Treating Tendinopathy with Physical Therapy

What comes to mind when you look at the four diseases below?

  • Rotator cuff pain(shoulder)
  • Pre-patellar pain(knee)
  • Achilles pain(ankle)
  • Tennis/golfer’s elbow

These diseases have something in common: tendon related pain.

Common Tendon Injuries

Tendinopathy is a failed healing response of the tendon, with haphazard proliferation of tenocytes, intracellular abnormalities in tenocytes, disruption of collagen fibers, and a subsequent increase in non-collagenous matrix.

Tendon Pathophysiology

Tendinopathy Pathophysiology
Tendinopathy has 4 different stages.

  1. Normal tendon
  2. Reactive tendinopathy
  3. Tendon dysrepair
  4. Degenerative tendinopathy.

Various treatments can help Tendon dysrepair to Normal tendon but, once it becomes degenerative tendinopathy, there is a rare chance to get back to normal tissue.

What is a Tendon

tendons and ligamentsIt won’t be easy for ordinary people to tell the difference between tendon and ligament.

Simply explain, tendons are tissues that connect bones and muscles. On the other hand, ligaments are tissues that connect bones to bones.

Tendons are dense fibrous tissues that bind the muscles to the bone.

They play an important role in the movement by transmitting the contraction force produced by the muscles to the bone they hold. (absorbing and emitting force)

At the same time, their contribution to stability to the joints is extremely important.

Why does tendon tissue have a pain?

When it comes to tendon pain, there are two diagnoses generally.

  1. Tendinitis:  Pain caused by inflammatory reactions around tendon area such as Achilles tendinitis and patellar tendinitis
  2. Tendinopathy: Pain due to degenerative changes of the tendon itself such as Achilles tendinopathy and patellar tendinopathy.

If you have the following symptoms, you are more likely to have tendinopathy than tendinitis.
(It is most accurate to take a physical examination and an imaging examination together.)

  1. Rather than the pain spreading, one area is specifically painful.
  2. It hurts more when you’re under load or when you’re accompanied by movement than when you’re resting.
  3. Pain with compression and stretched.
  4. Pain occurs during exercise, and the pain gets worse after exercise.
  5. There is stiffness in the morning, and stiffness decreases after one to two hours of activity.

Why does tendinopathy occur? (Risk factors)

  1. When tendon load capacity is low due to a long time of unloaded situation but there are many uses for it. For example, people who have a low capacity in tendons of the elbow but play tennis without making strong tendon tissues.
  2. When tendon tissue is exposed to excessive load with no proper recovery. (Mainly athlete, sportsman)
  3. Systemic problem (Diabetes and cholesterol problems, and ETC)

Physical Therapy Management of Tendinopathy

  1. Therapeutic exercises (progressive weight-loading on the damaged tendon)

Muscle ContractionIsometric contractions provide an early starting place for loading, especially for a sensitive tendon. Whether the patient is fearful of loading the tendon or prone to flare ups, isometric exercises can start the loading progression and empower the patient to continue improving the tissue tolerance of the tendon. If the isometric contraction also provides analgesia, this would be an additional benefit to starting to place load on the tendon.

With that being said, isometrics are not always necessary in the loading progression of a tendinopathy. While eccentric exercises have been considered to be the standard tendinopathy rehabilitation, it does not appear that isolating eccentric contractions is superior to concentric-eccentric contractions. If the tendon can tolerate isotonic loads, then the loading progression can start at concentric-eccentric muscle contractions.

In conclusion, the choice on loading progression for a patient with tendinopathy will depend on their individual tolerance to load. For some isometric exercises are an appropriate place to start loading on the tendon and may produce analgesic effects. For others with a higher tissue tolerance, concentric-eccentric loading may be an appropriate starting place.

2. ESWT (Extracorporeal Shockwave Therapy)

ESWT is of interest to clinicians for two reasons. Firstly, it is said to stimulate the metabolic activity of the targeted cells, to promote tissue healing; and secondly it is hypothesized to have an influence on the localized nociceptors, interfering the pain pathway to the brain.


  1. Thermotherapy (laser, ultrasound, heat pack)

The goal of thermotherapy is to alter tissue temperature in a targeted region over time for the purpose of inducing a desired biological response. The majority of thermotherapies are designed to deliver the thermal therapy to a target tissue volume with minimal impact on intervening or surrounding tissues.

  1. Electrotherapy (TENS; Transcutaneous electrical nerve stimulation)

TENSThrough a TENS machine, electrical impulses are transmitted to the skin via electrode pads, which has two effects. Firstly, the electrical impulses can block the transmission of pain to the brain, which may mean that the pain is no longer felt. On the other hand, TENS application can support our body’s natural pain control mechanism by releasing the body’s own pain-relieving substances, the so-called endorphins. The application with a TENS machine can also promote the blood circulation.

Insoo-Kim Physiotherapist Korehab Dubai


Strength Training & Coordination Course Master
KT Tape Therapy
Corrective Exercise Therapy
Nerve Entrapment Treatment Therapy
Soft Tissue Mobilization Therapy
Myofascial Release Therapy


  1. Tanusha, Cardoso,Tania Pizzari, Rita Kinsella, Danielle Hope, Jill L. Cook. Current trends in tendinopathy management. Best Practive & Research Clinical Rhoumatolog Volume 33, Issue 1, February 2019, Pages 122-140.
  2. C.M. Waugh,D. Morrissey, E. Jones, G.P. Riley, H. Langberg and H.R.C. Screen. iN VIVO BIOLOGICAL RESPONSE TO EXTRACORPOREAL SHOCKWAVE THERAPY IN HUMAN TENDINOPATHY. European Cells and Materials Vol. 29 2015 (pages 268-280)