Before we discuss tendonitis treatment, let's first consider the anatomy! Tendons connect our muscles to bones, and therefore are the main way that we produce force.1 Before the 90s, it was thought that inflammation was the primary cause of tendon pain, so people used to call these issues “tendonitis”. As more research came out focusing on the damage in the tendon (primarily due to degenerative changes) being the main driver for both pain and decreases in function, this terminology shifted to “tendinopathy” (largely based on the work of Mafulli et al.). 2, 3
Stages of Tendinopathy
So, there has been damage to a tendon, and the most prominent model currently followed is Jill Cook’s three-stage model (reactive, disrepair, degenerative).4 The first stage, reactive tendinopathy, has also been called the “injury” stage, and is typically an acute response.5 Another way of putting this is you may have jumped into something too rapidly or advanced load or volume too quickly. An example of this could be starting a new workout routine or doing a lot of repetitive movements. Another potential mechanism is direct trauma – let’s say that you fell directly on your knee or shoulder. This could trigger the reactive stage as well.
The second stage of tendon disrepair has also been called the “failed healing” stage, where changes in the extracellular matrix become more pronounced, and the tendon is thus more susceptible to the damage. Typically, this occurs when that initial stage continues to be handled poorly and advances to this stage. An example of this would be continuing to work out or perform the same repetitive motions once you already have tendon pain.
The final stage is the degenerative stage, also labeled the “clinical presentation,” as this is typically when patients seek medical attention. This is when tendons are most susceptible to ruptures, and also where we start to see large scale degenerative changes in both the extracellular matrix and within the tissue cells (which is what may lead to those ruptures).
Symptoms of tendonitis include difficulty and pain with movement, joint stiffness, swelling, and a “crackling” or grinding sensation.
I think I have tendonitis/tendinopathy. What do I do now?
Seeing a physical therapist is a great place to start for tendonitis treatment. Our skilled doctors of physical therapy will identify contributing factors such as muscle imbalances or improper biomechanics (movement of joints and muscles). Based on this evaluation, a personalized exercise program is developed, incorporating targeted stretches and strengthening exercises to gradually restore the affected tendon's integrity and flexibility. Manual therapies, such as soft tissue and joint mobilization, can further aid in reducing pain and promoting blood flow. Additionally, our doctors of physical therapy will educate you on proper body mechanics and ergonomic practices to prevent future recurrence.
I shouldn't start physical therapy for tendonitis treatment unless I have imaging first, right?
Medical imaging, such as ultrasound or MRI, is not always necessary to diagnose tendonitis. In many cases, a skilled healthcare professional, such as a physician or physical therapist, can diagnose tendonitis based on a thorough clinical examination, medical history, and a discussion of symptoms. Our highly trained doctors of physical therapy will assess your pain, range of motion, strength and functional movements in addition to your symptoms and medical history.
Tendonitis can often be effectively managed and even resolved with physical therapy alone, especially in mild to moderate cases. Physical therapy plays a significant role in promoting healing, reducing pain, and restoring normal function to the affected tendon and surrounding tissues.
If you think you are dealing with tendonitis/tendinopathy, request an appointment so we can help get you back to the activities you enjoy!
Written by Matt Harper, PT, DPT, CSCS
1. Canosa-Carro, Lorena, et al. "Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice." Disease-a-Month 68.10 (2022): 101314.
2. Khan, Karim M., et al. "Time to abandon the “tendinitis” myth: painful, overuse tendon conditions have a non-inflammatory pathology." Bmj 324.7338 (2002): 626-627.
3. Maffulli, Nicola. "Overuse tendon conditions: time to change a confusing terminology." Arthroscopy: The Journal of Arthroscopic & Related Surgery 14.8 (1998): 840-843.
4. Cook, J. L., and Craig R. Purdam. "Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy." British journal of sports medicine 43.6 (2009): 409-416.
5. Fu, Sai-Chuen, et al. "Deciphering the pathogenesis of tendinopathy: a three-stages process." BMC Sports Science, Medicine and Rehabilitation 2 (2010): 1-12.