Tendinopathy describes a chronic condition where the structure of a tendon breaks down and becomes disorganized, typically due to repetitive strain or overuse. This differs from “tendonitis,” which refers to acute inflammation often absent in long-standing tendon pain. Treatment for tendinopathy must address the degeneration of collagen fibers rather than simply targeting inflammation. Managing this condition involves a deliberate, multi-stage approach, ranging from immediate self-care to controlled rehabilitation and, rarely, surgical intervention.
Immediate Steps for Reducing Tendon Pain
The first response to tendon pain involves modifying the activities that caused the irritation. It is important to stop the specific movement that aggravates the tendon. Temporary relative rest helps protect the tendon from further overload and allows the tissue to settle down, though complete immobilization is generally not recommended.
The choice between cold or heat therapy depends on the nature of the pain. Ice application can reduce acute pain by numbing the area. For chronic tendinopathy, which lacks significant inflammation, heat is often more beneficial as it increases blood flow, relieves stiffness, and may promote healing processes within the degenerated tissue.
Over-the-counter pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, can be used temporarily to manage discomfort. These medications primarily address pain symptoms and do not correct the underlying structural disorganization of the tendon. The goal of these immediate steps is to reduce irritation to a manageable level before beginning long-term physical rehabilitation.
Progressive Loading and Physical Rehabilitation
The most effective, long-term treatment for tendinopathy is progressive mechanical loading, which aims to restore the tendon’s capacity to handle stress. This process must be carefully managed to provide an appropriate stimulus for adaptation without causing overload or pain flare-ups. A physical therapist is invaluable in designing a program that progresses the load based on the individual tendon’s tolerance.
Rehabilitation often begins with isometric exercises, which involve contracting the muscle without changing the joint angle or tendon length. Heavy, sustained isometric contractions, typically held for 30 to 45 seconds, have been shown to provide an immediate pain-relieving effect in some tendons. This analgesic effect can temporarily reduce pain before moving on to more dynamic exercises.
As the tendon’s pain sensitivity decreases, the program advances to isotonic loading, which includes both muscle shortening (concentric) and lengthening (eccentric) phases. Eccentric training, where the muscle lengthens under tension, was traditionally considered the gold standard for rebuilding tendon structure. However, newer evidence suggests that Heavy Slow Resistance (HSR) training, which uses both concentric and eccentric phases with a slower tempo and heavier weight, produces similar or superior long-term outcomes.
HSR training involves lifting a heavy weight slowly, typically focusing on a load greater than 70% of the maximum a person can lift for a single repetition. The slow speed helps control the rate of loading on the tendon, stimulating the repair process within the collagen matrix. Consistency over many months is necessary for these mechanical loading programs to drive the required structural adaptations.
Targeted Medical Procedures
When conservative loading protocols fail or pain significantly impedes rehabilitation, a physician may recommend targeted medical procedures. Corticosteroid injections are a common option, providing powerful anti-inflammatory effects and significant short-term pain relief. However, repeated injections carry a risk of compromising the tendon’s structural integrity and are not recommended as a long-term solution.
Platelet-Rich Plasma (PRP) injections involve drawing a patient’s own blood, concentrating the platelets and growth factors, and injecting this solution into the damaged tendon. PRP aims to stimulate a regenerative response using concentrated healing factors rather than a purely pain-masking effect. While evidence is mixed, some studies suggest PRP may offer better long-term outcomes than corticosteroids for chronic tendinopathy.
Other minimally invasive interventions include dry needling or tenotomy, which involve puncturing the abnormal tissue with a fine needle to create microtrauma. This procedure is intended to trigger a localized healing cascade and stimulate the body’s natural repair mechanisms. Extracorporeal Shockwave Therapy (ESWT) is another non-invasive option, using high-energy acoustic waves applied externally to the tendon to promote blood flow and healing.
When Surgery Becomes Necessary
Surgery is considered the last option for tendinopathy, typically reserved for severe, chronic cases that have failed a minimum of six to twelve months of comprehensive non-operative treatment. The primary goal of surgical intervention is to remove the degenerative or damaged tendon tissue and, if necessary, repair or reattach the tendon.
The most common surgical procedures involve debridement, where the surgeon excises the abnormal, non-healing sections of the tendon. For extensive damage or partial tears, the tendon may need to be repaired or augmented to restore functionality. Patients must be prepared for a significant recovery period following surgery, often involving several months of rest and subsequent physical rehabilitation to regain full strength and function.