By Dr. Robert Engelen | Utah Tendon Institute | Salt Lake City, Utah
If you've been dealing with a stubborn tendon — an Achilles that won't settle down, a patellar tendon that flares every time you try to get back to training, a rotator cuff that's been "almost better" for six months — you've probably already had a cortisone shot. Maybe two.
And maybe they helped. For a little while.
Here's what I want to talk about: why that short-term relief often comes at a real cost, and what a more complete approach to tendinopathy actually looks like.
What's Actually Happening in a Painful Tendon
Most people assume tendon pain means inflammation. It's a reasonable assumption — that's what we've been told for decades. But the research has shifted significantly. What we now understand is that chronic tendinopathy is largely a degenerative process, not an inflammatory one.
Under a microscope, a chronically painful tendon doesn't look inflamed. It looks disorganized — the collagen fibers are disrupted, there's ingrowth of abnormal blood vessels and nerves, and the tendon's normal architecture has broken down. This is called tendinosis, and it explains why anti-inflammatory treatments like cortisone often don't provide lasting relief. You can't fix a structural problem with a drug that targets inflammation that isn't really there.
The Problem With Repeated Steroid Injections
I'm not saying cortisone is never appropriate. For acute bursitis or true inflammatory conditions, it has a place. But for chronic tendinopathy, repeated steroid injections are a problem for several reasons:
They weaken the tendon. Corticosteroids inhibit collagen synthesis — the very process your tendon needs to repair itself. Multiple injections over time can accelerate the degenerative changes that are already present and increase the risk of tendon rupture.
The relief is temporary. Most patients feel better for four to eight weeks. Then the pain returns, often at the same level or worse. The underlying structural problem hasn't changed.
They don't address the root cause. Steroids suppress symptoms. They don't stimulate healing, restore collagen architecture, or address the mechanical and biological reasons the tendon broke down in the first place.
After the second or third cortisone shot with no lasting improvement, it's time to think differently.
A Better Framework: Stimulate Healing, Don't Just Suppress Pain
The approach I use combines three evidence-supported treatments, each targeting a different aspect of tendon pathology. Used together — in the right sequence, for the right patient — they work far better than any single injection ever could.
Shockwave Therapy (SWT)
Shockwave therapy uses high-energy acoustic waves delivered to the tendon through the skin. It sounds aggressive, but it's non-invasive and well-tolerated by most patients.
What it does: shockwave disrupts the calcific deposits and abnormal nerve ingrowth that contribute to chronic pain, while simultaneously stimulating cellular activity and growth factor release. It essentially "wakes up" a tendon that has become metabolically quiet — no longer trying to heal itself.
The evidence for shockwave in calcific rotator cuff tendinopathy, Achilles tendinopathy, and patellar tendinopathy is among the strongest we have for any regenerative procedure. For many patients it's the right first step — improving tissue biology before we do anything more targeted.
Needle Tenotomy (Percutaneous Tendon Fenestration)
This procedure sounds intimidating but is simpler than it sounds. Using ultrasound guidance, I use a needle to create multiple small perforations through the diseased portion of the tendon.
The goal is deliberately controlled microtrauma. By disrupting the disorganized, degenerated tissue, we trigger the tendon's healing cascade — bringing in the growth factors, platelets, and collagen-producing cells that the tendon stopped recruiting on its own. It essentially resets the tendon's biology from "chronic" to "acute healing."
Tenotomy is particularly effective for mid-tendon pathology — the area of degeneration that doesn't respond to conservative treatment and doesn't resolve on its own.
Platelet-Rich Plasma (PRP)
PRP is made from your own blood. We draw a small sample, concentrate the platelets through centrifugation, and inject the resulting solution directly into the tendon under ultrasound guidance.
Platelets are the body's first responders to tissue injury. They release a cocktail of growth factors — PDGF, TGF-β, VEGF, IGF-1 — that directly stimulate tendon cell proliferation and collagen production. When we inject PRP into a tendon, we're flooding a damaged area with the biological signals it needs to start rebuilding.
PRP pairs especially well with tenotomy. The needling creates the healing environment; the PRP supplies the biological fuel. Combined, they address both the structural disruption of the tendon and the biological deficit that's been preventing recovery.
How I Sequence These Treatments
Every patient is different, and the protocol gets tailored based on imaging, symptom duration, activity demands, and what's already been tried. But as a general framework:
- Shockwave first — improve tissue biology, address calcification and nerve ingrowth, reduce pain enough to load the tendon
- Structured loading — progressive tendon loading exercises are non-negotiable; no injection replaces this
- Tenotomy + PRP — for patients with clear tendinosis on ultrasound who haven't reached full resolution, this is the targeted intervention
- Continued rehabilitation — the injection starts the healing process; rehab is what finishes it
This isn't a one-and-done approach. It's a program. And that's exactly why it works where isolated cortisone shots don't — because we're treating the tendon's biology, not just its symptoms.
Who Is This For?
If you've had tendon pain for more than three months, tried physical therapy, and still aren't back to full activity — this is worth a serious conversation. Especially if you've already had one or more steroid injections without lasting improvement.
The patients who do best are the ones who commit to the full process: the procedures, the loading program, and the timeline. Tendons heal slowly. But they do heal — when given the right biological environment to do it.
If you're in Salt Lake City or anywhere in Utah and want to talk through what's going on with your tendon, I offer discovery calls for exactly this purpose. No obligation — just an honest conversation about whether this approach makes sense for you.
Request a Discovery Call → or call 385-419-0692
Also treating knee and joint conditions at Engelen Sports & Orthobiologics →
Dr. Robert Engelen is a sports medicine physician and tendinopathy specialist at Utah Tendon Institute in Salt Lake City, Utah.