Physical therapy is the primary, non-surgical pathway for resolving the pain and dysfunction associated with tendon injuries. These injuries, often categorized as tendinopathy, are a common cause of musculoskeletal pain affecting millions of people. Successful treatment depends on correctly identifying the underlying issue and implementing a progressive, load-based rehabilitation program. Physical therapy provides a structured approach to alleviate symptoms and address the root causes of tendon overload.
Understanding Tendonitis
The term tendonitis refers to acute inflammation of the tendon and is frequently used to describe all types of tendon pain. This abrupt, short-term condition involves inflammatory cells and typically resolves within a few weeks with basic care. However, most persistent tendon pain lasting longer than six weeks is actually a chronic condition called tendinosis.
Tendinosis is characterized by the degeneration of the tendon’s collagen structure without significant inflammation. This condition involves a breakdown of the collagen fibers, the main structural proteins of the tendon. Treatment for tendinosis differs significantly from tendonitis because reducing inflammation is not enough; the compromised structure must be rebuilt. A specialized physical therapy approach is necessary to repair the collagen and restore the tendon’s capacity to handle stress.
The Foundational Goals of Physical Therapy
The role of physical therapy is to look beyond the painful site and identify the mechanical causes contributing to tendon overload. These causes often include faulty movement patterns, muscle imbalances, or poor biomechanics that place excessive strain on the tendon. By correcting these underlying issues, the therapist ensures the painful site is not continually re-injured by the same stressors.
A central objective of physical therapy for tendinopathy is to restore the tissue’s capacity and load tolerance. Tendons respond to mechanical load, and the goal is to gradually increase the force the tendon can withstand without pain. This process involves a controlled, progressive application of stress that stimulates tendon cells to rebuild and strengthen the collagen matrix. Complete rest is often counterproductive, as it reduces the tendon’s capacity and makes it more vulnerable to injury.
Key Therapeutic Interventions Used in PT
The most effective physical therapy treatments for chronic tendon pain are active, load-based exercises designed to promote structural change. Two highly studied techniques are eccentric training and heavy slow resistance (HSR) training. Eccentric training involves focusing on the lengthening phase of a muscle contraction, which loads and remodels the tendon tissue.
HSR training involves performing both the shortening (concentric) and lengthening (eccentric) phases of an exercise using heavy weights and slow movement tempos (e.g., three seconds up and three seconds down). Studies show that HSR is equally effective as eccentric training in reducing symptoms for conditions like Achilles tendinopathy, often with better patient compliance. The heavy, slow load provides a substantial stimulus that encourages structural adaptations in the tendon.
Manual therapy, such as soft tissue mobilization or joint manipulation, may be used to address surrounding muscle tightness or joint stiffness. While these hands-on techniques can provide temporary pain relief and improve muscle function, they do not directly increase the load tolerance of the tendon. Other modalities like heat, ice, or therapeutic ultrasound are supportive measures for managing pain and swelling but are not curative for the underlying tendon pathology.
Setting Realistic Recovery Expectations
Tendon healing is a slow biological process that requires patience and commitment. Unlike muscle injuries, which can heal in weeks, significant structural changes in a tendon often require a minimum of 12 weeks of consistent, progressive loading. The entire remodeling stage can last from several weeks to many months, depending on the chronicity and severity of the injury.
Recovery success relies on strict adherence to the home exercise program and carefully managing daily activities to avoid the “too much, too soon” cycle. The therapist guides a progressive loading regimen where a small, tolerable amount of pain during the exercise (rated no higher than a 4 or 5 out of 10) is acceptable. It is important to monitor the tendon’s response not just during the exercise, but also the following day, to ensure the load was appropriate and did not cause a flare-up.