Tendinopathy: How to Deal With Chronic Tendon Pain

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Tendinopathy, tendinosis, tendinitis… three terms to describe basically the same injury. Confusing right? It should be! Part of the confusion around naming this injury is the fact that for the longest time we didn’t really know much around the SCIENCE behind the injury. Since then, we have made steps in deciphering this problem. The current theory of WHAT HAPPENS when this injury occurs was summarized nicely by a very recent review article (1):

  1. We start with tendon overload (more on this later)
  2. Tendon cells respond to the overload and not only reproduce (create more of themselves) but also produce more protein molecules
  3. The protein molecules do two things: disrupt the collagen system in the tendon (tendon’s are HIGH in collagen), and cause vascularization (blood vessels grow into the tendon)
  4. Vascularization likely leads to inflammation which often results in pain production


So what does that really mean? Well, in order to prevent injury we need to focus on modifiable factors. If you review the above, what we can modify is how much load we put on a tendon unit. Here is an example: You decide to start training at a boxing gym and within the last 6 months you have completed no regular exercise. A large part of boxing training is the aerobic component which, lets say, involves A LOT of skipping. You don’t skip, but now you are skipping for 15 minutes over the course of a one hour class. The day after the class your calves and achilles are sore, this is likely the start of a tendinopathy injury (it is truly considered “reactive tendinopathy” at this stage) (2). Incorrect recovery at this stage and continued overload to the muscle-tendon unit can lead you down the road to ‘tendon dysrepair’ or ‘degenerative tendinopathy’ (2), which is a much less favourable injury classification and much more challenging to rehab.


In order to avoid the development of this injury we need to know what it means to ‘overload’ a muscle-tendon unit. Unfortunately this is really difficult to QUANTIFY since it varies by person and by muscle-tendon unit.  We can assume however that overloading a muscle-tendon unit means that we expose the muscle-tendon unit to more force than it can tolerate. The tricky part is, muscle growth occurs when we overload the muscle and we force it to adapt. Tendinopathy injury occurs when we REPETITIVELY overload it. So looking back at our example of the boxer, they might complete 1000 skips or more of their body weight in the 15 minute session, but someone trying to strengthen their calves might lift their body weight PLUS 30 or 40 kilos for 30 to 40 repetitions total… this is truly a HUGE DIFFERENCE of load on the tendon.


So what types of activity can be the main culprits to injury? Here are a few examples:

  • Repeated high ‘compressive loads’ like hill running on the achilles and doing a ‘dip’ exercise on the biceps (1)
  • Repeated ‘tensile’ loads such as jumping, sprinting, skipping (1)
  • Improper programming to your training, or simply put, doing too much too soon (1)


Now, let’s say you are injury free at this time, what can you do to reduce your injury risk? Given that this is a repetitive overloading injury, the main preventative care revolves around controlling load to your body. This might mean consulting a physiotherapist, athletic therapist, or personal trainer on proper exercise dosing, programming, and establishing realistic fitness goals. If you didn’t read my last post on how awesome exercise can be, check it out here. If you are returning to a sport such as running, maybe you start at a lower mileage per week as not to overload your body. If you are pain free and running 2-3 times per week, increasing distance per run by 10% maximum on a 1-2 week basis is commonly regarded as safe. Alternatively, maybe you play soccer, volleyball or ultimate frisbee for a 4-6 month span throughout the year. In this case you may be able to limit the number of minutes you play in the early season and increase as you become conditioned again.


Finally, let’s say you have succumbed to injury of the tendinopathy type, what can your healthcare provider do to help? Great question…but you might not like the answer, because a lot of research points to EXERCISE! A thorough assessment is definitely required to highlight and treat contributing biomechanical faults (less optimal methods or ranges of movement), but more importantly to discuss safe and effective ways to reload the muscle-tendon unit. Let’s consider two scenarios to compare the method of treatment from a physiotherapeutic perspective:


Scenario 1: Client decides to run a 5 km ‘fun-run’ despite never running regularly in the past. Reporting achilles pain after the run and it has only been 2 days since running.

  • This person is likely in the ‘reactive tendinopathy’ stage so we have a chance to rest (let’s say one week) and manage the risk of this developing into a more serious injury
  • Once cleared to return to running, education around dosing (mileage, speed), frequency, and rest is key to preventing future injury


Scenario 2: Same client above but after the 5 km ‘fun-run’ they decided to continue running three times a week, 5 km each time for one week and then increasing to three 8 km runs per week. They also report achilles pain at the start of the run that improves with running and then feels sore after the run (sound familiar?). It has been 3 months since the initial pain started and this is their first visit with the physiotherapist.

  • First and foremost, this scenario is way less awesome than the one above as this client is either in the tendon ‘dysrepair’ or ‘degenerative’ phase
  • Instead of a week, we may be looking at a 3-4 month recovery plan (I’d suggest re-reading the prevention section!)
  • Complete rest is NOT INDICATED, but a progressive loading programming to build tendon tolerance is (1,2)
  • Here are the types of exercise we can incorporate to build tendon tolerance
    • Isometric exercise (engage the injured muscle without your body moving) has been shown to be beneficial for pain management (3)
    • Eccentric exercise (slowly lengthening the injured tendon while loading it) and heavy slow resistance training (slowly shortening and lengthening the tendon while loading it) are an effective way to control the dose of loading to the tendon and aid with recovery (1,2,4)


If all biomechanical factors are clear or managed, the remainder of the rehabilitation process is fairly straight-forward as long as adherence to your rehab program is maintained and activities that can lead to overload are controlled/minimized. Obviously there is some complexity to prescribing and progressing exercising for this type of injury, so please consult your trusted physiotherapist so that a safe and effective rehabilitation program is implemented for your needs.


Lastly and in the spirit of bringing on Dr. Johann, our expert in Naturopathic medicine, I wanted to highlight a few of the key treatment options he would utilize when treating tendinopathy.  Similarly to physiotherapist, naturopathic medicine is concerned with the management of pain and inflammation, circulation, and collagen strength:

  • Pain and inflammation can be modified through medications quite easily, but unfortunately some over-the-counter medications can impair tendon remodelling (5) . Certain natural therapies (including acupuncture) can improve pain, inflammation, AND support repair. (6,7)
  • Circulation and lymphatic drainage are naturally important for tissue repair, and natural therapies have been shown to help with both! (8)
  • Collagen is a key constituent to tendon structure. Being able to appropriately supplement some of the building blocks of collagen (ex. Vitamin C, proline, glycine) may further facilitate tendon repair. (9)
  • BONUS: chronic tendinopathy may result in negative effects on the cartilage. Previously, it was thought that cartilage repair was limited throughout the body due to its poor blood supply. More recent evidence suggests that certain supplements for cartilage repair can now enter the cartilage tissue through specialized proteins that we all have in our body! (10)

There is a lot more to it than simply reading this list, and a tailor-made approach is necessary when prescribing these treatments, so please keep that in mind and consider consulting Dr. Johann for more information.


As always, thanks again for reading!

Jordan Fortuna, Manager of Clinical Services

Jordan is a graduate of the University of Toronto Physiotherapy program and has since been practicing in orthopaedic settings. He has developed an interest in sports physiotherapy through his many years as an athlete, participating in baseball, golf, snowboarding, and more recently rock-climbing, cycling, and strength training. He has worked with a variety of clientele including athletes from disciplines such as competitive dancing, running, rock-climbing, and mixed-martial arts, as well as non-athletes of a wide age range and ability. Regardless of activity level, he is dedicated to improving mobility, optimizing function, and strengthening to help achieve your goals through the use of an individualized exercise prescription and manual therapy. He also has additional training in acupuncture and sports taping.


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  1. Cardoso, TB, Pizzari, T, Kinsella, R, Hope, D, and Cook, JL. Current trends in tendinopathy management. Best Practice & Research Clinical Rheumatology. 2019; available online 8 March 2019.
  2. Kaux, JF, Forthomme, B, Le Goff, C, Crielaard, JM, and Croisier, JL. Current opinions on tendinopathy. J of Sports Sci and Med. 2011; 10: 238-253.
  3. Rio, E, Purdam, C, Girdwood, M, and Cook JL. Isometric exercise to reduce pain in patellar tendinopathy in-season; Is it effective “on the road”?. Clin J Sport Med. 2017; 0: 1–5.
  4. Burcal, CJ, Rosen, AB, Taylor, T, and Nicola, M. Best practices in patellar tendinopathy management: An evidence to practice review. Clin Pract Athl Train. 2019; 2(1): 4-10.
  5. Carroll, CC. Analgesic Drugs Alter Connective Tissue Remodeling and Mechanical Properties. Exerc Sport Sci Rev. 2016; 44(1) 29-36.
  6. Neal, B, Longbottom, J. Is there a role for acupuncture in the treatment of tendionpathy? Acupunct Med. 2012; 30(4); 346-9.
  7. Zhu, L; Zhao, F.; Cui, R. Effect on acupuncture on release of substance P. Ann N Y Acad Sci. 1991’ 632;488-9
  8. Lipman, K, Wang, C, Ting, K, Soo, C, Zheng, Z. Tendinopathy: Injury, repair, and current exploration. Drug Des Devel Ther. 2018; 12: 591-603.
  9. Preaet, S. Purdam, C, Welvaert, M, Vlahovich, Lovell, G, Burke, L, Gaida, J, Manzanero, S, Hughes, D, Waddington, G. Oral Supplementation of Specific Collagen Peptides Combined with Calf-Strengthening Exercises Enhances Function and Reduces Pain in Achilles Tendinopathy Patients. Nutrients. 2019; 11(1): 76
  10. Rees, J, Stride, M, Scott, A. Tendons – Time to revisit inflammation. British Journal of Sports Medicine. 48(21); 2014; 48; 1553-7

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