Chronic tendon pain, often called tendonitis, is now understood as tendinopathy—a condition involving changes in the tendon’s collagen structure over time, rather than acute inflammation. This injury occurs when the tendon is repeatedly overloaded without sufficient time for repair, reducing its capacity to handle tension. Effective rehabilitation requires a structured, multi-phase approach that progressively restores the tendon’s strength and resilience.
Immediate Steps for Pain Reduction
The initial response to tendon pain should focus on activity modification rather than complete immobilization, which can weaken the tendon. Relative rest means reducing or eliminating specific activities that aggravate the tendon while maintaining a baseline level of activity. Ice application is beneficial primarily for short-term pain relief, not for reducing inflammation, as tendinopathy is largely non-inflammatory. Applying a cold pack for 10 to 20 minutes several times a day can help manage immediate discomfort. Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) can also be used for short-term pain management.
These initial steps are for managing symptoms and reducing irritation to create a window for active rehabilitation. While NSAIDs relieve pain, they have not been shown to improve the long-term structural outcomes of tendinopathy. The goal is to settle the acute pain enough to begin introducing controlled movement without triggering a significant flare-up.
Early Stage Restoration of Movement
Once the initial sharp pain has subsided, rehabilitation transitions to introducing controlled, low-load movements to gently stimulate the tendon. The primary tool in this phase is the use of isometric exercises, which involve muscle contraction without changing the joint angle or tendon length. This static hold is effective for pain relief and is the first step toward restoring function.
A common protocol involves performing five repetitions of a 45-second hold at a moderate intensity, typically around 70% of maximum effort. This should be done two to three times daily, with a rest period between contractions. The intensity must be challenging but should not increase the pain beyond a manageable level (e.g., 3 or 4 out of 10).
The immediate pain-relieving effect of isometric contractions can last for at least 45 minutes after the exercise is completed. This early phase establishes tolerance to load and prepares the tendon tissue for heavier strengthening work.
Building Tendon Resilience Through Strengthening
The most crucial phase of rehabilitation involves progressively increasing the load on the tendon to stimulate the remodeling of its collagen structure. This is achieved through heavy slow resistance (HSR) training and the specific inclusion of eccentric exercises. This strengthening must be distinctly heavier and slower than the initial isometrics to promote collagen alignment and improve the tendon’s tensile strength.
Eccentric training, where the muscle lengthens under tension, is highly valued because it stimulates collagen cross-linkage formation within the tendon. For example, in Achilles tendinopathy, this is performed as a heel drop, where you use the healthy leg to raise up and then slowly lower down on the injured leg, typically over a three-to-five second count. For elbow tendinopathy, wrist curls or extensions are performed by slowly lowering a weight.
The resistance level should be heavy, starting with three to four sets of 15 repetitions and gradually progressing to sets of six repetitions as strength improves, performed every other day. The speed of movement is slow—often a three-second lift and a three-second lower—to maximize the time under tension and encourage the required biological adaptations. This progressive mechanical stress signals the tenocytes, the tendon cells, to increase collagen production and organize the fibers into a more robust structure.
The ultimate goal of this strengthening phase is to increase the tendon’s capacity to tolerate the high loads and speeds necessary for daily life and sport. As the tendon adapts, the exercises are eventually progressed to include faster, energy-storage movements like plyometrics, which simulate the spring-like action required in running and jumping. This gradual increase in both magnitude and rate of loading ensures the tendon is systematically prepared for a full return to activity.
Preventing Recurrence and Returning to Activity
The final stage focuses on maintaining the tendon’s resilience and safely transitioning back to full activity. Recurrence often happens due to the “too much, too soon” principle, where the load is increased quickly after pain resolves. The tendon may feel better long before its structure has fully remodeled, which can take several months.
It is important to correct any underlying biomechanical or technical faults that contributed to the initial injury, such as refining a running stride or adjusting posture. Supportive gear, like a brace or orthotic, can be used temporarily to reduce strain during the transition back to high-demand activities.
The return to sport or intense activity must follow a gradual, monitored progression, paying close attention to the tendon’s response over a 24-hour period. Rehabilitation exercises should continue as a maintenance program, even after symptoms are gone, to ensure the tendon retains its strength and load tolerance.