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Tendinopathy Rehabilitation

Original Editor - Tom Goom

Top Contributors - Jess Bell, Admin, Rachael Lowe, Tarina van der Stockt, Kim Jackson, Rucha Gadgil, Wanda van Niekerk, 127.0.0.1, Naomi O'Reilly, WikiSysop, Fasuba Ayobami, Claire Knott, Lucinda hampton and Robin Tacchetti  

Introduction

Tendinopathy is a complex, multifactorial musculoskeletal condition that affects both active and sedentary populations, causing localised pain, reduced function and decreased exercise tolerance.[1][2][3] Our understanding of tendinopathy is continuing to evolve. While primarily linked to repetitive tendon overload and insufficient recovery,[4] research suggests that persistent painful tendinopathies are not fully explained by local tendon injury and/or inflammation.[5] Psychosocial factors are also increasingly recognised as contributors to tendinopathy.[1][5]

The main histological and molecular features of tendinopathy include disorganised collagen fibres, increased microvasculature and sensory nerve innervation, altered extracellular matrix, increased immune cells and inflammatory mediators, and increased cellular apoptosis (i.e., the process of programmed cell death).[1]

As our knowledge evolves, so too do our treatment approaches. Exercise and load management are generally considered first-line treatments,[5] but the rehabilitation approach varies depending on the site and stage of the tendinopathy, the person's function, activity levels, contributing kinetic chain issues, comorbidities, psychological factors,[6] and concurrent presentations.[7]

Ultimately, rehabilitation aims to improve the capacity of the tendon and muscle to manage load through a progressive loading programme[8] while addressing pain-related beliefs and behaviours.[2]

Core Principles

Several key concepts underpin tendinopathy rehabilitation. Tendon and muscle function together as a musculotendinous unit and must be considered collectively during rehabilitation.[9][10] Load tolerance varies between people and depends on the stage of the tendinopathy. Thus, individualised progression is essential in rehabilitation.[11] Recovery can be lengthy, with muscle strength changes taking 6-8 weeks and tendons potentially requiring 12+ weeks to respond to loading programmes.[12]

Research also shows that pathological changes in tendons and muscle dysfunction may persist after tendinopathy symptoms have resolved. Thus, other non-tissue mechanisms may be involved in symptom improvement, such as decreased pain-related fear, improved self-efficacy, reconceptualising pain perceptions or increased load tolerance.[5]

Load Management Strategy

Effective tendinopathy rehabilitation requires provocative loads to be removed and appropriate therapeutic loading to be implemented.[13] Provocative loads might involve fast movements or movements that produce compression.

Clinical examples of compression: people with insertional Achilles Tendinopathy should avoid dorsiflexion in early rehabilitation, as it compresses the tendon against the calcaneus.[14][15] In proximal hamstring tendinopathy, compression can occur with sitting and certain gym exercises like deep squats and deadlifts. However, exercises like prone hamstring curls that maintain neutral positions can be continued.[13]

Clinical examples of high load: activities like jumping and squatting are high-load activities for the patella, but running is a low-load activity. Conversely, running is a high-load activity for the Achilles tendon. Therefore, during rehabilitation planning, it’s important to consider the biomechanics of each tendon and the demands of different activities.[13]

Rehabilitation Progressions

In 2015, Malliaris et al.[16] proposed a four-stage approach to tendinopathy management, which is discussed below with reference to more recent research. It is, however, important to remember that there is no recipe for tendinopathy management. Each person requires an individualised programme that caters to their unique needs.

Stage 1: Increase Load Tolerance and Pain Management (Isometric Loading)

During this stage of rehabilitation, Malliaris et al.[16] propose that isometric exercises can be introduced to reduce/manage pain and initiate loading when a person is unable to perform isotonic exercises due to pain. They recommend the following parameters for isometric loading:[16]

  • 5 repetitions of a 45-second hold
  • performed 2 to 3 times per day
  • take 2 minutes of rest between holds for recovery
  • perform at 70% maximal voluntary contraction load

Isometric exercises are generally well-tolerated and may help to reduce pain.[17][18][19][20][21] However, the response across populations is variable. For instance, isometric exercises don’t appear superior to isotonic exercises in people with chronic tendinopathy,[22] but isometric protocols may provide analgesic effects for some people, particularly for patellar tendinopathy.[17][19]

It is important to select exercises that isolate and challenge the musculotendinous unit. For patellar tendinopathy, this might include isometric leg extensions or a Catalonian squat. For Achilles tendinopathy, isometric calf raises can be graded from double-leg body weight resisted exercises to single-leg exercises with added load.[13]

Isometric exercises should be performed in mid-range positions to avoid compression. For highly irritable tendons, bilateral exercises with shorter holding times may be indicated.[23]

When implementing isometrics, start with the load your patient can sustain for 45 seconds. Progress can be rapid—once their pain reduces 24 hours post-loading, it’s acceptable to transition them quickly to isotonic exercises.[13]

Stage 2: Improve Strength (Isotonic Loading)

Malliaris et al.[16] propose that Stage 2 exercises can be introduced when a person can perform isotonic exercises with minimal pain (i.e., 3/10 or less on a numeric pain-rating scale). Isotonic exercises focus on building strength through isolated, single-leg exercises where possible. This approach should specifically target deficits identified in the objective assessment. The following exercise parameters have been proposed for isotonic loading:[16][24]

  • 3-4 sessions per week, performed every other day
  • load progression commencing at 3-4 sets of 15 repetition maximum (RM), and progressing to 6RM

There is strong evidence to support the use of heavy slow resistance training (HSR) in tendinopathy rehabilitation. Heavy slow resistance training incorporates loads of approximately 70% of 1RM, which equates to roughly 7RM.[25] This approach allows patients to both moderate the rate of loading and achieve an appropriate load.

Functional preparation should begin towards the end of Stage 2. For example, walking up and down stairs while keeping the heel off the ground builds endurance in the calf muscles and retrains the spring function of the Achilles tendon.[13]

Tendon neuroplastic training also shows promise in tendinopathy rehabilitation. Rio et al.[26] found that providing external pacing cues during strength training (e.g., auditory cues using a metronome) increased excitability and released inhibition in both trained and untrained limbs. When using external auditory cues during isotonic exercises, Rio[13] recommends making the eccentric phase slightly longer than the concentric phase (e.g., 2 seconds up, 3 seconds down for calf exercises, or 3 seconds concentric, 4 seconds eccentric for multi-joint exercises).

"Tendinopathy is likely to result in reduced muscle strength and function. Restoring this is essential for the long term health of the tendon. Several strengthening options exist but all share a common goal – gradually increase the load on the muscle and tendon while carefully monitoring pain."[10]

Stage 3: Functional Rehabilitation (Energy-Storing Loading)

Patients can progress to functional rehabilitation when their pain is low and stable.[13] Malliaris et al.[16] suggest that good strength, good load tolerance with initial energy-storage exercises, and a return to baseline pain (if there was an initial increase) during load tests indicate that a person is ready for Stage 3.

Stage 3 focuses on retraining the tendon's spring function through progressive plyometric and energy-storage activities. The progression must be gradual as tendons do not respond well to sudden changes in loading patterns.

Achilles tendon progressions could begin with stair climbing at an increased pace, progress to skipping (double-leg non-continuous jumps advancing to continuous jumps), then to alternating patterns like two-two-one hopping sequences. Advanced progressions include forward and backward skipping, and various track and field drills.[13]

Patellar tendon progressions could start with controlled landing exercises (step down and stop with upright tibia position), progress to split-squat jumps with landing and pause, then advance to alternating split-squat jumps. The specific progression depends on sport demands—volleyball players require extensive jumping training whilst basketball players need more change-of-direction focused exercises.[13]

Again, all progressions must be tailored to individual goals. Creating an individualised programme helps to prevent both under-training and over-training.

Key Considerations

Rehabilitation should be functional for the muscle and the tendon. It's important to work out how the muscle is working and in what positions through the activity. Then, exercises need to be adapted to be performed in these situations.. Also, think about the strength-endurance demands on the muscle and consider changing load and repetitions to match.[27]

It's important to address relevant movement dysfunctions and strengthen the entire kinetic chain (i.e., the rest of the body that is involved in a function). Strengthening other muscles in the kinetic chain should reduce some of the load on the affected muscle and tendon. In doing so, it may be possible to improve economy and performance.[27]

Stage 4: Return to Sport

Progressing to Stage 4 is indicated when load tolerance to energy-storage exercises replicates training demands.[16] This stage incorporates sport-specific movements and a graduated return to full training. Important considerations include tendon healing stage, mechanical loading capacity, and additional factors impacting healing, such as age, hormonal status, and medications. Because tendons require up to 3 days to recover from heavy loading, appropriate recovery periods are required.[28]

Progressive elements include: training drills specific to sport or activity, graduated return to full training intensity, with competition permitted only when tolerance to full training is demonstrated. All impairments, including strength, endurance, range of motion, and jumping ability, must be addressed, as these may not automatically resolve when symptoms decrease.[28]

In-Season Modifications

In-season management differs significantly from off-season rehabilitation. In-season management focuses on managing existing loads rather than adding additional high loads or plyometric exercises that could be provocative on top of already high training demands.[13]

Key modifications:[13]

  • remove compression loads from gym exercises while maintaining isotonic and isometric loading
  • maintain single-leg strengthening to maximise kinetic chain support
  • negotiate spacing between high tensile loads within the week, where possible
  • focus on load management rather than load addition

Load Monitoring and Progression

The 24-hour response to loading is the primary indicator of tendon tolerance. If pain is the same or better, or morning stiffness is the same or better 24 hours post-exercise, the tendon has tolerated the load appropriately. This allows for progressive increases in the next session.[13]

Progression principles:[13]

  • change one variable at a time to identify causes of any flare-ups
  • if flare-ups occur, return to isometric and isotonic exercises, then reduce the provocative load for the next session
  • an ideal outcome is increasing load with pain decreasing to 0/10
  • an acceptable outcome is increasing load with low, stable pain levels
  • an unacceptable outcome is increasing load with increasing pain.

It is essential to communicate clearly with your patient about pain expectations. Complete pain resolution may not occur, particularly in-season, but load tolerance can still improve with stable, low-level symptoms.[13]

Patient Education and Pain Neuroscience Education

When delivered in conjunction with other interventions, pain education (also called pain neuroscience education (PNE)) shows promise for improving various tendinopathy outcomes, including reducing pain, pain catastrophising, kinesiophobia, and perception of illness, and improving physical performance and self-reported function.[5]

Pain education should focus on patient empowerment.[2] It uses metaphors, pictures or videos to help modify patients' beliefs about pain. Core educational messages might include concepts of central and peripheral sensitisation (especially for people with nociplastic pain) and emphasising that pain doesn't always equal harm or tissue damage.[5]

Summary

Understanding tendon-specific biomechanics, identifying provocative loads, and implementing appropriate therapeutic loading are the cornerstones of evidence-informed tendinopathy rehabilitation.

Tendinopathy rehabilitation must be individualised—successful outcomes depend on appropriate selection of load, progression, and monitoring, rather than adherence to rigid protocols. The four-stage framework discussed in this page provides a general structure for rehabilitation and highlights that ongoing clinical reasoning and individualised management are essential.

Resources

[29]
[30]
[31]

Click on Patellar Tendinopathy for a YouTube Playlist with more videos

References

  1. ↑ 1.0 1.1 1.2 Millar NL, Silbernagel KG, Thorborg K, Kirwan PD, Galatz LM, Abrams GD, et al. Tendinopathy. Nat Rev Dis Primers. 2021 Jan 7;7(1):1. Erratum in: Nat Rev Dis Primers. 2021 Feb 3;7(1):10.
  2. ↑ 2.0 2.1 2.2 Edgar N, Clifford C, O'Neill S, Pedret C, Kirwan P, Millar NL. Biopsychosocial approach to tendinopathy. BMJ Open Sport Exerc Med. 2022 Aug 1;8(3):e001326.
  3. ↑ Stubbs C, McAuliffe S, Mallows A, O'sullivan K, Haines T, Malliaras P. The strength of association between psychological factors and clinical outcome in tendinopathy: A systematic review. PLoS One. 2020 Nov 30;15(11):e0242568.
  4. ↑ Williamson PM, Freedman BR, Kwok N, Beeram I, Pennings J, Johnson J, et al. Tendinopathy and tendon material response to load: What we can learn from small animal studies. Acta Biomater. 2021 Oct 15;134:43-56.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Escriche-Escuder A, Nijs J, Silbernagel KG, van Wilgen CP, Plinsinga ML, Casaña J, Cuesta-Vargas AI. Pain neuroscience education in persistent painful tendinopathies: A scoping review from the Tendon PNE Network. Phys Ther Sport. 2023 Sep;63:38-49.
  6. ↑ White G, Bright F, Rio EK, Chimenti RL, Murphy MC. Do anxiety, depression, fear of movement and fear of Achilles rupture correlate with Achilles tendinopathy pain, symptoms or physical function? J Clin Med. 2025 Jan 13;14(2):473.
  7. ↑ Scott A, Docking S, Vicenzino B, Alfredson H, Murphy RJ, Carr AJ, et al. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. Br J Sports Med. 2013 Jun;47(9):536-44. Erratum in: Br J Sports Med. 2013 Aug;47(12):774. Murphy, Richard J [added]; Carr, Andrew J [added]. PMID: 23584762; PMCID: PMC3664390.
  8. ↑ Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Pract Res Clin Rheumatol. 2019 Feb;33(1):122-140.
  9. ↑ Kountouris A, Cook J. Rehabilitation of Achilles and patellar tendinopathies. Best Pract Res Clin Rheumatol. 2007 Apr;21(2):295-316.
  10. ↑ 10.0 10.1 Goom T. Tendinopathy – rehab progression – part 1. Available from https://www.running-physio.com/tendinopathy1/ (accessed 8 September 2025).
  11. ↑ Palermi S, Corsini A, Guelfi M. Comprehensive management of lower limb tendinopathies in athletes: advances and challenges. Joints. 2024;2:e931.
  12. ↑ Bohm S, Mersmann F, Arampatzis A. Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults. Sports Med Open. 2015 Dec;1(1):7.
  13. ↑ 13.00 13.01 13.02 13.03 13.04 13.05 13.06 13.07 13.08 13.09 13.10 13.11 13.12 13.13 13.14 Rio E. Tendinopathy Rehabilitation Course. Physiopedia Plus, 2019.
  14. ↑ Demangeot Y, O'Neill S, Degache F, Rapin A, Asgher U, Alfredson H, et al. Exercise parameters to consider for Achilles tendinopathy: a modified Delphi study with international experts. Br J Sports Med. 2025 Aug 28:bjsports-2025-110183.
  15. ↑ Pringels L, Capelleman R, Van den Abeele A, Burssens A, Planckaert G, Wezenbeek E, Vanden Bossche L. Effectiveness of reducing tendon compression in the rehabilitation of insertional Achilles tendinopathy: a randomised clinical trial. Br J Sports Med. 2025 Apr 24;59(9):640-650.
  16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 16.6 Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: Clinical diagnosis, load management, and advice for challenging case presentations. J Orthop Sports Phys Ther. 2015 Nov;45(11):887-98.
  17. ↑ 17.0 17.1 Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015 Oct;49(19):1277-83.
  18. ↑ Henriksen M, Aaboe J, Graven-Nielsen T, Bliddal H, Langberg H. Motor responses to experimental Achilles tendon pain. Br J Sports Med. 2011 Apr;45(5):393-8.
  19. ↑ 19.0 19.1 Van Ark M, Cook JL, Docking SI, Zwerver J, Gaida JE, van den Akker-Scheek I, Rio E. Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial. J Sci Med Sport. 2016 Sep;19(9):702-6.
  20. ↑ Goom TS, Malliaras P, Reiman MP, Purdam CR. Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. J Orthop Sports Phys Ther. 2016;46(6):483-93.
  21. ↑ Rio E, Purdam C, Girdwood M, Cook J. Isometric Exercise to Reduce Pain in Patellar Tendinopathy In-Season: Is It Effective "on the Road"? Clin J Sport Med. 2019;29(3):188-192.
  22. ↑ Clifford C, Challoumas D, Paul L, Syme G, Millar NL. Effectiveness of isometric exercise in the management of tendinopathy: a systematic review and meta-analysis of randomised trials. BMJ Open Sport Exerc Med. 2020 Aug 4;6(1):e000760.
  23. ↑ Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. Br J Sports Med. 2014 Apr;48(7):506-9. Erratum in: Br J Sports Med. 2014 Sep;48(17):1333.
  24. ↑ Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009 Dec;19(6):790-802.
  25. ↑ Morrison S, Cook J. Putting "heavy" into heavy slow resistance. Sports Med. 2022 Jun;52(6):1219-1222.
  26. ↑ Rio E, Kidgell D, Moseley GL, Gaida J, Docking S, Purdam C, Cook J. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med. 2016 Feb;50(4):209-15.
  27. ↑ 27.0 27.1 Goom T. Tendinopathy – functional rehab. Available from: https://www.running-physio.com/tendinopathy2/ (accessed 8 September 2025).
  28. ↑ 28.0 28.1 Silbernagel KG, Crossley KM. A proposed return-to-sport program for patients with midportion Achilles tendinopathy: Rationale and implementation. J Orthop Sports Phys Ther. 2015 Nov;45(11):876-86.
  29. ↑ Fix Physio. Achilles tendinopathy Stage 1: Isometric calf raise exercises Available from: https://youtu.be/MYehmaMlKSs [last accessed 01/03/2018]
  30. ↑ Fix Physio. Achilles Tendinopathy Stage 2: Isotonic calf raise exercises. Available from: https://youtu.be/JM9yxhxrqus [last accessed 01/03/2018]
  31. ↑ Bourassa Rehab. Isometric Calf strengthening Available from: https://youtu.be/ijJ4bzFPDMM [last accessed 01/03/2018]
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