The Ins and Outs of Tendinopathies

knee pain 3There are many terms to describe various injuries to tendons which can be confusing to understand.

In simplified terms:

Tendinopathy refers to an overuse injury of a tendon.

Tendinosis refers to a non-inflammatory degeneration of a tendon, this term is often used instead of tendinopathy to mean more of less the same thing, especially during the later stages.

Tendonitis refers to inflammation of a tendon, this may occur in the early stages of a tendinopathy.

Tendon partial and complete rupture refers to tears in the tendon, these are more likely to occur in a tendon in which tendinopathy or tendinosis has occurred, but not always.

Let’s focus on tendinopathies as this is what we see most often in the clinic.

What is going on in a tendinopathy?

The pathology in tendinopathy has been proposed as a continuum.1

Stage 1. The reactive tendon
This is seen clinically in patients with an acutely overloaded tendon. It refers to the response of tendon cells and matrix proteins to an acute tensile or compressive overload. These cells become activated and may proliferate, i.e reproduce rapidly, so produce more repair proteins. This results in short-term thickening of a portion of the tendon that reduces stress. Mild swelling can be seen on both ultrasound and MRI. This is the early more ‘acute’ phase which may appear to be related to inflammation.

Stage 2. Tendon dysrepair
At this stage, the tendon pathology is worsening with greater matrix breakdown. The cells become more prominent and rounded and protein production increases (proteoglycans and collagen). The collagen separates with an ingrowth of vessels and nerves and the fibrils becomes disorganised so instead of them being tight and neatly in line, they are swirling in different directions! This stage may be difficult to detect clinically but imaging such as doppler ultrasound and MRI will reveal increased swelling and signal of the tendon. This is the tendon ‘trying to heal’ phase during which correct treatment and loading of the tendon must be applied to avoid moving on to the next stage.

Stage 3. Degenerative tendinopathy
The above stages continue to progress until there are areas of cell death evident. Large areas become disorganised, filled with vessels and nerves, with little collagen present. Degenerative pathology is interspersed with the other stages and healthy tendon. Clinically, this stage might be seen in the older less active patient or in young athletes with substantial repeated load. These changes are evident on ultrasound as dark regions. MRI will also show increased tendon size. This is the failed healing response phase, it may be more difficult to treat these tendons and the response may be slower and so requires patience. The best strategy is to avoid getting to this stage by seeking treatment during stage 1 or stage 2, ie the sooner the better.

Imaging, is it the gold standard in diagnosis?

It is important to consider that the presence of tendinopathy on imaging such as ultrasound or MRI does not necessarily mean you will have symptoms of a tendinopathy. 80% of those with pathology on imaging do not go on to develop symptoms.2

However, it does increase your risk. Pathology on imaging also does not mean your tendon is weaker or impaired. It has been found that athletes with tendon pathology are actually the ones who can jump the highest. It is proposed that the thickening that occurs may actually be a good thing and provides more strength and explosive force to the tendon!

Common areas where tendinopathy may develop

  • Achilles tendon (back of heel)
  • Rotator cuff tendons (shoulder)
  • Gluteal tendon (outer side of hip)
  • Patellar tendon (front of knee)
  • Lateral epicondyle (outer side of elbow)

How does a tendinopathy feel and what does it affect?3

  • Pain during or after exercise, or the following morning
  • Painful at rest and more painful with use with everyday activities
  • In the case of Achilles tendinopathy for example, athletes can ‘run through’ the pain or it disappears when they warm up but returns when they cool down in the early stages of tendinopathy.
  • May be aggravated by acceleration, sprinting, change in direction or throwing, reaching or doing repetitive shoulder, elbow, wrist or hand movements.
  • In early stages, may be able to continue training, in the later stages pain usually prevents training altogether.
  • Local tenderness and and possibly thickening of the tendon
  • Swelling
  • Crepitus or ‘grinding’ on movement

Physiotherapy and other treatment 3,4

  • Avoid aggravating activity at the outset, and then carefully managing the load or strain placed on the tendon during everyday activities and sports.
  • Specific types of exercises, which may involve long and slow sustained contractions of the muscle and tendon unit have been shown to be helpful for pain relief in some types of tendinopathy.
  • Anti-inflammatories such as Ibuprofen may be useful in the early reactive stage.
  • Graduated loading or strengthening exercises improve the muscle and tendons ability withstand the load stresses required.
  • Stretching and manual therapy release of taut muscles may be clinically useful and assist in preparation for loading exercises.
  • Correcting faulty biomechanics, with the use of an orthotic if required in lower limb tendinopathies, may assist in the ability of the tendon to withstand higher loads over time.
  • Correcting faulty walking, running and throwing techniques may be important for some clients.
  • Advice on correct footwear, training regimes and return to sport/activity protocols.
  • Corticosteroid injection for short-term relief may be helpful, however best practice now suggests physiotherapy results in improved long term healing and recovery with a reduced risk of recurrence.
  • Surgery for is sometimes performed for certain types of tendinopathy in certain locations, however the results are highly variable, some clients benefit and others don’t.

If you are suffering with pain in any of the area’s mentioned above, which may be affecting your ability to do daily activities, exercises or sports, please give us a call on 01-2834303 to book and assessment. I will make an accurate diagnosis and we can then put together a treatment plan for you.

By Hannah Moran BSc Physio, MISCP

Chartered Physiotherapist


1. Cook J, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load–induced tendinopathy. British journal of sports medicine. 2008 Sep 23.
2. McAuliffe S, McCreesh K, Culloty F, Purtill H, O'sullivan K. Can ultrasound imaging predict the development of Achilles and patellar tendinopathy? A systematic review and meta-analysis. Br J Sports Med. 2016 Sep 15:bjsports-2016.
3. Brukner and Khan. Clinical Sports Medicine. Fourth edition.
4. PhysioEdge Podcast ‘Tendinopathy imaging assessment and diagnosis’ with Sean Docking.

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