Tendon Troubles


What are tendons?


Tendons are tough, sinewy structures that attach muscles to bones in the body. Unlike a ligament, which attaches bones to other bones in the body, tendons attach bones to muscles. The body contains hundreds of tendons. You may be familiar with the Achilles tendon in your heels, patellar tendon under your kneecap, and biceps tendon in your elbow. Like the chain on a bike, tendons help to transfer force from muscles (pedals) to bones (the rear bike wheel) in your body. Tendons are much more elastic than bike chains, however, which makes them crucial in allowing us to move efficiently and explosively while exercising and working.




What is a tendinopathy?1


Tendons can be a source of pain if the tendon is used in excess or in a new way. This disorder of the tendon is termed “tendinopathy”. It can be further subdivided into tendinitis and tendinosis.


When a tendon begins to hurt after an activity, there may be an inflammatory response from the body, resulting in symptoms such as swelling and redness. This acute pain response is referred to as “tendinitis.” If managed properly, tendinitis rarely lasts more than a few weeks.


Ongoing tendon pain which lasts over several weeks could instead be due to a other structural changes in the tendon, and/or due to the way the body processes pain. This ongoing pain is usually referred to as “tendinosis.”. Unlike tendinitis, tendinosis can take several months (sometimes longer) to heal, and may no longer be associated with symptoms of inflammation.

Where do tendinopathies usually occur?


In the upper body, common sites include:


  • Shoulder tendons – Pain here is often related to the rotator cuff or upper biceps tendons, but may move down the outside of arm, even as far down as the elbow.
  • Elbow tendons – Both the inside (golfer’s elbow) and outside (tennis elbow) are common sites of tendon irritation. The lower biceps tendon may also hurt in the front or “deep” in the elbow.


Common sites of the lower body:


  • Gluteal tendons– Pain in the sides, or back of the hips may be aggravated by walking, climbing stairs or crossing your legs.
  • Hamstring tendons – Both the upper (under the gluteal fold) and lower (back of knee) hamstring tendons can develop tendinopathy. Walking up hill or running may aggravate these tendons
  • Patellar tendon – Just below the kneecap. Jumping or running often aggravates this area, and it is proportionately more common in younger populations.
  • Achilles tendon – At the back of the lower limb and heel, this one of the most common sites of tendinopathy, and often a source of pain for runners.


When should I suspect tendinopathy?


Generally, you should consider tendinopathy if you are experiencing specific pain in the area of a tendon. Other clues include:


  • Your pain increases with increased stress or load to the tendon. For the lower limbs, an increased load could occur when weight bearing or running fast. In upper limbs, manual work or throwing motions increase load on tendons.
  • You feel increased pain at the ends of your joint range of motion, such as reaching overhead for the shoulder or going up/down stairs for the ankle. At the end of the joint’s range of motion, the tendons will be stretched or compressed more.
  • There is thickened appearance of the tendon, compared to the other side of your body.


Risk factors for tendinopathy include2:


  • A previous history of tendinopathy, especially in the same area of the body.
  • Family history of tendon-related pain.
  • A sudden increase in activity level.
  • For athletes, a recent change in footwear or technique.
  • Biomechanics (how your body is aligned during movement).
  • Increased age.
  • High blood lipid levels and chronic conditions such as diabetes may also increase your risk.
  • Psychological or socioeconomic stress may contribute to the pain experience.


What should I do if I suspect tendinopathy?3


The following are important measures to take:


  • Reduce or modify aggravating activities! The tendon needs a break from the movements that are causing it pain. It is important to think about stressors both at work and outside of work.
  • BUT, it is crucial that you stay active. While this point seems to oppose the advice above, research shows that tendons do not heal well with complete rest. Instead, tendons need an optimal load” a happy medium between working the tendon too hard and taking it to easy.
  • SO, pay attention to your pain. A daily tendon test (such as a calf raise for your Achilles tendon) should not change your pain by more than 2 points on a 10 point scale, and pain should not increase for longer than 24 hours after exercising. Either of these experiences probably indicate that you need to reduce your activity level.
  • Initially, avoid stretching the affected tendon. Stretching may increase compressive forces on an irritated tendon (like pushing into the middle of a taught rope), which can exacerbate symptoms instead of improving them. Stretching may be helpful later on in treatment, however.


How can a physiotherapist help with tendinopathy?


Your physio can:

  • Develop an personalized exercise programme to improve your tendon capacity. Physiotherapists are well trained to help you with this.
  • Progress your exercise programme as it begins to feel easier. This progression will depend on your activity goals and previous activity level, which your physio will discuss with you. Generally, the exercises will start with slow (or static) contractions and low loads, then progress to higher loads and faster movements. For many athletic populations, it is important that tendons be able to act like springs, absorbing and returning force during movement.
  • Help fit you with a temporary aid or brace to modify the stress on your tendon during daily activities. Examples include a compression strap for tennis elbow, or a heel lift for Achilles tendon pain.
  • Employ pain relief techniques such a ice, ultrasound, and electrotherapy, which can help you manage your pain and empower you to move more.
  • Look for the underlying cause of your tendinopathy, which may be related to other areas of your body and how they interact during movement. If your knee hurts, don’t be surprised if your physio works on your hip!


Somebody suggested I just do a alternative treatment or an injection for my tendon? Will this work?


A number of new alternative therapies that look at injections (such as cortisone and platelet rich plasma), as well as shockwave. Though injections may provide some temporary pain relief, current literature doesn’t support their use in most cases3. Likewise, from a cost/benefit perspective shockwave does not show positive effect except periodically in chronic tendinopathies. 

However, the most evidence supported treatment for tendinopathy is mechanical loading via exercise! Furthermore, passive treatments likely work best when done with exercise.



My Ultrasound/MRI/CT scan shows a “degeneration” in my tendon! What does this mean?


Diagnostic imaging can have an important role in confirming the presence and location of tendinopathy. Imaging can also help rule out other conditions (a tendon rupture, for example), which need to be treated differently. When your imaging results mention “degeneration”, however, it is important to take this news with a grain of salt. Most symptomatic tendons show some evidence of structural changes, which may be called “degenerative.” However, many people without any symptoms and full function of the tendon also have these changes in their tendons when imaged5. This means that diagnostic imaging doesn’t necessarily tell the whole story about your tendon pain. If you have tendinopathy, don’t let the results of imaging convince you that you need to stop moving, or that your affected tendon is doomed. Instead, pay attention to your symptoms, and focus on slowly improving the capacity of your tendon!






  1. HealthLinkBC: Tendon Injury (Tendinopathy) [Internet]. Canada: HealthLinkBC, 2017. Available from: https://www.healthlinkbc.ca/health-topics/uh2113i
  2. Malliaras P & O’Neill S. Potential risk factors leading to tendinopathy. Apunts Med Esport. 2017 Jun; 52 (194): 71-77. doi: 10.1016/j.apunts.2017.06.001
  3. Cook JL. Ten treatments to avoid in patients with lower limb tendon pain. Br J Sports Med. 2018 Feb; 0: 1-2. doi: 10.1136/ bjsports-2018-099045 [Epub ahead of print]
  4. Ioppolo F, Rompe JD, Furia JP, Cacchio A. Clinical application of shock wave therapy (SWT) in musculoskeletal disorders. Eur J Phys Rehabil Med. 2014; 50: 217-230.
  5. Ryan M, Bisset L, Newsham-West R. Should we care about tendon structure? The disconnect between structure and symptoms in tendinopathy. J Orthop Sports Phys Ther. 2015 Nov; 45(11): 823-825. doi: 10.2519/jospt.2015.0112.
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