Treating tendinopathy: A clinical Framework : Part 1
Introduction
Tendinopathy is one of the most common complaints we manage in physical therapy, and also one of the most mismanaged. Too much rest. Too much passive treatment. Not enough loading. After years of clinical work and a growing body of research, we have a reasonably clear picture of what works and why. This post lays out a treatment framework I use in practice, grounded in the current evidence. Part one here provides a background and key principles. Part two will cover the actual strategies I use in practice to successfully rehab painful tendons.
Background
Tendinopathy is not an primarily an inflammatory condition, which is why as a profession we dropped the -itis and changed the clinical term from tendinitis to tendinopathy. Again, it is a clinical term, which means that having a painful tendon and reduced tendon function is part of the requirement to make this diagnosis. You can’t have tendinopathy without pain and reduced tendon function, definitionally. It's a chronic imbalance between mechanical loading and the tendon's capacity to adapt and repair. When repetitive or excessive load exceeds what tenocytes and fibroblasts can handle, a cascade of pathological changes follows: structural degradation, neovascularization, altered collagen quality, and changes in the mechanical properties of the tissue itself (decreased stiffness, decreased strength, impaired force transfer).
This is often described along a tendon continuum model. This concept was named and popularized by therapist and researcher Jill Cook (1). It goes as follows: reactive tendinopathy → tendon disrepair → degenerative tendinopathy. The stage of pathology matters for how aggressively we load the tissue, though in practice we're often managing across multiple stages simultaneously.
Two other points worth keeping in mind:
You can have pathology without pain. Imaging changes are common in asymptomatic tendons. Folks with positive findings are more likely to develop tendinopathy in the future, and are more likely to have worse tendon function.
You can have pain without structural pathology. Pain is a lousy proxy for tissue damage in tendons.
This matters clinically because it shapes how we communicate with patients and how we set expectations around progress.
Principle #1: Tendons Require Load
As one of my mentors Chris Johnson (2) says: “Tendons love load”.
Unloading a tendon leads to decreased mechanical properties, reduced muscle power, kinetic chain dysfunction, and changes in motor cortex drive (both hyperexcitability and hyperinhibition). When the patient returns to loading after a rest period, pain often spikes back because the tendon and neuromuscular system are now less prepared for load. I often liken tendons to springs: when we unload the tendon, we are allowing the mechanical properties of the spring to plummet. Our spring is no longer dense and elastic, it is thin and stretchy. It is not a perfect metaphor, but it highlights the importance of a mechanically sound tendon.
The landmark 2007 Silbernagel RCT(3) put this to the test directly. Thirty-eight patients with Achilles tendinopathy were allowed to continue running and jumping during rehabilitation using a pain-monitoring model (working up to a 4/10 pain in rehab); another 38 were told to rest for six weeks. Both groups followed the same strengthening program. At 12 months, VISA-A scores improved from 57 to 85 in the exercise group and 57 to 91 in the rest group — no significant difference. Continuing activity, guided by pain, was just as effective as stopping it. Importantly, the exercise group was able to get more activity which results in better tendon health and function. It also is a benefit for mental health, as these folks did not need to stop doing the things we love.
This has since been replicated and incorporated into tendinopathy clinical practice guidelines. The clinical takeaway is that relative rest (activity modification based on pain) is the target, not absolute rest.
Principle #2: Pain Monitoring Model
The pain-monitoring model is the backbone of how we communicate loading decisions to patients. Here's how I frame it:
During activity: 4–5/10 NPRS is generally acceptable for tendinopathies (Silbernagel's threshold).
The 24-hour rule Stubbornly, folks with tendinopathies don’t always feel pain during activity (if they do, it often warms up). However, pain can be worse after activity if the tendon was overloaded. Because of this, we need to educate patients to follow pain responses over 24 hours after a loading session. In this time, pain should return to baseline.
Warm-up effect is normal: As mentioned, tendons often feel better mid-activity than at the start. This is always nice, but make sure things aren’t worse later.
The patient education piece matters here. I tend to say something like: "Pain doesn't necessarily mean your tendon is getting worse. What matters most is how you feel the next day. If your morning symptoms aren't elevated, we're on the right track." Getting patients to monitor 24-hour behavior rather than moment-to-moment pain is one of the highest-leverage things you can do.
Principle #3: Progressive Tendon Loading
Exercise-based rehabilitation is the most evidence-supported treatment for tendinopathy. Research protocols have shown that high volume eccentrics are very helpful for tendon pain but lead to less satisfaction than heavy slow resistance training (4). To my surprise, newer evidence actually shows BFR training was helpful at improving tendon structure in patients with patellar tendon pain (5). My bias is to still get folks to perform heavy slow resistance training as previous studies (6) have shown high strain magnitudes are important to assist in tendon remodeling. There are also other health benefits that only come with heavy loading (bone health etc). Below are the stages I usually take patients through. There aren't strict criteria to go from one stage to the next, and often there are components of each working simultaneously in one's program.
Summary
That is all for part 1. I hope this posts helps bring together a few concepts you may have heard elsewhere as you begin to develop your own framework for treating painful tendons. In part 2, I will discuss which interventions in the clinic with my patients day in and day out.
