Tendinopathy Physiotherapy Brisbane

Jill Cook and Craig Purdam, two Aussie physios, developed what they termed the tendinopathy continuum. It is the gold standard for our current, but somewhat limited knowledge of tendons. Previously there used to be an understanding that tendinopathy was an inflammatory condition – hence the name tendonitis, but according to most recent research, the appears to be such a small amount of inflammatory markers that it’s almost not even worth mentioning. Jill and Craig proposed a three-stage continuum that tendinopathy develops along, so let’s dig into it.

Manual therapy, whilst not the be-all and end-all in the management of tendinopathy, is still an integral part. Exercise is truly what you need to be doing, but let’s talk about how hands-on treatment and some other adjuncts can help. Manual therapy is one of the core treatments physiotherapists can provide. We are arguably one of, if not the best professionals at it. Utilising massage and trigger point release work helps to reduce muscle tone and improve the capacity for the muscle to work (but doesn’t increase load tolerance of the tendon), allowing you to do more for the same level of symptoms. It’s important to remember that massage often has short-term effects, so don’t expect one massage to fix you, no matter how good you feel after.

Joint mobilisations is another technique physiotherapists use pretty often. Often there may be an underlying joint stiffness either at the ankle or knee that may be affecting the way your body can load and adapt to movements and positions during either sport or daily life. Mobilisations are moving the joint in a gliding motion through its plane of movement to increase the range of motion.

Dry needling is one of the most popular adjunct treatments out there that physiotherapists can use. Some people make some audacious claims about its effectiveness but I like to keep it simple. I utilise dry needling where hands-on release doesn’t seem to do the job of releasing muscle tone. Dry needling can have really nice short-term effects really quickly, like 30 seconds to a minute quickly. If we use it well, it can provide you with some significant benefits that we can then build on with a strengthening program.

Taping is probably the last of the adjuncts that I commonly use in tendinopathy cases. Often I will look to support something to take the stress away, for example, a low dye taping of the foot to improve force absorption to reduce stress on the Achilles or a deload taping for the shoulder to allow the rotator cuff tendons to settle. In other cases, though, such as tennis elbow, we can look to do a direct offload of the tendon to reduce symptoms and improve function. Just always keep in mind that tape isn’t a long-term fix, we can’t just keep strapping something up and expect you to be better in 4 weeks’ time, it needs to be part of a complete rehabilitation plan.

I regret to inform you that tendinopathy rehabilitation cannot be completed without an exercise program. I get that home exercise programs aren’t the most enjoyable thing in the world, but research says they are simply the most effective way to manage tendinopathy in the long term and the only way to improve a tendon’s load tolerance. This is exactly why we don’t recommend complete rest as a treatment option, at least only in extenuating circumstances. If you rest and do nothing, the pain will settle, but the amount of load your tendon can tolerate decreases. Completion of the functional and load tolerance assessment forms the baseline knowledge of where we can begin an exercise program. If you can tolerate hopping on the spot, that’s great because we can probably start with some plyometric tendon loading. But if you can only perform double leg calf raises before it becomes too painful, that’s ok too, we just develop your program starting at a lower loading point.

With tendons, we are realistically looking at a three-day exercise cycle, but in the earlier days, it could be shorter. Once we reach the end of rehabilitation, we will probably have a low load day, which is where we perform isometric holds to keep the load going through but causing no irritation of symptoms. The second day is often when we perform our strengthening work. This could be as simple as some single leg calf raises if you have Achilles tendinopathy, or if you have access to a gym, it could be a complete gym strengthening program. Day three is our high load day. This is where we perform plyometric work for the tendon. Looking at an Achilles tendinopathy, this could involve stair walking on your tiptoes, skipping, hopping drills, or many other options. After this day, we will revert to day one, where we again load lightly and aim to let any lingering symptoms settle.

We can’t neglect the rest of the body though, we will have a targeted tendon loading program, outside of that though we will also have a specific and individualised exercise program to address other potential weaknesses, areas of tightness or stiffness that may have predisposed you to tendinopathy, or are a secondary adaptation after symptoms started.

Tendinopathy usually causes pain that is well localised to the tendon, such as just above the heel, below the kneecap or on the outside of the hip or elbow. It is typically stiff and sore first thing in the morning or after rest, eases as you warm up, and then is often worse later that day or the next morning after activity. Pain is closely linked to load, so movements like jumping, running, climbing stairs or gripping usually hurt more. The tendon may also feel tender to touch and slightly thickened.

Tendinitis suggests the main problem is inflammation, and for many years that is how tendon pain was described. Research now shows that most painful tendons are not primarily inflamed. Instead, the tendon has been overloaded and its structure has changed as it tries to adapt. That is why tendinopathy is the preferred term. The difference matters, because it explains why anti-inflammatory approaches and rest alone often do not fix the problem, while progressive loading of the tendon does.

Morning stiffness and pain are classic signs of tendinopathy. After a period of rest, the tendon and surrounding tissues stiffen, so the first steps out of bed or the first movements of the day feel tight and sore. It usually eases within a few minutes to half an hour as the tendon warms up. How bad your morning stiffness is can be a useful guide to how the tendon responded to the previous day, so I often ask you to track it to help guide how hard we push your rehab.

Usually not. Tendinopathy is diagnosed from your history and a clinical assessment, and scans often do not change the treatment plan. Ultrasound or MRI can show changes in the tendon, but similar changes are often seen in people with no pain at all, and they do not reliably predict how you will recover. A scan is more useful if a tendon tear or rupture is suspected, if the diagnosis is unclear, or if you are not improving as expected. If imaging is needed, I will write to your GP to organise it.

It can, particularly if load increases suddenly or you stop doing your strength work once the pain settles. Tendons respond to the load they are used to, so a big jump in training, a new sport, a change in footwear or a return after time off are common triggers. The best protection is continuing some tendon strengthening as part of your routine and increasing training gradually. If you notice early warning signs, like more morning stiffness, adjusting your load early usually stops it becoming a bigger problem.

Musculoskeletal Physiotherapy

Sports Physiotherapy

Service Areas

Service Areas

Service Areas

Company