Understanding Tendinopathy

Tendinopathy is a general term used to describe a painful problem affecting a tendon, the strong connective tissue that transfers force between muscle and bone.

When I graduated as a physiotherapist around 10 years ago, tendon rehabilitation often focused heavily on the painful tendon itself. If the Achilles was sore, we loaded the Achilles. If the elbow tendon was sore, we loaded the wrist and forearm. There was good reason for this, because progressive loading remains an important part of tendon rehabilitation, and certain types of loading can also help some people manage symptoms.

Over the years, we’ve also seen plenty of passive treatments directed at tendons, including massage, dry needling and shockwave therapy. Some may have a role in symptom management for selected presentations, but none removes the need to answer a much bigger question: why did the demands placed on this tendon exceed what it could currently tolerate?

Sometimes the answer is surprisingly obvious. Someone dramatically increases their running volume. They spend an entire weekend sweeping or pressure washing a driveway. They suddenly do a workout containing far more clean and jerks or pull-ups than they normally perform. Someone working in a kitchen has an unusually long shift involving hours of repetitive cutting and lifting.

The activity itself isn’t necessarily harmful. It may simply represent a sudden spike in load that the muscle-tendon unit wasn’t prepared to tolerate. Other times, we need to look more broadly. With an elbow or shoulder-related tendon problem, what is happening through the shoulder, neck and upper limb?

Is there enough strength and mobility available for the task?

Is the person coordinating the movement efficiently, or are smaller muscles further down the arm repeatedly being asked to contribute more?

With an Achilles problem, we might assess the calf and soleus directly, but we may also look at the knee, hip, balance, jumping ability, running mechanics and overall training history.

The answer may simply be that the calf wasn’t prepared for the sudden increase in running or jumping. In another person, there may be several physical and training factors contributing at once.

This is where good tendon rehabilitation becomes much more individual than simply handing everyone the same loading program.

We want to establish what the tendon and surrounding muscle can currently tolerate, identify the activities repeatedly aggravating it and determine which physical capacities need to improve.

We can then modify load without necessarily removing movement altogether. We often use a simple traffic-light concept to help people understand symptoms. Some discomfort during rehabilitation may be acceptable depending on the presentation, particularly when it remains manageable and settles back towards baseline afterwards. A significant or escalating response, worsening function, or symptoms that remain substantially aggravated after the activity tells us that the dose may need to change. The exact boundaries are individual rather than one universal 24-hour rule. The aim is to stop bouncing between doing too much, flaring the tendon, completely resting it and then repeating the same cycle.

From there, rehabilitation becomes about progressively closing the gap between current capacity and required capacity.

Early on, that might mean temporarily modifying the most provocative activities, adjusting range of motion, changing exercise selection or reducing training volume while maintaining tolerable strength work.

As irritability improves, we can progressively introduce more range, heavier resistance, faster movements, repeated loading and eventually the specific demands of work or sport. An Achilles tendon that needs to tolerate running requires more than being able to perform a controlled calf raise. Eventually it needs to tolerate repeated contacts, speed, fatigue and whatever weekly running volume that person wants to return to. Likewise, an upper-limb tendon needs to be prepared for the actual pulling, gripping, lifting or repetitive work required of it.

This is also why relying entirely on passive treatment can become problematic. Shockwave, massage or needling may be used in some circumstances, but even if something makes the tendon feel better temporarily, you still need to prepare the body for the activity that caused the problem in the first place. You cannot massage an Achilles into being prepared for 30 kilometres of running each week. You cannot shockwave an elbow into being prepared for hundreds of repetitive gripping movements at work. At some point, capacity has to meet demand.

The goal isn’t simply to make the painful tendon stronger either. It’s to understand the person attached to it. What changed before the symptoms began? What can they currently tolerate? What repeatedly causes a flare? What happens above and below the painful area? What strength, mobility, coordination or task-specific capacity might be missing? And most importantly, what does this person eventually need their body to do again?

Once we understand those things, tendon rehabilitation becomes much less about finding the perfect treatment and much more about building the right progression.

Dealing with persistent tendon pain?

If you’ve tried resting, massage or other treatments but your tendon keeps flaring when you return to activity, it may be time to look at your loading and rehabilitation plan.

Book a physiotherapy assessment at By Design and let’s build a plan around what you need your tendon to do.