Tendinopathy
Persistent tendon pain and reduced function from mechanical overload. A clinical diagnosis, not an imaging finding.
Terminology
“Tendinitis” and “tendinosis” are both discouraged. True inflammation is rare beyond the first 1 to 2 weeks, and painful and pain-free tendons look alike on imaging.
| Term | Meaning | Status |
|---|---|---|
| Tendinitis | Acute inflammation | Abandoned |
| Tendinosis | Degeneration, failed healing | Abandoned |
| Tendinopathy | Load-related tendon pain | Preferred |
Continuum (Cook and Purdam)
- Reactive: acute overload, reversible with load reduction
- Dysrepair: collagen disarray, neovascularisation, partly reversible
- Degenerative: matrix breakdown, poorly reversible
A clinical reasoning tool, not validated biology.
Presentation
- Pain on loading, eases with rest, returns next day
- Morning stiffness (“first steps are the worst”)
- Warm-up phenomenon: eases during activity, returns afterwards
- Focal tenderness, sometimes nodular thickening
Common sites
Achilles, patellar, lateral and medial elbow, rotator cuff, gluteal, proximal hamstring, peroneal, long head of biceps.
Management
- Load management is the treatment. Complete rest is counterproductive.
- Progressive loading: eccentric (3 × 15, twice daily, at least 12 weeks) or heavy slow resistance. Pain up to 4 to 5/10 is acceptable if settled by next morning. Choose the programme the patient will finish.
- Adjuncts
| Option | Evidence |
|---|---|
| Shockwave (ESWT) | The adjunct with the strongest evidence in chronic cases |
| Corticosteroid | Relief for 4 to 8 weeks, worse long-term outcomes, rupture risk |
| NSAIDs | Short-term symptom relief only |
| PRP | Inconsistent, not routinely recommended |
| Therapeutic ultrasound | No benefit over placebo |
Expect 3 to 6 months of consistent loading. Imaging changes persist after pain resolves, so do not rescan to “check healing”.
Red flag
sudden pop with inability to push off suggests rupture. Examine with the Thompson (Simmonds) test.
References
- Cook & Purdam, Br J Sports Med 2009, doi:10.1136/bjsm.2008.051193
- Millar et al., Nat Rev Dis Primers 2021, doi:10.1038/s41572-020-00234-1
- Silbernagel et al., J Athl Train 2020, doi:10.4085/1062-6050-356-19
Related
Medical disclaimer: this article is general information, not personal medical advice. Always consult a qualified doctor about your own situation.