance.

Returning rapidly to normal activity after symptom suppression can therefore create a false sense of recovery.

No.

The evidence is not identical for every tendon, and treatment should be based on the actual diagnosis rather than a blanket rule.

An important 2022 randomized trial studied 100 patients with chronic midportion Achilles tendinopathy.

Patients received the same exercise programme, combined either with ultrasound-guided corticosteroid injection or placebo injection.

The corticosteroid plus exercise group improved more, and no long-term deterioration was observed during two years of follow-up.

This result matters.

It shows that tendon site, diagnosis, injection technique and the treatment accompanying the injection can influence the outcome.

Importantly, this was not cortisone instead of rehabilitation. Corticosteroid was combined with an exercise programme.

The study does not erase the poorer longer-term results seen in other tendinopathies. It shows why every tendon should not be treated as though it were the same condition.

The question is therefore not simply whether cortisone is “good” or “bad”.

The better questions are:

Which tendon is affected?

What exactly is the diagnosis?

How long have the symptoms been present?

What treatment has already been tried?

And are we aiming primarily for temporary symptom suppression or longer-term recovery?

For someone looking beyond temporary pain suppression, the treatment question changes.

Instead of asking how quickly we can switch off the symptoms, we ask what the tendon needs to recover, rebuild capacity and tolerate load again.

Depending on the tendon and the individual situation, treatment can include:

• modification of the load provoking the symptoms

• progressive tendon-loading exercise

• rebuilding muscle strength and movement capacity

• addressing relevant training or biomechanical factors

• improving recovery between repeated loads

• shockwave therapy in certain tendinopathies

• selected local or percutaneous treatments

• percutaneous hydrotomy at Centre Algos when clinically appropriate

• further imaging or specialist assessment when the diagnosis is uncertain or significant structural injury is suspected

The objective is not permanent rest.

A tendon needs load to maintain and rebuild its capacity.

The challenge is finding the right load, at the right intensity, with the right progression.

Exercise is one of the best-supported components of tendinopathy rehabilitation.

A 2023 systematic review and meta-analysis included 110 studies and 3’953 participants across Achilles, rotator cuff, lateral elbow, patellar and gluteal tendinopathies. Resistance-based exercise consistently forms an important part of modern tendon rehabilitation.

For midportion Achilles tendinopathy, the 2024 clinical practice guideline gives tendon-loading exercise a Grade A recommendation as first-line treatment.

Rehabilitation is no longer limited to eccentric exercises.

Depending on the tendon and individual situation, it can include isometric exercise, eccentric and concentric loading, heavy slow resistance and later sport-specific or activity-specific loading.

The central principle is simple:

the tendon must progressively be exposed to the forces it eventually needs to tolerate.

Too little loading can leave it underprepared.

Too much loading too quickly can repeatedly provoke symptoms.

Good rehabilitation progressively closes the gap between what the tendon can currently tolerate and what everyday life, work or sport requires from it.

This is where percutaneous hydrotomy becomes particularly interesting.

At Centre Algos, it is an important treatment option for persistent and recurrent tendon problems.

Its therapeutic objective is fundamentally different from that of a corticosteroid injection.

Rather than using cortisone to suppress pain and inflammatory signalling, we use targeted local injections as part of a strategy directed towards the affected tissue and longer-term recovery.

The technique involves small, targeted injections through the skin around the area being treated. The precise treatment protocol depends on the tendon, clinical findings and individual treatment plan.

In clinical practice, patients with persistent tendon and musculoskeletal problems treated with percutaneous hydrotomy experience improvements in pain, mobility and function, including when previous treatments have failed to produce lasting improvement.

Percutaneous hydrotomy does not necessarily mean waiting weeks or months for an effect. In clinical practice at Centre Algos, many patients notice a clear reduction in pain after the first treatment, with further substantial improvement often occurring over the first one or two sessions. The response varies between patients and according to the tendon, the duration of the problem and the individual clinical situation.

The difference from cortisone is therefore not simply ‘fast versus slow’. Both treatments can produce relatively rapid pain relief. The difference lies primarily in the therapeutic strategy: corticosteroids suppress pain and inflammatory signalling, whereas percutaneous hydrotomy is used as a local treatment directed towards the affected tissue and longer-term recovery.

This makes hydrotomy particularly interesting when the objective is not another brief period with less pain, but a treatment strategy focused on longer-term improvement.

Percutaneous hydrotomy and rehabilitation are not competing approaches.

They can work together.

The local treatment is directed towards the painful tissue environment, while progressive loading rebuilds the functional capacity the tendon needs for daily activity, work or sport.

The formal controlled evidence base specifically for percutaneous hydrotomy is currently smaller than that for exercise-based tendon rehabilitation. Clinical experience with the technique, including its use in persistent tendon disorders, is therefore an important part of how its therapeutic role is currently understood.

If a corticosteroid injection has recently been performed in the area concerned, percutaneous hydrotomy is not started immediately afterwards. An appropriate interval is respected before treatment. A previous cortisone injection does not, however, prevent percutaneous hydrotomy from being considered later.

:::compare title="Cortisone, rehabilitation and percutaneous hydrotomy: what is the difference?"

• Primary objective: rapid suppression of pain and inflammatory signalling.
• Early effect: can be strong and rapid.
• Long-term perspective: in several tendinopathies, higher recurrence, deterioration after initial improvement or poorer longer-term results have been documented.
• Tendon biology: experimental evidence shows adverse effects on tendon cells, collagen synthesis, collagen organisation and mechanical properties.

• Primary objective: rebuild tendon strength, capacity and tolerance to load.
• Early effect: improvement is generally progressive rather than immediate.
• Long-term perspective: a foundation of longer-term tendinopathy management.
• Tendon biology: progressive loading supports tendon adaptation and functional capacity.

• Primary objective: targeted local treatment of the affected tissue environment as part of a longer-term recovery strategy.
• Early effect: often noticeable from the first treatment, with further improvement frequently occurring over the first sessions.
• Long-term perspective: used at Centre Algos for persistent and recurrent tendon problems with the objective of sustained improvement in pain, mobility and function.
• Therapeutic principle: does not rely on corticosteroid as its therapeutic mechanism and can be combined with progressive rehabilitation. :::

Persistent tendon pain deserves reassessment when:

• symptoms continue despite an appropriate rehabilitation programme

• pain repeatedly returns when activity increases

• there is significant weakness or loss of function

• symptoms started with a sudden injury or tearing sensation

• the tendon appears markedly swollen or structurally abnormal

• the diagnosis remains uncertain

• symptoms do not behave like a typical tendinopathy

• an inflammatory, metabolic or medication-related factor may be contributing

A sudden loss of strength, a snap or pop followed by major functional loss, or suspected tendon rupture requires prompt medical assessment.

We do not assume that every painful tendon needs the same treatment.

We look at where the pain is located, how it began, which movements provoke it, how long it has persisted, the loads placed on the tendon and which treatments have already been tried.

Previous imaging and medical reports are reviewed when relevant.

We then determine whether the problem is primarily related to load and rehabilitation, whether further assessment is needed and whether a local treatment such as percutaneous hydrotomy could add value.

The aim is not simply to make the tendon hurt less for a few weeks.

We want to create a treatment strategy that gives the tendon the best possible conditions for longer-term recovery and function.

Cortisone can be highly effective at making a painful tendon feel better quickly.

That is its principal attraction.

But for several common tendinopathies, its longer-term record is considerably less attractive.

Randomized studies show recurrence, deterioration after the initial response and poorer longer-term outcomes in several tendon conditions. Experimental research also raises important biological concerns about the effects of local glucocorticoids on tendon cells, collagen and mechanical properties.

A short period without pain is therefore not the same thing as tendon recovery.

Progressive rehabilitation aims to rebuild what the tendon actually needs: strength, capacity and tolerance to load.

For persistent and recurrent tendon problems, percutaneous hydrotomy gives us an additional local treatment strategy at Centre Algos. Rather than relying on corticosteroid-based symptom suppression, it forms part of an approach focused on the affected tissue and longer-term improvement in pain, mobility and function.

For many patients, the more useful question is therefore not:

“How can we switch off this pain today?”

but:

“What does this tendon need to recover and stay resilient over the long term?”

Can tendinopathy heal without cortisone?

Yes. Corticosteroid injections are not required for most tendinopathy rehabilitation programmes. Progressive loading, load management and other targeted treatments can be used depending on the tendon and individual situation.

Does cortisone heal a tendon?

Cortisone can rapidly reduce pain and inflammatory signalling. This is not the same as rebuilding tendon structure or load capacity. Experimental research has also identified adverse effects of local glucocorticoids on tendon cells, collagen synthesis and mechanical properties.

Can a cortisone injection weaken a tendon?

Experimental studies have found reduced tendon-cell viability and proliferation, reduced collagen synthesis, collagen disorganisation and deterioration of mechanical properties after glucocorticoid exposure. The clinical effect depends on the circumstances, but these findings are important when considering repeated injections around tendons.

Why can pain return after a cortisone injection?

Pain can disappear before the tendon has rebuilt its capacity. If normal or high loading resumes while the underlying load problem remains, symptoms can return. High recurrence has been documented after corticosteroid injection in some tendinopathies.

Are cortisone injections bad for all tendons?

No. Outcomes vary between tendons and treatment contexts. A 2022 Achilles trial, for example, found benefit when ultrasound-guided corticosteroid injection was combined with exercise. Treatment should therefore be based on the specific diagnosis.

What is the best alternative to cortisone for tendinopathy?

There is no single alternative for every tendon. Progressive loading is one of the foundations of treatment. Depending on the diagnosis, options can also include shockwave therapy, selected local treatments and percutaneous hydrotomy.

Is exercise enough for chronic tendinopathy?

Exercise is central, but persistent cases sometimes require broader assessment and additional treatment. Diagnosis, load, biomechanics, previous treatment and possible structural or medical contributors should be considered.

What is heavy slow resistance training?

It is progressive strength training using relatively heavy resistance and controlled movement. It is one method of progressively increasing tendon and muscle capacity and has been studied in conditions including patellar tendinopathy.

Can percutaneous hydrotomy be used for tendinopathy?

Yes. At Centre Algos, percutaneous hydrotomy is used for persistent and recurrent tendon problems when clinically appropriate. It can be combined with progressive rehabilitation as part of a longer-term treatment strategy.

Is percutaneous hydrotomy the same as a cortisone injection?

No. Their therapeutic principles differ. Corticosteroid injections primarily suppress inflammatory signalling and pain. Percutaneous hydrotomy is used as targeted local treatment around the affected tissue and does not rely on corticosteroid as its therapeutic mechanism.

Can tendinopathy be treated without surgery?

Yes. Most tendinopathies are initially managed without surgery. Rehabilitation and other conservative or minimally invasive treatments are generally considered before surgery unless there is a major structural injury or another specific surgical indication.

When should I have an MRI or ultrasound for tendon pain?

Imaging can be useful when the diagnosis is unclear, symptoms persist despite treatment, significant structural injury is suspected or the result would change management. Imaging findings should be interpreted together with the clinical picture.

• Coombes BK, 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
• Dean BJF, et al. The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Semin Arthritis Rheum. 2014
• Smidt N, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002
• Coombes BK, et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia. JAMA. 2013
• Kongsgaard M, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009
• Mellor R, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy. BMJ. 2018
• Johannsen F, et al. Effect of ultrasonography-guided corticosteroid injection vs placebo added to exercise therapy for Achilles tendinopathy: a randomized clinical trial. JAMA Netw Open. 2022
• Pavlova AV, et al. Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis. Br J Sports Med. 2023
• Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2024. Clinical Practice Guideline. J Orthop Sports Phys Ther. 2024

• Tendinopathy
• Percutaneous Hydrotomy
• Percutaneous Hydrotomy in Practice
• Tendinopathy: Why Tendon Pain Persists
• Sports Injuries