Tendon pain: why, what, how?

What are tendinopathies?

Patella tendon

Tendons attach muscle to bone. Hence the common tendons in the lower limb that may develop tendinopathy are: patella tendon, Achilles tendon, gluteal tendon and the plantar fascia. Tendinopathy is a clinical diagnosis based on:

  • Localised tendon pain
  • Pain with loading the tendon
  • Pain that increases with increasing loads on the tendon
  • Alterations in the collagen make up of the tendon

What causes tendinopathies?

Tendinopathy image

It is best understood by considering tendinopathy as an imbalance in the rate of wear versus the rate of repair.  Tendonitis is a rarely used term now as it is very rare to actually find inflammatory cells or inflammatory signs (swelling, heat, redness) at the tendon but in fact what is found in the tendon when looked at microscopically is a lack or tendon cells/ alterations in the collagen make up of the tendon  making the tendon less strong and unable to ‘met the demands’ it is placed under causing pain.

Classically there can be a change in training load, surface, footwear that will trigger the injury  when questioning a patient (not an exhaustive or definitive list). The load the tendon is being placed under cannot cope and the failure triggers pain. This then has to be managed carefully as rest alone is unlikely to fully resolve the problem.

What works for tendinopathies?

Back of shirt shot

Activity modification is crucial– historically management was rest and anti-inflammatory medications. At best these methods show an improvement purely due to luck and at worse, result in a deterioration of the patient’s condition (Scott et al, 2013). Although, rest will reduce the pain it takes away the loading and like muscle it will lead to further de-conditioning of the tendon.  Therefore, it’s important to load the tendon within the limits of the pain. As physio’s we tend to guide this rehab process using a pain monitoring model and this will vary from patient to patient depending on what is found in assessment.

Eccentric tendon loading has been well documented for a number of years and will be found in all ‘running magazines’ when advise is required for tendon issues. It certainly can and does help recovery from tendon issues but has to be tempered with careful activity modification and understanding as its most common reason for failing to help is poor application and lack of external loading. More recently isometric loading (static loading of tendon with no movement) has been found to be helpful creating neuro-motor changes, tensile tendon load, reduction in fear avoidance and pain behaviours.

Heavy slow resistance training has been shown to be effective for patella (Kongsgarrd et al, 2009) and more recently Achilles tendinopathies (Beyer et al, 2015) using weight lifting machines to provide concentric and eccentric contractions to load the tendon. However, this does require access to a gym environment which isn’t always an option for patients.

Its important to remember rarely there is a ‘quick fix’ and therefore acknowledgement and pro-active steps to seek treatment / get advice will reduce the time in which the injury (tendinopathy) impacts training and performance.

Why get professional advice on tendinopathies?

Well you might get lucky and the tendon pain just goes away never to return. You may be able to train through the tendon issue... but you may not! The comprehensive physiotherapy assessment and treatment / rehabilitation plan should answer:

-Is the pain / functional issue is actually a tendinopathy or is there something else going on

-Why do you have a tendinopathy? What needs to change to stop it happening again or worsen?

-How can you manage the tendinopathy to recover as quickly as possible?

Frankly, limited hands on treatment are needed (as the research supports). Perhaps – taping to manage pain, soft tissue release / stretching for tight compensating muscles / release of stiff joints that have again compensated would be the only real reasons for ‘hands on treatment’. The key is development of a progressive rehabilitation plan to gradually increase the tendon loading to return it to its optimal level of strength to meet the demands it is placed under.

Jo Avery

Chartered Physiotherapist MSc, BSc (Hons), MCSP, MHCPC

Owner First Physio


Disclaimer: The opinions expressed are those of First Physio only and do not constitute medical advice.



Beyer et al, (2015). Heavy slow resistance versus eccentric training in the treatment for Achilles tendinopathy: a randomised controlled trial. American Journal of Sports Medicine. 43:1704-1711

Kongsgarrd et al, (2009). Corticosteriod injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scandinavian Journal of Medicine and Science in Sports. 19 (6): 790-802

Scott et al, (2013). Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. British Journal of Sports Medicine 47: 774