Tendinopathy: Understanding Persistent Tendon Pain and Treatment Options

A tendon connects a muscle to a bone. When the muscle contracts, the tendon transfers that force to the skeleton, which is what allows you to walk, run, grip an object or lift your arm. A healthy tendon is both strong and elastic, and it tolerates repeated loading throughout the day.

Tendinopathy is the term for persistent tendon pain together with a reduced ability of the tendon to tolerate its usual demands. The tendon becomes sensitive, it copes less well with load, and certain movements become painful or less effective.

This relationship between tendon capacity and the demands placed on it sits at the centre of treatment, far more than the idea of a simply inflamed tendon.

The word tendinitis, also spelled tendonitis, literally suggests inflammation of the tendon. Tendinopathy is the broader term: it describes persistent tendon pain and impaired tendon-related function without assuming a single mechanism.

Inflammatory processes can play a role, particularly in certain stages or clinical situations. But persistent tendon pain is often more complex than ongoing inflammation alone.

So saying that tendinopathy is simply inflammation is inaccurate, and saying that tendinopathy has nothing to do with inflammation is equally simplistic. Both statements oversimplify a multifactorial condition.

Tendinopathy can affect many tendons, but some locations are particularly common.

Pain often appears when lifting the arm, reaching for something above shoulder height or working with the arms out in front. Night pain, especially when lying on the affected shoulder, is possible. Not every shoulder pain is a tendon problem, which is exactly what clinical assessment helps to clarify.

This causes pain around the outer elbow, often provoked by gripping, lifting, using tools or repetitive hand and forearm activity. The term tennis elbow is widely used, although most affected people do not play tennis.

Pain and stiffness are felt in or around the Achilles tendon or where it attaches to the heel, during or after walking, running or sport. Start-up stiffness in the morning or after sitting is common and often eases with movement.

Pain is located just below the kneecap, over the patellar tendon. It is often associated with jumping, running, acceleration or repeated knee loading, and is typically provoked by stairs and squatting.

Tendinopathy can also affect other tendons, including at the wrist, hip or foot. The clinical reasoning stays the same: understand the tendon involved, the demands placed on it and the factors keeping symptoms going.

Calcium deposits can develop within a tendon, most commonly in the rotator cuff of the shoulder. These deposits can cause pain that is sometimes intense, but they are also found in people who have no symptoms at all.

A calcification seen on imaging therefore does not automatically explain someone's pain, and management depends on the whole clinical picture.

Symptoms vary with the tendon involved, how long the problem has been present and the demands of your daily activities.

Pain intensity does not tell us exactly how much structural change exists in a tendon. Severe pain does not automatically mean severe tendon degeneration, and the reverse is also true.

A single explanation is rare. Several factors usually combine, and their relative importance differs from person to person.

Overuse is therefore not always the explanation. Some people develop tendinopathy without sport or obvious repetitive strain, which is a reason to look beyond local mechanics alone.

Tendon health is not determined by local mechanics alone. Research has identified associations between tendinopathy and certain metabolic conditions.

A systematic review with meta-analysis found a substantially higher prevalence of tendinopathy among people living with diabetes. Other work, including a recent systematic review on metabolic disorders and tendinopathies, continues to examine dyslipidaemia, metabolic health and body composition.

These findings describe associations rather than causation, and they do not explain every tendinopathy. They are, however, one reason why in selected patients it can be useful to consider the broader health picture rather than looking only at the painful tendon.

When pain lasts, several elements usually interact.

When pain persists, the nervous system can gradually become more responsive to pain signals. This does not mean the pain is imaginary, and it does not mean there must be ongoing tissue damage. It means that persistent pain becomes more complex than a simple tissue alarm.

Read: Why does tendon pain persist? You can also read about our approach to chronic pain.

Assessment is primarily clinical: what you feel, since when, in which circumstances and with what functional consequences.

Not routinely. Typical tendinopathy is usually diagnosed clinically. Imaging becomes useful in selected situations.

Depending on the question, ultrasound or MRI may be relevant. X-ray does not image the tendon directly, but it can answer specific questions such as calcification or bone-related pathology.

Tendinopathy rarely has a single treatment that is right for everyone. Depending on the tendon involved, how long symptoms have been present and the factors contributing to the problem, treatment may combine movement and progressive loading, modification of aggravating activities, recovery strategies and other treatments aimed at pain and the broader clinical picture.

These elements do not have to follow a fixed sequence. They can run alongside each other, and they are reassessed and adapted as we see how you respond.

Tendons adapt to what is asked of them. Appropriate, progressive loading is often a central component of tendinopathy management, and it can take place alongside other treatments rather than instead of them.

The right amount and type of loading depends on the tendon involved, how irritable the symptoms are, current capacity, work or sporting demands and the stage of recovery. Progressive strengthening or specific tendon-loading exercises are frequently part of this.

Exercise programmes need to be individual and cannot be prescribed online. No single modality cures every tendinopathy, and the logic is never to push through significant pain.

Temporarily modifying activities that strongly aggravate symptoms can be useful. Prolonged complete rest, however, reduces tendon capacity and is usually not the objective in persistent tendinopathy.

The principle is to adapt load rather than eliminate it, when this is clinically appropriate.

You may already have been prescribed pain-relieving or anti-inflammatory medication for tendon pain. These treatments may have a role in certain situations, particularly for short-term symptom management, depending on the diagnosis and individual health factors.

At Centre Algos, we take medication you are already using into account when assessing your symptoms, previous treatments and overall health. We may also consider other approaches as part of the wider treatment strategy.

A corticosteroid injection can provide short-term pain relief for some tendon-related conditions. The benefit varies with the tendon and the diagnosis, and repeated injections are not a universal long-term solution.

The decision depends on location, diagnosis, expected benefits and potential risks, and is made case by case. Many patients want to explore options without cortisone, and that can be discussed calmly, without setting approaches against each other.

Some situations call for specialist assessment or a specific procedure, particularly a tendon rupture, a significant structural tear, major and persistent functional limitation, certain calcific tendon problems, or a diagnosis that remains uncertain.

We do not work with a standard treatment package. Depending on your situation, some of the following may be discussed with you.

Percutaneous hydrotomy may be considered for selected persistent or recurrent tendon problems. It uses very fine superficial intradermal and subcutaneous injections of sterile physiological saline NaCl 0.9% in the area being treated, rather than a deep injection into the tendon itself.

The formal evidence base for percutaneous hydrotomy in tendinopathy is more limited than the evidence for established tendon-loading rehabilitation. We state this openly: we explain what is known, what remains uncertain, and we decide together whether the treatment is appropriate in your individual situation.

Learn more about percutaneous hydrotomy

Tendon health can be influenced by more than mechanical load alone. In selected patients, broader factors such as metabolic health, nutritional status, recovery and certain health conditions may be relevant to the overall clinical picture.

When the history or clinical situation suggests that broader factors may be relevant, we may use targeted functional assessment or laboratory testing rather than looking only at the painful tendon. This does not mean that every person with tendinopathy needs extensive testing, and laboratory abnormalities should not automatically be assumed to be the cause of tendon pain.

Learn more about Functional Biology & Micronutrition

Phytotherapy may be considered as a supportive part of an individual strategy, depending on your symptoms, overall health and other treatments. Where appropriate, we integrate it into the broader treatment strategy.

Most tendon pain is not an emergency. Some situations, however, deserve prompt medical assessment.

If tendon pain is limiting sport, walking, work, sleep or everyday activities, an assessment can help clarify what may be contributing and which options are appropriate.

At Centre Algos, we review your symptoms, history, functional limitations, previous treatments and broader clinical factors where relevant. We then discuss the available options and build the treatment plan together. You can request a consultation.