by Alex Blacke (B.Chiro Sci, M.Chiro) - Chiropractor

What is it?

Tendinopathy is an overuse clinical condition of tendons which can involve a combination of pain, swelling and impaired function. The cause of tendinopathies remains unknown due to conflicting findings in the literature, which therefore can make it a challenging condition to treat. Manual therapists often see tendinopathy occur in areas such as the Achilles tendon, patella tendon, rotator cuff and the elbow.

Risk Factors

Some research has identified intrinsic and extrinsic risk factors for developing tendinopathy. These risk factors include:

  • Intrinsic
    • Age – young (history of Osgood-Schlatter disease, Sinding-Larssen disease) old (partial or complete ruptures)
    • Men – overall greater prevalence
    • Women – more common at wrist and elbow
    • Biomechanics – muscle imbalances, joint instability or stiffness
    • Poor technique, demanding range of motion
    • Torsional forces
    • Prior tendon problems
  • Extrinsic
    • Training errors
    • Sudden increase in volume, excessive hill work
    • Environmental conditions
    • Poor equipment

While some studies have reported these as risk factors for tendinopathy, the evidence behind them is often weak or conflicting. But the one thing that is consistently found to contribute to the development of tendinopathy is excessive overload.

Who tends to develop them?

  • Achilles – elite endurance athletes, running or jumping athletes
  • Patella – jumping athletes, basketball players, volleyball players
  • Rotator cuff – sports that involve overhead motions such as throwing, tennis, swimming, weight lifting
  • Elbow – tennis players or any activities that excessively grip or wring
  • In general – athletes that have had an increase in load or frequency in training sessions or deconditioned weekend warriors, where both groups have not had enough recovery time.


So what is actually happening to the tendon?

One of the most widely used models to explain tendinopathy is the 2009 continuum model by Purdam and Cook. This model involves three phases: reactive tendinopathy, tendon dysrepair and degenerative tendinopathy.



  • Reactive Tendinopathy
    • Occurs when the tendon is subjected to acute overload (unaccustomed activity, direct blow to the tendon)
    • What happens? The tendon temporarily thickens itself in order to reduce stress and increase stiffness.
    • How does it do it? Tenocytes (or tendon specific cells) proliferate in response to the overload, and with that their organelles inside them start pumping out proteins called proteoglycans into the extracellular matrix (ECM). Proteoglycans attract water and as these proteins get pumped into the extracellular matrix, water follows which can cause the tendon to swell. In this acute phase, there is little disruption to the collagen fibres and their arrangement.
    • In a recent study by Purdam and Cook in 2016, they suggest that there may be a normal adaptive phase before reactive tendinopathy. This is a normal response of a tendon when subjected to acute overload, which may progress to reactive tendinopathy depending on factors such as genetics, age, loading history and recovery time.
    • Heavy loading and injections are not recommended in this phase as it can be provocative. Pain reduction strategies and isometric muscle contractions are recommended.
  • Tendon Dysrepair
    • If the overload isn’t decreased or removed when the person is in the reactive tendinopathy phase, they may be pushed along to tendon dysrepair
    • Purdam and Cook describe this phase as attempted healing similar to reactive tendinopathy but with more ECM disorganisation/destruction.
    • There is continual cell proliferation which leads to a large increase in proteoglycan production, leading to more water following the proteins into the ECM but this time it starts separating the collagen fibres and disrupting the matrix. There may be an increase in blood vessel and nerve ending formation in the area also.
    • There may be some reversibility of this phase with management of load and exercise to stimulate the matrix.
  • Degenerative Tendinopathy
    • The tendon further progresses along the continuum and there is both matrix and cell changes.
    • Areas of cell death are apparent
    • Large areas of the matrix are disorganised and filled with blood vessels, matrix breakdown products and little collagen.
    • There are patchy areas of degenerated tendon, reactive tendinopathy and tendon dysrepair.
    • There is increased tendon size
    • Primarily seen in older patients but can be present in younger people or elite athletes with chronically overloaded tendons
    • Often present with repeated bouts of tendon pain often resolving but returning once it is subjected to load again.
    • Can rupture if the degeneration is widespread enough and subjected to high load
    • Little to no reversibility

Treatment Modalities

Treatment strategies should be tailored to what phase the tendinopathy is in. These may include:

  • Non-steroidal anti-inflammatories (eg, ibuprofen)
  • Shockwave therapy
  • Dry needling
  • PRP injections
  • Corticosteroid injections
  • Surgical scraping

(Side note: while the above treatments may be effective in the short term on pain, they don’t do much in the way of improving faulty biomechanics and tissue load capacity.)

  • Isometric muscle contractions (isometric quadricep contractions in patella tendinopathy has been shown to induce analgesia and reduce inhibition of the muscle which can improve strength)
  • Progressive loading rehabilitation to help improve load capacity

When should I see someone?

  • If you are interested in joining a gym (especially ones with a strong weight lifting focus such as CrossFit) to have someone check you out for any biomechanical faults that may place you at a higher risk for injury
  • If you have increased your training frequency or load and have been experiencing some persistent pain or a decrease in strength or function
  • If you have in the past experienced pain in the same area/tendon that resolves but keeps coming back


By Alex Blacke (B.Chiro Sci, M.Chiro) - Chiropractor



Cook, J.L. and Purdam, C.R., 2009. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine, 43(6), pp. 409-416.

Cook, J.L., Rio, E., Purdam, C.R. and Docking, S.I., 2016. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British journal of sports medicine, pp. Bjsports-2015

Krey, D., Borchers, J. and McCamey, K., 2015. Tendon needling for treatment of tendinopathy: a systematic review. The Physician and Sportsmedicine, 43(1), pp.80-86.

Maffulli, N., Wong, J. and Almekinders, L.C., 2003. Types and epidemiology of tendinopathy. Clinics in sports medicine, 22(4), pp. 675-692.

Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G.L., Pearce, A.J. and Cook, J., 2015. Isometric exercise induces analgesia and reduces inhibition in patella tendinopathy. British journal of sports medicine, 49(19), pp. 1277-1283.

Scott, A. And Ashe, M.C., 2006. Common tendinopathies in the upper and lower extremities. Current sports medicine reports. 2006 Oct 1;5(5):233-41.

Scott, A., Docking, S., Vicenzino, B., Alfredson, H., Zwerver, J., Lundgreen, K., Finlay, O., Pollock, N., Cook, J. L., Fearon, A. and Purdam, C.R., 2013. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. British journal of sports medicine, pp. Bjsports-2013.