1. Has different risk factors, mainly sudden change in activity levels

Although there is a number of different risk factors involved, tendinopathy generally occurs after a sudden change in activity levels. These can include an increase or change in load that involves walking, jumping, running, etc. Sometimes it is the sudden change in load – doing too much too soon, after doing too little for too long, and the tendons react acutely. Other times there may be biomechanical predispositions such as poor muscle capacity and strength that contributes to tendon pain over a period of time.

There are other systemic factors such as age, menopause, diabetes, elevated cholesterol, etc. that can increase someones susceptibility to tendon pain. People with these factors are more likely to develop tendon pain with no change or more subtle changes in their activity.

 

2. Rest is not the answer

Rest may help reduce pain in the short term, but the discomfort is likely to return once you resume the aggravating activity. This occurs because the tendon’s ability to handle the load has not been improved. Additionally, if a sudden change in load initially caused the tendon pain, complete rest followed by a return to activity only perpetuates an all-or-nothing cycle. This creates a repetitive pattern of abrupt changes in load, which keeps the tendon under strain.

 

3. Load modification is important

While complete rest is not effective, modifying activities is a key strategy in managing tendon pain. By adjusting activities, we can reduce the overall load on the tendon to a level that it can tolerate, helping to alleviate pain and prevent further irritation. Often, the goal is not to eliminate pain entirely, but to manage it. A mild level of pain during activity is generally acceptable, as long as it doesn’t worsen during the activity or persist for more than a few hours afterward. This approach is suitable for most people and helps maintain progress without overloading the tendon.

 

4. Passive treatments may help in the short term but not in the long term

Unfortunately, there is rarely a quick fix for managing tendinopathy. Treatments like massage, ultrasound, injections, and shockwave therapy may provide short-term relief, but they lack the essential component needed for long-term management. These approaches can be helpful when used alongside exercise, which is far more effective over time in reducing pain and helping you return to your preferred activities. Corticosteroid injections in particular should be avoided most of the time, as this is generally associated with poorer outcomes in the long term.

 

5. Imaging does not tell us about your pain

Imaging does not directly correlate with pain. While it can identify specific pathologies, many of these findings are also commonly seen in people who experience no pain. This doesn’t mean imaging isn’t relevant in certain cases, but even with severe pathology or tendon tears, the outcome may not necessarily be worse. When treatment is focused on improving pain and function, the pathology seen on imaging is unlikely to fully resolve, even in individuals who achieve excellent results. The priority should be on managing symptoms and enhancing function rather than trying to “fix” the underlying structural issues.

 

6. Evidence suggests exercise is the best line of care

As mentioned earlier, most tendinopathies stem from a mismatch between the strength or capacity of the muscle and the load or activity it’s being asked to handle. In addition to modifying your activity, it’s important to gradually build the muscle’s capacity to better manage the demands placed on it. The good news is that tendons are highly adaptable and can become stronger over time with the right exercise. Exercise programs need to be tailored to each individual, taking into account your current pain level, activity tolerance, and specific goals. The key is to personalise the exercise plan and progress it gradually, enhancing the tendon’s capacity while respecting pain limits.

 

7. Tendinopathy responds very slowly to exercise, it takes time.

The overall goal is to strengthen the muscle and improve the tendon’s ability to handle the load you want it to manage. Just like you wouldn’t expect to reach your strength goals after just one or two gym sessions, tendinopathy responds gradually to exercise and requires patience. It’s crucial that the exercise program is properly prescribed and progresses appropriately over time. As with most injuries, flare-ups are a possibility, which is why it’s important to be able to adjust exercises based on pain levels, progressing or regressing them as needed.