Tendinopathy is one of those conditions that tends to hang around longer than anyone would like – especially in runners, gym-goers, and field sport athletes. When tendon pain lingers past the early reactive stage, it becomes a chronic issue – often driven more by load mismanagement and tendon degeneration than inflammation.
In this blog, we’ll break down:
● The tendon continuum model
● Why chronic tendinopathy behaves differently from acute pain
● How we, as physiotherapists, guide long-term tendon rehabilitation through progressive loading
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What is Chronic Tendinopathy?
Chronic tendinopathy refers to a non-inflammatory condition involving degeneration and disorganisation of tendon tissue, often due to cumulative overload over time. It’s no longer about swelling or an ‘itis’ – the problem lies in the tendon’s structure and its inability to tolerate repeated force (1).
You might see this in conditions like:
● Achilles tendinopathy
● Patellar tendinopathy
● Gluteal tendinopathy
● Proximal hamstring tendinopathy
● Tennis/golfer’s elbow (lateral/medial epicondylalgia)
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The Tendon Continuum Model (Cook & Purdam)
This framework helps guide both diagnosis and treatment by describing the tendon’s state and its response to load:
- Reactive Tendinopathy: A short-term, non-inflammatory response to excessive load. Usually seen in younger athletes or after a sudden spike in training.
- Tendon Disrepair: The tissue begins to show structural changes, with disorganised collagen and increased vascularity. Load tolerance drops.
- Degenerative Tendinopathy: Common in older or chronically overloaded tendons – extensive matrix breakdown and very poor load capacity. Often seen in people with longstanding symptoms (2).
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Key Point: Chronic tendinopathy usually sits in the tendon disrepair or degenerative phase. Rest alone won’t help. It needs structured, progressive mechanical loading to restore function.
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Assessment Considerations for Chronic Tendinopathy
When a patient presents with persistent tendon pain, a detailed assessment helps us determine the stage of their
condition and build a targeted plan.
Subjective Clues:
● Dull, aching pain that worsens with use (e.g. after running, stairs, jumping).
● Morning stiffness or pain at tendon insertion.
● Long history of “off and on” flare-ups, often linked to load changes.
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Objective Findings:
● Pain on palpation over the tendon or enthesis.
● Pain and/or weakness during resisted isometric contractions (3).
● Reduced tendon loading capacity (e.g. single leg heel raises for Achilles, decline squat for patellar
tendon).
● Compensation during functional movements (valgus collapse, trunk sway, altered running gait).
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Load Tolerance Testing:
Tools like handheld dynamometers (e.g. ActivForce) or force plates (e.g. VALD Hub) can help quantify deficits and identify left-right asymmetries in force production and rate of force development (RFD).
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Exercise Prescription: What Works in Chronic Tendinopathy?
Forget about anti-inflammatories and stretching – the evidence overwhelmingly supports progressive loading as the cornerstone of tendon rehab. Here’s a phased outline:
Early Stage – Isometric Loading
Goal: Reduce pain and begin stimulating the tendon (4).
● Example exercises:
○ Mid-range isometric holds (e.g. wall sits for patellar tendinopathy, isometric heel holds for
Achilles).
○ 45-second holds, 4–5 reps, up to 3x/day.
● Why: Reduces pain through cortical inhibition and begins gentle tendon loading without excessive strain.
Mid Stage – Heavy Slow Resistance (HSR)
Goal: Improve tendon structure and muscular strength.
● Progress to:
○ Slow, heavy resistance (e.g. heavy leg press, eccentric decline squats, weighted heel raises).
○ 3–4 sets of 6–8 reps, 2–3 times per week.
● Why: Encourages tendon remodelling and increases load tolerance. Slower tempos reduce reactive
flare-ups (5).
Key Tip: Avoid explosive or plyometric work at this stage.
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Late Stage – Plyometric and Functional Reintroduction
Goal: Build power and prepare for return to sport or full function (6).
● Progress to:
○ Bounding, skipping, single-leg hopping, loaded jumping drills.
○ Change of direction, acceleration/deceleration tasks for field athletes.
● Monitor: Rate of force development (RFD) and asymmetry using force plate analysis if available.
● Reinforce motor control strategies and kinetic chain involvement (hip/knee/trunk coordination).
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Load Management Principles to Remember
1. “Goldilocks” Loading: Not too much, not too little – just right. Monitor pain response 24 hours after loading (7).
2. Pain Monitoring Model (Silbernagel): Mild pain (≤3/10) during or after exercise is acceptable, as long as it doesn’t worsen over time (8).
3. Avoid Compressive Load: Be mindful of positions that compress the tendon (e.g. long sitting with hamstring tendinopathy, deep hip adduction in gluteal tendinopathy).
4. Long-Term View: Tendons adapt slowly. Rehab may take 3–6 months or longer in longstanding cases.
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Other Considerations in Chronic Tendinopathy
● Extracorporeal Shockwave Therapy (ESWT): Can be useful adjunct in degenerative tendinopathy where loading alone stalls progress.
● Energy Deficiency: Especially in female athletes – screen for RED-S if symptoms don’t improve.
● Biomechanical Contributors: Poor pelvic control, ankle mobility restrictions, or poor movement patterns often need addressing alongside local loading.
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Conclusion
Chronic tendinopathy is not a condition you can foam roll, stretch, or rest your way out of. It’s a complex interplay of tendon pathology, biomechanics, and loading history – but one that responds brilliantly to well-structured, progressive rehab.
As physiotherapists, our role is to:
● Identify the tendon’s current capacity
● Load it with intention and structure
● Address the kinetic chain
● Guide patients back to their goals – whether that’s running a marathon or playing five-a-side without
flare-ups
Our Barnet, Cockfosters & Enfield Physio’s have tons of experience and are specialists in treating chronic tendinopathy. Have confidence that our specialist Physiotherapists will closely assess, diagnose & treat you in the correct & evidence-based way for all injuries. You can book an appointment here.
Blog By: Emre Oz (Musculoskeletal Physiotherapist at Crouch Physio).
References
- Millar, Neal L., et al. “Tendinopathy.” Nature reviews Disease primers 7.1 (2021): 1.
- Cook, J. L., et al. “Revisiting the continuum model of tendon pathology: what is its merit in clinical practice
and research?.” British journal of sports medicine 50.19 (2016): 1187-1191. - MacDermid, Joy C., and Karin Grävare Silbernagel. “Outcome evaluation in tendinopathy: foundations of
assessment and a summary of selected measures.” journal of orthopaedic & sports physical therapy
45.11 (2015): 950-964. - Clifford, Christopher, et al. “Effectiveness of isometric exercise in the management of tendinopathy: a
systematic review and meta-analysis of randomised trials.” BMJ open sport & exercise medicine 6.1
(2020). - Prudêncio, Diego Ailton, et al. “Eccentric exercise is more effective than other exercises in the treatment
of mid-portion Achilles tendinopathy: systematic review and meta-analysis.” BMC Sports Science,
Medicine and Rehabilitation 15.1 (2023): 9. - Ramírez-delaCruz, María, et al. “Effects of plyometric training on lower body muscle architecture, tendon
structure, stiffness and physical performance: a systematic review and meta-analysis.” Sports
medicine-open 8.1 (2022): 40. - Jahn, Jacob, Quinn T. Ehlen, and Chun-Yuh Huang. “Finding the goldilocks zone of mechanical loading:
A comprehensive review of mechanical loading in the prevention and treatment of knee osteoarthritis.”
Bioengineering 11.2 (2024): 110. - Silbernagel, Karin Grävare, Shawn Hanlon, and Andrew Sprague. “Current clinical concepts: conservative
management of Achilles tendinopathy.” Journal of athletic training 55.5 (2020): 438-447.
