Tendinitis, Tendinosis, Tendinopathy: A Guide to Optimising Recovery

Tendinitis, Tendinosis, Tendinopathy: A Guide to Optimising Recovery

January 12, 2025

So you may have already heard the term “tendinopathy” or more likely “tendinitis” or perhaps “tendinosis” but maybe unsure what this actually is and how you can get it better. Before we dive into what is meant by the terminology, let’s have a quick reminder of what is a tendon.

Tendons are fibrous connective tissue that attaches muscles to bones which helps the transmission of force produced by our muscles onto the anchor point of the bone, creating movement.

So what is a Tendinopathy?

Previously the term tendinopathy used to be characterised as tendonitis or tendinosis. The term tendonitis traditionally refers to the inflammation of a tendon. It is often used to describe acute conditions where there is swelling and pain associated with a tendon injury. However, the term can be misleading as it implies a significant inflammatory component, which may not always be present in chronic cases. Whereases the term tendinosis describes a chronic condition characterized by degenerative changes in the tendon without significant inflammation. It typically involves the accumulation of poor-quality collagen and structural disorganisation within the tendon due to repetitive stress and overuse. A tendinopathy is a tendon that is still intact, and generally still very strong, but is aggravated – and typically quite easy to annoy. This is a classic example of what physiotherapists refer to as a ‘Irritable’ pathology.

A good guide is to look at the suffix in the name of the condition e.g.:

  • ‘itis’ indicates inflammation
  • ‘osis’ is more indicative of a generic pathological disorder but was used in tendon issues to separate from tendinitis as a way to state a non-inflammatory disorder
  • ‘opathy’ simply refers to a disease of disorder, so tendinopathy = tendon disorder, neuropathy = nerve disorder etc.

 These days the best evidence we have suggests using the term tendinopathy, which is essentially an umbrella term that encompasses both tendinitis and tendinosis. This term refers to a spectrum of tendon injuries that can include inflammation, degeneration, or a combination of both. The term is used to describe non-rupture injuries in the tendon or paratendon that are exacerbated by mechanical loading.

Some of the most common tendinopathy sites for the general population are seen in the shoulder (Rotator Cuff Tendinopathy) and outside of the elbow (Tennis Elbow/Lateral Epicondylitis) and for the athletic population, this issue can be more commonly seen in the achilles tendon and the patella tendon.

How does this happen?

Tendinopathies can occur as a result of a combination of mechanical, biological, and environmental factors that lead to tendon injury and degeneration.

However the mechanism we know that tends to trigger the issue in most people comes down to doing ‘Too Much, Too Soon’

This can be anything from doing too much of a repetitive action, going too hard or too heavy on a lift or movement, remaining with a joint in a position too long. Couple this with having too little preparation and you have your mechanism for developing tendinopathy.

Some people will be able to remember a day where one of these things happens, for many others it will be a slow build up over a period of time – generally tendinopathy will have a more unclear presentation than an acute trauma in which there is a sudden and memorable moment of discomfort.

Though we know from the science that there are many underlying components and gentle risk factors. The process can be summarised as follows:

  • Mechanical Overload:
    • Tendon injuries often begin with excessive loading, which can be due to increased training volume, intensity, or abrupt changes in activity. This overload can lead to microtrauma in the tendon fibers, disrupting their structural integrity.
  • Biological Response:
    • The initial mechanical overload triggers a biological response in the tendon. This includes inflammation and a cascade of cellular events aimed at repairing the damaged tissue. However, if the loading continues or is excessive, this repair process can become maladaptive, leading to degeneration rather than healing.
  • Movement Dysfunction:
    • Tendon pain often results in motor inhibition, where the affected muscles reduce their activity, leading to altered movement patterns. These faulty movement patterns can place abnormal loads on the tendon, contributing to chronicity and slow resolution of symptoms.
  • Intrinsic Factors:
    • Factors such as age, obesity, previous and pre-existing medical conditions (e.g., diabetes, dyslipidaemias) can predispose individuals to tendinopathy by affecting tendon structure and function.
  • Extrinsic Factors:
    • Environmental conditions (e.g., temperature, surface) and training errors (e.g., poor-quality equipment, footwear) can also contribute to the risk of developing tendinopathy.

How long with it take to get better?

Tendinopathy is generally a very slow recovery, often ranging from 6-18 months, in most cases the recovery can be significantly enhanced and surprisingly often sped up thanks to physiotherapy.

Timescales will vary widely from each condition depending on the location of your tendinopathy and other lifestyle factors. However, what we do know from the research that building tendon tissue takes at least 6-12 weeks so if you’re not seeing any improvement in those first few weeks of your programme try not to worry.

How can Physiotherapy help?

Firstly, physiotherapy can help with diagnosing whether you have a tendinopathy or not following an initial assessment. This will involve listening to your story of what may have happened or changed in your day-to-day life. From here on an objective assessment will take place to assess the quality of your movement and utilise further clinical tests to help determine whether you have a tendinopathy or not. Then it’s on to how you and your physiotherapist work together to plan out your recovery!

Physiotherapy: Exercise-Based Rehabilitation and Activity Modification

Crucially, what we know from recent scientific evidence physiotherapy can help tailor an exercise programme to help you build the tendon back to the tasks and activities you are required. The type of exercises can vary as research has shown successful outcomes for programmes that include isometric exercises, eccentric exercises and heavy slow resistance exercise. Knowing how and when to progress exercises and return to higher level of functional activities and sports pursuits can be crucial for optimising recovery, and as you would expect, there are a great many factors to consider in tendinopathy rehab.

Our goals of your recovery programme are varied, but generally they will involve: Modifying load to reduce aggravation, rebuild the ‘Load Capacity’ of the tendon by instilling a personalised exercise programme that is suitably challenging, monitoring and adapting the protocol and prescription of the programme based on how you respond over the coming weeks, guiding graduated return to activities, and managing symptoms  & flare-ups where possible. Rehab needs to be individualized and gradually progressed or at times regressed, patience is key!

Here are 5 important points to consider that make tendinopathy rehab unique, and rather tricky:

  • Rehab, don’t fully rest. While rest will reduce the pain, the underlying issue remains as the tendon’s capacity has not improved – pain will likely recur on return to the activity you have had to take a break from.
  • Exercise is the most backed treatment for tendinopathy from scientific research – in order for a tendon to change, we must give it the stimulus to learn to adapt to higher loads.
  • Load management is still key. Reducing, or even ceasing, the most aggravating activities allows time for the tendon to adapt without being abused, and means rehab can be added without increasing the overall load. This strategy is sometimes referred to as ‘Relative Rest’.
  • Rehab must be individualised. A person’s daily load, pain level, pain tolerance, athletic pursuits, job stresses, and goals are entirely unique. And rehab plans must assess for this, checking in with physio’s on a relatively regular basis allows the pattern to be more clear and progressively increasing your rehab is more likely to be successful.
  • Unclear timescale of recovery, tendons heal very slowly, patience and perseverance is key – there are no short cuts.

Concluding Thoughts

Alongside this, physiotherapy can help you manage this through various avenues from manual therapy techniques such as massage and deep transverse frictions that may help you manage your pain. Other strategies may be trialled such as taping techniques, dry needling, extracorporeal shockwave therapy (which you can read about here) to help you manage your pain on a day-to-day basis.

If you found this helpful or you feel you may have a tendon issue. Drop us an email or book in for your assessment now and we can help you get back to doing what you love.

To get in contact you can call us at 01324 227 370 or drop us an email at info@espphysio.com and we will get you going in no time!

Written by Adam Gilmartin BSc (Hons), MSc, MCSP, MHCPC and Student Physiotherapist Damien McCoy

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