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What is Tendinopathy?



A tendon is a connective tissue that attaches muscles to bones. They have the capability of storing energy as well as releasing energy to allow for efficient movement. Tendon injuries typically occur at insertion points near joints, however than can also occur within the muscle belly. It may seem tendon injuries occur spontaneously, though it is usually a result of repetitive overload.

In recent years tendon injuries have been referred to as tendonitis, which refers to an inflammatory process. If tendons are repetitively and chronically stressed in the same manner they endure microtears. Microtears encourage inflammatory chemicals and swelling creating acute pain. The purpose of the inflammatory response is to minimize cellular injury and initiate the healing process. Signs of inflammation include: redness, swelling, heat and pain.

This inflammatory process lasts approximately 3-6 days and if treated correctly will resolve. Most individuals who experience a tendon injury do not seek a healthcare provider until weeks after the initial incident. This is when tendons are no longer inflamed but instead begin to become degenerative from suboptimal healing, lacking sufficient strength.


Rapid, repetitive and blunt forces are primary mechanisms that produce tendon breakdown. Tendons have the capacity to withstand high loads from various directions and will adapt to the stresses they are exposed to. However, if the same load is continuously applied there will be an imbalance between the rate of breakdown and repair. This creates a weakened, less resilient, tendon unable to tolerate high loads or generate sufficient strength.

Tendinopathies do not respond well to anti-inflammatory treatments thus are treated best with functional rehabilitation to restore strength. Strength work to enhance tendon load capacity is essential to improve tissue healing and prevent re-injury. The load a tendon is exposed to is the most critical variable in improving function. Load refers to:

Volume: The amount of work done (total number of sets/reps)  

Frequency: How hard you work (how heavy the weight is)  

Intensity: How often you train or perform a certain movement (days per week)

In order to optimize healing and incorporate proper loading strategies exercise selection should be specific to the individual and take into account where an individual sits on the continuum of tendon pathology.

Tendinopathy Phases

1. Reactive Tendinopathy

  • Normal tissue adaptation response to decrease stress

  • Acute pain with thickened tendon due to swelling

  • Prognosis: Excellent

2. Tendon Dysrepair

  • Injury rate exceeds Repair rate

  • Prognosis: Good. Attempting to heal   

  • Proper work to rest ratio

3. Degenerative Tendinopathy

  • Areas of cell death

  • Prognosis: Suboptimal

  • Proper Loading Program


The below risk factors are not all inclusive but can give you an idea of what a health professional looks for to help you make modifications for an optimal outcome.

Intrinsic risk factors

  • Previous Tendon injury

  • Age

  • Gender

  • Inadequate strength/power

  • Insufficient flexibility

Training risk factors

  • Sudden change in activity- (increasing overall training or increasing from recent time off)

  • Changes in loading – (volume, intensity)

  • Frequency of training

  • Improper technique biomechanics (unwanted stress on certain tendons)


Current research and rehabilitation has shifted away from the RICE (Rest, Ice, Elevate, Compress) mindset. This is especially true of tendonopathies as rest may worsen symptoms and tendon health. Rest further weakens the tendon and associated muscle making it prone to re-injury, as it will not have the strength or compliancy to endure loads placed upon it. Additionally, rest yields a suboptimal environment for healing to take place. Thus, exercise, even at the acute reactive phase, is the preferred and most validated method of treatment.

Exercises should be designed to improve the load capacity of the affected tendon and muscle as well as the rest of the kinetic chain. The first step in managing tendinopathy is to reduce pain. This can be accomplished by isometrics as well as skilled manual therapies/modalities such as: cupping, dry needling and instrument assisted soft tissue mobilization. Not only are these techniques effective for reducing pain but encouraging a proper environment for tendon healing.

After pain has been reduced general strength and eventually functional strength should be obtained. Strength is defined as the ability to produce force. In regard to tendon injury the goal is to improve the muscle and tendon’s ability to produce force and manage load. This is accomplished via a combination of eccentric and concentric work and heavy slow resistance training. Many times after strength is equal to the uninjured limb an individual returns to prior activity level. However, power, plyometrics and sports specific drills are also implemented at Rehab2Perform to ensure a truly resilient tendon.  

If you are experiencing acute or chronic tendon injury schedule an appointment with Rehab 2 Perform on determining the best plan of care that is individual to your needs.

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