Physiotherapy for Tendinopathy

Tendon problems are way too common for my liking. From runners with Achilles or hamstring tendinopathies, to basketball players with patellar tendinopathies, all the way through to the cases of tennis elbow and rotator cuff tendinopathy. There are a lot of different sites, and they all do a lot of different things, so how do we manage them all? Thankfully, even though lower limb tendons operate slightly differently from upper limb tendons some of the principles are similar. 


I guess the first question people usually have is “What is a tendon?” Tendons are essentially the link between muscles and bones and allow your bones to move as your muscles contract and relax. They absorb high levels of force and help prevent muscular injury during higher-force activities like hopping, jumping, or sprinting. They are extraordinarily important for athletic performance. But if you start to do too much, or load them too much too quickly (such as a big New Years’ resolution) you can start to get problems.


What will occur at the start is a reactive response within the healthy tendon tissue with some clients presenting with what looks to be a swollen tendon. This swelling response is part of the body’s natural reaction to an overloaded tendon, you’ll be happy to know that this is reversible and it will reduce with time and proper management. 


Some people might refer to it as tendinitis, but this is a pretty common misconception, tendinopathy is the truly correct term. Tendinitis infers that there is an inflammatory response occurring, but from all of the research that has currently been conducted there haven’t been any findings of an inflammatory cascade occurring. The end “apathy” essentially indicates a disorder of the tendon, I look at it as a disorder of the tendon’s capacity to continue to accept and transmit load. In most cases, there is no structural damage, unless you have a tendon tear, and in most cases have an extremely positive outlook if you commit the time and effort to work with me and commit to an exercise program.

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What we will discuss:


Tendons are all about load, so after finding out about how your symptoms started and why you are calling me to come to assist you, what you have been doing is the biggest thing I am interested in. As soon as someone mentions pain on a tendon or at a tendon attachment site my interest is already piqued. What I’m interested to know isn’t what you did the few days leading up, I want to know what you have been doing for the last 3 or 4 months and whether something has changed. It often isn’t a big change, it could be that you run consistently but you suddenly decided to increase your pace and distance at the same time, or perhaps you added in more hill work, for tennis elbow it could be something as simple as needing to write a big report at work and spending a lot more time at the computer. It can be these small and simple things that can often result in a tendon overload process kickstarting.

The next biggest thing I’m interested in is how the pain behaves, specifically what makes it worse and when do you feel it. Some clients may report that they can do a 5km run and feel good but then be hobbling the next morning, others may find they can type at a computer for 45 minutes but then they will need a break due to the pain building up. Understanding how the pain is affecting your quality of life and ability to function is integral to understanding tendinopathy. This also provides us with a baseline of where we will be performing our functional and tendon loading assessment and how we will develop an exercise program. If you have more latent symptoms the day after we may be a little more cautious with our programming to avoid any significant spikes early on and set ourselves back, but instead take small but consistent steps forwards. 


Understanding your fitness and exercise program, along with your goals and what you are wanting to achieve allows us to understand your goals and how we will develop a plan to get you to where you want to be. If you are a runner or playing in a sports team, knowing whether you have an upcoming event or game that you are aiming for will allow us to plan backwards and have markers for what you need to be achieving when to make sure you are on track for achieving your goal.

What we will assess:

Tendinopathy can be a simple pattern to pick up in a subjective assessment, but ruling out other structural causes is necessary. Here I’ll split this into upper and lower limb sections so we can discuss them a little separately given there are a few differences.

Upper Limb


Upper limb tendons are a bit simpler than lower limbs, particularly at the elbow. When looking at cases of either tennis elbow or golfers elbow isometric assessment of the affected muscles and palpation of the affected tendons and bony origin point are the two key identifiers. The absence of any acute trauma to the elbow will rule out a lot of other potential factors. The main differential diagnosis to make can be determining if there is any neural system involvement. This finding can be quite common in tennis elbow as either a distinct diagnosis or occurring at the same time as tendinopathy.


Looking at rotator cuff tendinopathy it can be quite a common finding on ultrasound or MRI but how common is it to be symptomatic of it? It can be quite difficult to truly say, special tests that are designed to isolate structures such as specific rotator cuff muscles are notoriously poor at being specific. The hallmark signs of a rotator cuff tendinopathy are weakness and pain with shoulder external rotation and shoulder elevation, two things that are present in about 80% of the clients with shoulder pain that I see. So what do we do? I utilise some specific special tests around the shoulder but not to try to prove that it is rotator cuff tendinopathy, but to try and test if it isn’t the cause. Some of the special tests are better to rule out causes of symptoms than they are at ruling in. 


Lower Limb

 Tendinopathies affecting the lower limb are generally a little bit easier to assess and diagnose but there are still a few key things that we need to make sure of so that we don’t misdiagnose tendinopathy if it’s something else. Because tendons essentially act like big springs in the lower limb we need to assess their capacity to do just that. We need to work through a loading spectrum to assess how the tendon responds, what should occur in a classic case of tendinopathy is that the pain stays isolated in the same spot and increases in intensity. For an Achilles tendinopathy a loading progression might look like this:
  1. Double-leg calf raises
  2. Single-leg calf raises
  3. Jump on spot
  4. High knee running on the spot
  5. Hop on spot
  6. Hopping forwards
  7. Hopping forwards as fast as you can


This is typically the progression I work through and tend to try to get up to 6-7/10 pain to at least have enough information to match with a clinical picture. For hamstring tendinopathy, we may be wanting to assess some other factors, in those cases, compression of the tendon is generally a big factor. In those cases, we will want to see what happens to the pain response as we begin to load into more and more amounts of hip flexion.


In those cases, a loading spectrum could look something like this:


  1. Double leg bridge
  2. Single leg bridge
  3. Long level single leg bridge
  4. Single leg bridge with the foot on my shoulder
  5. Deadlift
  6. Single leg deadlift


Differential diagnosis can take on many different fronts, for hamstring tendinopathy, it is often a case of ruling out sciatic nerve and lower back referral as two potential sources. For patellar tendinopathy, it is most often a case of ruling out patellofemoral pain as the cause. For Achilles tendinopathy, I find it is often differentiating between different disorders of the tendon – for example, tenosynovitis which is a friction-based disorder of the sheath that surrounds the tendon can be quite a common presentation too.

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Hands-on Treatment

 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), essentially allowing you to be able to perform 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 is able to load and adapt to movements and positions during either sport or daily life. Mobilisations are a process of moving the joint in a gliding motion through its plane of movement with the aim of increasing 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 in cases where hands-on release doesn’t seem to quite be doing 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 great benefits. 


Taping is probably the last of the adjuncts that I commonly use in tendinopathy cases. Often I will be looking 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. In other cases though, such as tennis elbow, we can look to do a direct offload of the tendon to simply 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.

Exercise Programs


I regret to inform you that tendinopathy rehabilitation cannot be completed with an exercise program. I get that home exercise programs aren’t the most fun thing in the world but research says that 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 resting as a treatment option, at least only in extenuating circumstances, if you rest and do nothing the pain will settle but the amount you can do decreases. Completion of the functional and load tolerance assessment forms the baseline knowledge of where we can begin a program. If you are able to 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 likely 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 tip toes, skipping, hopping drills, or many other options. After this day we will revert back 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.

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Treatment Options

Tendinopathies are a little different to most acute injuries, we don’t really have a tissue injury that we have to respond to or manage. It is simply a matter of respecting the tendon and its load tolerance and working within those limits. For that reason I don’t really recommend a treatment package for tendinopathies, It can be a little difficult to predict how they will respond and there isn’t typically the need for large amounts of hands-on treatment. I would often recommend that you simply undertake a recommended treatment plan that we will determine together in our initial consultation that will detail our goals and treatment timeline, what your treatment will involve, and any other adjuncts you may need such as orthotics. 

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A flowchart displaying the presentation of tendinopathies ranging from stress shielded, to reactive and degenerative tendinopathies.


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