Managing Difficult Tendinopathies

Introduction

Tendinopathy is a complex, multifactorial condition that remains challenging to treat. It accounts for up to 30% of all musculoskeletal disorders, and can cause persistent pain, decreased physical function, and reduced participation. People with tendinopathy have often tried multiple treatment strategies and seen several healthcare practitioners, often receiving conflicting advice. This page focuses on managing difficult tendinopathies and offers specific strategies to help when progress has stalled.

Confirm The Diagnosis

Accurate diagnosis is essential in tendinopathy management. When considering a diagnosis of tendinopathy, the key question is whether the tendon is the source of pain, not whether it shows pathology on imaging. If a patient presents with a diagnosis of tendinopathy, check that the hallmark features of tendinopathy are present: pain localised to the tendon that increases with loading and the “warm-up” phenomenon, where pain improves during a specific activity but worsens the day after high-loading activity. Certain tendinopathies have additional features; morning stiffness is characteristic of Achilles tendinopathy, and pain with prolonged sitting is characteristic of hamstring tendinopathy. If the patient's clinical signs and symptoms do not match those of tendinopathy, other conditions should be considered in the differential diagnosis.

Check Previous and Current Loading History

Tendon load versus capacity is an important concept to understand in tendinopathy. Injuries occur when the loads placed on a tendon exceed its capacity. In particular, compressive loads are provocative for tendons. When managing a patient with a difficult tendinopathy, it is important to carefully identify the initial aggravating load and any ongoing provocative loads.

When a patient is following an appropriate rehabilitation programme but not improving, the rest of their daily and training activities should be examined for provocative loads. For example, an athlete with an Achilles tendinopathy may still be performing plyometrics (high-tensile loads) or exercising in dorsiflexion, and thus maintaining compressive loading on the tendon. A patient with hamstring tendinopathy may be adhering to their rehabilitation programme, but continuing to sit for prolonged periods on hard surfaces, compressing the tendon against the ischial tuberosities.

Practical strategies to reduce compressive loading in hamstring tendinopathy: Compressive loading during sitting can be reduced by placing a rolled towel forward on the seat so the ischial tuberosities are suspended, or by angling the seat downward to reduce hip flexion. In the gym, exercises such as deadlifts and squats can be replaced with prone hamstring curls — this maintains slow tensile loading while removing compression.

Check For Co-morbidities

A general health assessment and screening for red flags are an essential part of the tendinopathy assessment. Tendinopathies driven by systemic conditions may not demonstrate the typical warm-up phenomenon, and loading and unloading may not alter symptoms in the expected way. Prolonged morning pain and stiffness that do not respond to modifications in training load should raise suspicion of a systemic driver. In such cases, a medical review is required, as physiotherapy alone is unlikely to be effective until the underlying condition is managed.

It is important to remember that insertional tendinopathy can be linked with spondyloarthropathy (SpA). The SCREEND'EM mnemonic can help to identify SpA:

• S - Skin: rash or psoriasis
• C - Colitis or Crohn's disease
• R - Relatives: family history of inflammatory arthritis/HLA-B27 positive
• E - Early morning stiffness lasting more than 30 minutes, unrelated to activity
• E - Eyes: has the patient had uveitis (inflammation of the middle layer of the eye)?
• N - Nail involvement, such as pitting, thickening, or onycholysis (detachment of the nail bed)
• D - Dactylitis: sausage-like swelling of the fingers
• E - Enthesopathy: inflammation of the entheses, the sites where tendons or ligaments insert into the bone
• M - Medication and Movement response: improvement with activity but not with rest; responds positively to NSAIDs

Check Management Programme

Successful tendinopathy management requires a combination of education, load management, exercise-based rehabilitation, and adjunct pain interventions.

Check for Progressive Loading

Progressive overload involves gradually increasing the weight, frequency, or repetitions of an exercise, and can be applied across different physical activities.

A person with tendinopathy who is not improving may not have received appropriate education on loading. Key principles to communicate include:

• complete rest is not recommended
• appropriate loading and load modification is the evidence-based approach
• progressive loading stimulates the tendon's biochemical and mechanical adaptation to load and exercise

Check the Amount and Type of Load Prescribed

Fast and compressive loads provoke tendons. Slow, heavy loads are not provocative, and can be applied safely. When tendon pain is understood as a speed-related condition, clinicians can confidently load tendons with slow, steady resistance. Any unnecessary speed work in the warm-up, gym programme, or training should be identified and removed.

Check for Single versus Double Leg Exercising

When prescribing a progressive loading programme to manage tendinopathy, it is important to prescribe single-leg loading for both the symptomatic and asymptomatic side. Loading should be proportional to each side's capacity, with the asymptomatic side typically tolerating greater loads. Double leg exercises should not be the basis of the programme, as the stronger leg can carry the weaker leg. For example, a patient with patellar tendinopathy may be able to perform a heavy double-leg squat but have significant quadriceps deconditioning on the affected side. Until these single-leg deficits are addressed, progress may stall.

Check The Kinetic Chain for Contributing Factors

The kinetic chain is the coordinated sequence of body segments that work together to produce movement. When there is a break in this chain, it can:

• increase the demands on distal segments, including increased muscle activation and segment velocity
• increase the forces that must be absorbed in the distal segments
• decrease the velocity or force at the distal segment

There may also be intrinsic factors that have contributed to excessive loading on a tendon. Assessing the entire kinetic chain helps identify contributing factors and ensures the rehabilitation programme addresses more than just the affected muscle-tendon unit.

Check the Management Plan Against the Diagnosis

If the management plan is appropriate for the diagnosed tendinopathy but is worsening symptoms, the diagnosis itself may need revisiting. Different conditions around the tendon respond differently to load. For example, peritendon irritation (paratenonitis) of the Achilles tendon is provoked by movement rather than the load itself, so even a low-load exercise like a calf raise could aggravate it.

Manage Expectations

Patients with tendinopathy may have unrealistic expectations about their recovery. Tendinopathies often take a long time to improve, and this should be communicated early. Everyone involved in the patient's care should understand what is provocative for the tendon and what loads should be removed and replaced, particularly for athletes or someone with multiple people involved in their management.

Pain that remains low and stable while load is progressively increasing is a positive outcome. Communicating this to patients helps them recognise progress even when some symptoms persist.

Using Outcome Measures to Monitor Progress

It is important to use standardised outcome measures to monitor a patient's progress objectively. Often, people do not feel they are getting better, but they have improved functionally.

Outcome measures should reflect what is meaningful to the patient — whether that is returning to sport, managing daily activities, or reducing morning symptoms. They must also be specific to the patient's injury and level of function. For example, rating pain with a hop may be appropriate for a runner with an Achilles tendinopathy, but not suitable for a less active person — morning pain and stiffness may be a more appropriate outcome measure for them.

Commonly used performance outcomes include the following:

• concentric and eccentric torque measured with an isokinetic dynamometer
• jumping performance (countermovement jump test)
• ankle range of motion
• hip abductor torque

Examples of outcome measures for tendinopathy include the following:

• Victorian Institute of Sport Assessment (VISA): VISA-A (Achilles), VISA-P (patellar tendinopathy), VISA-G (gluteal tendinopathy), VISA-H (proximal hamstring tendinopathy)
• Patient Specific Functional Scale: self-report outcome measure of function
• Foot and Ankle Outcome Score questionnaire (FAOS Questionnaire): 42-item subjective questionnaire consisting of 5 domains: pain, symptoms, function in daily activities, function in sports, and quality of life
• Hip Dysfunction and Osteoarthritis Outcome Score (HOOS): 40 items with five possible responses, graded from 0 to 4

Pain on palpation should not be used as an outcome measure for tendinopathy. Tendons can remain sensitive to palpation for an extended period, even with significant clinical and functional improvement. A systematic review by Escriche-Escuder et al. concluded that pain-based criteria to determine load progression in lower limb tendinopathy are not supported by substantial evidence and should be used "cautiously and critically". Patients should be educated that tenderness on palpation is often one of the last symptoms to resolve.

Conclusion

Tendinopathy can be challenging to treat. When progress stalls, clinicians should revisit the diagnosis, review the management plan, and consider contributing factors and co-morbidities. Pain-based criteria for exercise progression should be used with caution.

Clinicians should understand tendon loading and not be afraid to apply slow, heavy loads safely.