Demystifying Tendinopathy

Tendinopathy, a common musculoskeletal ailment, can affect individuals of all ages and activity levels. It encompasses a range of painful conditions that impact tendons, the connective tissues that attach muscles to bones. In this blog post, we will delve into the causes, types, histological presentations, neurological markers, and evidence-based treatments for tendinopathy.

Causes of Tendinopathy

Tendinopathy typically arises from a combination of intrinsic and extrinsic factors:

Overuse or Repetitive Stress

Excessive and repetitive use of a tendon is a primary cause. Activities like running, jumping, or lifting heavy weights
can place significant mechanical stress on tendons, leading to microtrauma and eventual tendinopathy.


Tendinopathy becomes more common with age as tendons naturally lose some of their elasticity and adaptability.
Aging tendons are more prone to injury.

Poor Biomechanics

Abnormal movement patterns or biomechanics can contribute.
Muscle imbalances, joint misalignment, and poor posture can lead to uneven stress on tendons.

Training Errors

Rapid increases in training intensity, duration, or frequency can strain tendons.
Training errors, such as inadequate rest and recovery, are risk factors.

Chronic Medical Conditions

Conditions like diabetes, rheumatoid arthritis, and hyperparathyroidism can affect tendon health and increase tendinopathy risk.


Certain medications, like corticosteroids, can weaken tendons and make them more prone to injury.


Tendinopathy can manifest in two main types:

1. Tendinosis

A more chronic condition, tendinosis involves degenerative changes in the tendon without significant inflammation. Normal tendons are characterized by their highly organized structure, with aligned collagen fibres and a low density of cells (primarily tenocytes). They have minimal blood supply (avascular), which contributes to their strength and resistance to stretching. In contrast, there are key changes in the structure of affected tendons which include;

  • Altered collagen structure: The collagen fibres in tendinopathic tendons may be disorganized, thicker, and less able to withstand tensile forces.
  • Increased cellularity: The presence of more cells, including tenocytes and inflammatory cells, is a hallmark of tendinopathy.
  • Neovascularization: The development of new blood vessels in tendinopathy disrupts the normal avascular nature of tendons.
  • Changes in ground substance: The composition and density of the ground substance can be altered, impacting the mechanical properties of the tendon.

    2. Tendinitis

    This is characterized by acute inflammation of the tendon. Histological changes include increased vascularity and infiltration of inflammatory cells. Tendinitis is often associated with recent overuse or injury and presents as the initial acute presentation.

 Tendinopathy and Nerve Changes

Tendinopathic tendons can also show changes in neurological markers which leads to changes in pain behaviour and perception:

Increased Sensitivity to Pain (Peripheral Sensitization)
Tendinopathic tendons often exhibit heightened pain sensitivity due to changes in nerve endings within the tendon. These nociceptors become more excitable and responsive to mechanical and chemical stimuli.

Altered Nerve Density
Some studies suggest increased sensory nerve fibre density in tendinopathic tendons, particularly in chronic cases. This heightened innervation may contribute to pain and altered sensory perception.

Central Sensitization
In chronic tendinopathy, central sensitization may occur, altering the central nervous system’s processing of pain signals and leading to heightened pain perception.

Motor Control and Proprioception
Altered feedback from tendinopathic tendons can affect muscle activation and coordination, influencing movement patterns and joint stability.

All this means is that you may feel more pain than the actual severity of the tendon. Understanding that your nervous system may produce more pain signals is important so that you can rationalise that it is not actually a sign of how severe your problem may actually be. This will allow you to continue with you’re rehab and keep moving forward. This is not to say however that you ignore pain signals all together. It means that you need to put pain output into context of you have done and functional input.

What is interesting is you may have a tendon that demonstrates tendinopathic changes on scan and histologically but is totally asymptomatic causing no restriction in function. A study demonstrated that a large proportion of basketball players showed tendinopathic changes but no pain or loss of function. This is an important consideration when interpreting scan results and relating pain to severity of results.

It also can guide expectations of the rehab process.


Managing tendinopathy requires a multifaceted approach:

Relative Rest

Rest during the acute phase is essential, followed by gradual reintroduction of activity as symptoms improve.

Physical Therapy
Skilled therapists use techniques like eccentric strengthening exercises, stretching, and manual therapy to promote healing and reduce pain. Guidance and goal setting is crucial to get the best outcome.

Exercise Rehabilitation
Progressive loading exercises, particularly eccentric exercises, strengthen the tendon and surrounding muscles will be key to recovery.

Orthotics and Bracing
These can help correct biomechanical issues and reduce stress on tendons, which can improve return to function.

Shockwave Therapy
Non-invasive shockwave therapy may stimulate tissue healing and tissue re-organisation.

Lifestyle Modifications
Improving posture and using proper technique during physical activities can reduce strain.

Education and Behavioural Changes
Understanding the condition and making necessary lifestyle changes are crucial.

Nutrition and Hydration
A balanced diet and hydration support tendon health.

In severe cases, surgical intervention may be considered when conservative treatments fail, but this should absolutely be the last resort.


@ZeniaWood wrote a great blog on about the do’s an dont’s of tendon rehab. The full blog can be found here, but this is the summary.

RULE #1 – Don’t rest completely

Rest is crucial, but that doesn’t mean immobilizing yourself. It’s essential to strike a balance between activity and recovery. Depending on your current tendon condition:

  • Your therapist might introduce gentle loading exercises immediately.
  • Or, suggest a period of moderated rest.

    But remember, we’re speaking about relative rest, not complete inactivity. Your tendon needs stimulation, even during flare-ups, just in the right amount.
    Takeaway: Total rest isn’t always the best answer. Active recovery can play a vital role.

RULE #2 – Do Introduce Gradual Loads

Your tendons need to be conditioned to bear and manage loads progressively. Together, your therapist will devise a structured plan considering:

  1. Intensity
  2. Volume
  3. Frequency

    With the research on our side, the primary focus will be on Heavy Slow Resistance (HSR) training, adjusting as per your comfort and progress. Both HSR and eccentrics studies utilised heavy (> 75%) loading strategies, so ensuring the resistance is heavy is important.

    As tendon healing progresses, we must continue to load it to cope with greater demands. To progressively overload a tendon effectively, the rehab pathway should look something like this:
    You can read more about rehab adaptation and progression in our blog here.

    Takeaway: Your tendons will learn and adapt, but patience and methodical approach are crucial.

RULE #3 – Don’t Avoid Pain- Understand Pain Is A Part Of The Process

During the sessions and your exercises, experiencing some pain is natural. The key is to gauge and understand this pain.
Tools like the Pain (and activity) Modification Scale, shown below, will be used to ensure you’re on the right track.
Always communicate with your therapist about any discomfort you feel, and adjustments will be made accordingly.

Takeaway: Some pain is acceptable and is expected through the rehab process but is controlled.

RULE #4 – Do Embrace The Recovery Timeline

Tendinopathy recovery isn’t an overnight process. While your therapist will provide you with general timelines based on research and experience, remember, everyone’s healing journey is unique. Research tells us tendinopathies need a minimum of 12 weeks of consistent loading to show sufficient healing. Therefore, it is important that we encourage continuation of rehabilitation that is progressive in nature. Where rehab is inconsistently performed and/or non-progressive, tendon healing is unlikely to occur. The focus will be on your consistent progression rather than strict deadlines.

Takeaway: Recovery is a journey, and every individual’s path can vary. Patience and persistence are vital.

RULE #5 – Do Use Isometrics As A Pre-Exercise Step

Isometrics might provide some temporary pain relief, and this option will be explored if it suits your condition. Done correctly, it can be a useful addition to your rehabilitation plan. New research has identified that isometrics can be beneficial for temporary pain relief, with a caveat: They must be performed with at least 80% Max Voluntary Contraction (MVC) to be effective-  5sets x 45s with 2 min rest is what the literature states as a starting point. This can be done in the latter stages of rehab as well, and is a great way to continue to maintain a level of consistent tendon loading.

Takeaway: Isometrics can be a valuable tool in the toolkit and must be used as part of the tendon rehab including in a pre-exercise routine.

RULE #6 – Don’t Compress The Tendon

Tendons, especially those healing from tendinopathy, hate compression, whether it be direct contact pressure or due to stretching. This means avoiding excessive stretching or any activity that might compress the tendon too much and cause further aggravation.

Takeaway: Tendons hate compression so beware of excessive stretching.

Tendinopathy is a complex condition that can affect many areas of the body. Evidence-based treatments encompass a range of approaches, from rest and physical therapy to shockwave therapy and surgery. Tailored management plans, early intervention, and active participation in rehabilitation are keys to successful recovery and improved tendon health.

Please consult your treating clinician for more information on the latest advancements and treatment approaches to manage your tendon condition.

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