Ok. So first of all, what is tendinopathy?

Tendinopathy is basically the term given to tendons that have been persistently painful and have a loss of function relating to loading (Alex et al, 2020). The terms tendonitis or tendinosis are other words that you may have heard, which essentially are just other names for the same thing. The general consensus is to use the word tendinopathy these days, but don’t freak out if you hear one of the other ones; they all mean essentially the same thing and the word teninopathy covers all bases. Large tendon tears are something different that I wont be covering in this blog post. 

What does a tendinopathy typically feel like?

Tendinopathies tend to have a set of clear clinical symptoms:

• They hurt when you use them
• They often warm up with use and then feel better
• They feel worse upon waking the next morning
• They feel stiff and/or sore when you have been still for a period of time and then move the affected area

Anyone presenting with these symptoms in an area where there is a tendon will make a clinician immediately suspect a tendinopathy.  

Common areas that get tendinopathy are:

• High hamstring tendon (high up at the top of the thigh, in the buttock)
• Achilles tendon (behind the heel)
• Plantar fascia (a fascia that acts like a tendon, underneath your foot, felt in the heel)
• Wrist extensors (outside of the elbow) 
• Patellar tendon (front of the knee)
• Rotator cuff tendons (shoulder. These tend to act a bit differently to other tendons and as such arent the focus of this blog post). 
• Gluteal tendons (outside of the hip)

Why does tendinopathy happen?

As with most things in the human body, there is some debate as to the exact mechanism that causes a tendinopathy. The general concept is as follows. Our tendons are designed to adapt to load. If we use a tendon more than normal, theoretically, the tendon should adapt to that load and become a bit stronger. With a tendinopathy, however, this process is disrupted. This could be because we load the tendon again too soon before the recovery has occurred, or it could be because the amount of load was simply too great for the tendon to adapt to. Instead of getting stronger, the tendon actually gets weaker (Cook et al., 2016). The tendon can become very thick when it is unhealthy and can have vascular cells and adipose tissue (i.e. fat cells and cells designed for circulation) deposited in the tendon where they are not supposed to be. 

Tendons usually take about 48-72 hours to adapt to something new, though this may be more or less depending on particular circumstances (Magnussen et al., 2010). Certain factors about a person may make a tendon less likely to adapt as well. For example, as we get older, our tendons are less adaptable. Certain health conditions can make tendons less easily adaptable. Our history of how we have used the tendon will have an impact on how it responds to new loads. Someone who plays sport is likely to find it easy to adapt to a new activity compared to someone who is sedentary, for example. 

Tendons tend to be happiest doing a similar amount of work to what they have been doing recently. So for example, say you have gradually worked your way up to being able to run 10kms. If you then have 6 weeks off running, and try to run 10km again, while you may still be capable of doing it, your soft tissues are no longer as adapted to be able to manage. Your tendons and soft tissues are adapted to what you have been doing for about the last 4 weeks.  

(I am basing this from a Peter Malliaris blog written in 2016 that discusses the research that looks at how long it takes for a tendon to return to baseline after a period of de-training, as well as considering how long it may take one to start to lose strength after ceasing strength training which is often said to be starting from about 3 weeks. Reference: https://www.tendinopathyrehab.com/blog/tendinopathy-updates/the-effect-of-detraining-on-tendons-and-how-to-prevent-it-causing-tendon-pain-in-your-patients)

Do I need a scan to diagnose my tendinopathy?

No. Scans are generally not indicated for tendinopathy (sometimes they may be). A diagnosis can be made with symptoms alone. Research has generally found that findings on scans correlate poorly to symptoms, which means that someone with a very bad looking tendinopathy can have much fewer symptoms than someone with a very minor looking tendinopathy. This fact alone makes the role of imaging questionable, especially as it can elicit fear due to the scary sounding language in the scans. 

How can I reduce my risk of developing tendinopathy?

My favourite way to consider this question is with the concept of capacity (Cook & Docking, 2015). As I just outlined, your tendons are happy doing things they are familiar with. If you exceed their current capacity, you are more at risk of having an issue. Building a high degree of capacity may reduce your risk of tendon injury, as it means you need to do a lot to send a tendon ‘over the edge’. Keeping active helps to keep your tendons strong and ready for whatever you throw at them. 

For upper body tendons this means doing strength and resistance training a few times a week. The same is true for your lower body tendons, though it makes sense to also include some jumping movements for the lower body, as tendons are particularly sensitive to energy store and release (i.e. explosive movements like running or jumping), which you are more likely to do with the lower body.

If I have a tendinopathy, what should I do to manage it? 

The mainstay of tendinopathy treatment is load management. This is because tendinopathy is generally a load problem. That is, a tendon was loaded more than it could handle. In my opinion there is no real treatment outside of this that makes much sense, as none of the other treatments address the root cause (loading) (Cook et al., 2016). (Bear in mind this is a huge over simplification of tendinopathy as there is a lot more to it and still a lot of mystery surrounding the condition.) 

Treatment involves, firstly, offloading the tendon just enough to enable some healing to occur. This means offloading it ONLY AS MUCH as required, and no more. This can require some close monitoring of symptoms to figure out what activities in particular make symptoms noticeably worse. Paying attention to the 24 hour pattern of symptoms is necessary, as tendons tend to hurt more the next morning if they have been overloaded. So this may mean allowing someone to exercise with a degree of tendon pain, provided it does not feel worse the next day.  

Tendinopathies are sensitive to two types of load: compressive load and tensile load, and a combination of both can be the most difficult for them (Lauren et al., 2022). So they are sensitive to being squashed (compressed) as well as being loaded directly (which will cause a tensile load from the muscle pulling on it). This is important to consider, as people often only think of load from use, not load from compression. Note that in certain tendon locations, loading can also cause a degree of compression against the bone the tendon is near… which is probably why some tendons seem to develop these issues more than others! 

A list of common tendinopathies & what positions may cause them to be compressed:

• High hamstring tendinopathy: compressed in hip flexion with a straight knee e.g. bending forward at the hips. Compressed with sitting, particularly hard chairs. Compressed with hamstring stretches. 
• Achilles tendinopathy: compressed with calf stretches and sitting/standing with calves on stretch (e.g. sitting with a flat foot and foot pulled underneath chair, standing with weight shifted forwards). 
• Plantar fasciiopathy: compressed with high arch support, rolling on golf balls. 
• Wrist extensor tendinopathy: compressed when wrist is bent downwards.
• Patellar tendinopathy: compressed when knee is bent backwards. 
• Rotator cuff tendoniopathy: compressed to lie on. 
• Gluteal tendinopathy: compressed to lie on, compressed when sitting with legs crossed. 

As tendons do not like compression or tensile load, it is often best to avoid stretching them, foam rolling them, or pressing hard on them.

The next component of tendinopathy management is to strengthen them. A tendon that has a tendinopathy is often less able to handle load itself, and if it has been chronic, the muscle attached to the tendon often also becomes weaker. It is not uncommon to see muscle wasting in the muscle adjacent to a long standing painful tendon. It is important to perform exercises that are actually hard for the muscle and tendon. Research indicates that the exercise must be harder than 40% of a muscle’s maximum contractibility (you need to be working greater than 40% of your maximum force output) to actually create any changes at a muscular or tendinous level. The exercise you select ideally should be one that does not cause too much compression at the tendon, especially in the earlier stages. While it is ok for the chosen exercise to be a bit uncomfortable, it should not make symptoms worse 24 hours later.  

There is an argument for allowing a degree of pain during tendon rehab exercises, as there is likely to be a degree of sensitisation (the area around the tendon becoming overly sensitive) once the pain has been ongoing for a period of time. Allowing some pain during exercise may help to reduce this sensitisation, but monitoring for symptoms afterwards is necessary. 

A graduated return to painful activities occurs concurrently to the above. The ‘harder’ the activity the tendon needs to get back to, the harder the rehab will need to be. e.g., a plantar fasciiopathy that needs to get used to standing still will not require the level of rehab exercises as one that needs to get used to someone playing basketball. 

The final component of tendinopathy management is PATIENCE. Tendons take a very long time to gradually re-model. Another reason why it is important to only rest just as much as you need to, and work to gradually increase how much you are doing over time, so that it does not take too much space up in your life. 

Should I have shockwave/acupuncture/dry needling/cortisone/PRP?

As stated above, my personal opinion is no. This is because these treatments will not restore the ability of a tendon to tolerate load, and will not restore the muscle weakness that is likely to accompany the tendinopathy. These treatments are often painful and expensive and carry a degree of risk. Cortisone in particular should be avoided if possible, as it is likely to weaken the tissues and possibly cause worse outcomes in the long term (Cook et al., 2016). 

Take home points:

• Tendinopathy occurs when a tendon is loaded beyond its capability 
• The tendon becomes less able to handle load instead of more able to 
• Tendons ‘like’ a similar amount of loading to what they have been exposed to in recent weeks
• A sudden load of too much, or repeating a given load again too soon can lead to a tendinopathy developing
• Treatment involves off-loading the tendon just enough to allow some recovery of symptoms
• Off-loading needs to consider both tensile and compressive loads (i.e. consider load on tendon in static postures not just while moving)
• Targeted exercise to restore capacity to a tendon is necessary
• A graduated return to activity is also part of appropriate tendon rehabilitation
• Tendons are SLOW to recover - you may need to allow 12 months for a tendon to feel back to normal 
• It is important to avoid total rest as this will not heal the tendon and will also cause the tendinopathy to have too much of an impact on your life 

I am working on specific advice pages for different tendinopathies that will be uploaded as I finish them!

1. Alex, S., Kipling, S., Hakan, A., Roald, B., Jill, L. C., Brooke, C., Robert-Jan de, V., Siu Ngor, F., Alison, G., Jeremy, S. L., Nicola, M., Magnusson, S. P., Peter, M., Sean Mc, A., Edwin, H. G. O., Craig Robert, P., Jonathan, D. R., Ebonie Kendra, R., Karin Gravare, S., Cathy, S., Adam, W., Jennifer Moriatis, W., Inge van den, A.-S., Bill, T. V., & Johannes, Z. (2020). ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. British Journal of Sports Medicine, 54(5), 260. https://doi.org/10.1136/bjsports-2019-100885 
2. Cook, J. L., & Docking, S. I. (2015). “Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ‘tissue capacity’: a core concept for clinicians. British Journal of Sports Medicine, 49(23), 1484. https://doi.org/10.1136/bjsports-2015-094849 
3. Cook, J. L., Rio, E., Purdam, C. R., & Docking, S. I. (2016). Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?British Journal of Sports Medicine, 50(19), 1187. https://doi.org/10.1136/bjsports-2015-095422 
4. Lauren, P., Jill, L. C., Erik, W., Arne, B., Luc Vanden, B., & Evi, W. (2022). Exploring the role of intratendinous pressure in the pathogenesis of tendon pathology: a narrative review and conceptual framework. British Journal of Sports Medicine, bjsports-2022-106066. https://doi.org/10.1136/bjsports-2022-106066 
5. Magnusson, S. P., Langberg, H., & Kjaer, M. (2010). The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol, 6(5), 262-268. https://doi.org/10.1038/nrrheum.2010.43