Tendinopathy is hard to cure quickly, but it is much easier to recognise early and prevent from becoming chronic. The editorial team explains what the first signals of a tendon problem look like, which exercises have the best evidence base for prevention and treatment, how a doctor makes the diagnosis and when tendon pain is a reason for an urgent visit.
Early signs of tendon problems
Tendinopathy has a fairly characteristic pain pattern. Most often it is localised at a specific point of the tendon, intensifies at the start of a workout, partly decreases after a warm-up and returns again after the session or the next morning. Such "warm-up" dynamics are misleading: the athlete decides that all is well and continues to train.
Morning stiffness is another typical signal. For example, in Achilles tendinopathy the first steps after sleep are painful and stiff, and after a few minutes of walking it becomes easier. Pain on pressing the tendon, thickening or a feeling of "creaking" under the skin also require attention.
The international consensus on tendinopathy terminology recommends describing the state precisely as load-related pain and impaired tendon function, and not using terms that assume a specific mechanism without confirmation (Scott et al., 2020).
The main rule: pain that appears at the same place of the tendon over several workouts in a row is a reason to adjust the load right now, rather than waiting until it becomes constant.
Prevention: load and strength work
Since a tendon adapts slowly, prevention is built first of all on gradualness. Mileage, the number of jumps and working weights should be increased smoothly, and after a break one should return to the previous volume over several weeks rather than in a single workout.
Strength exercises for the muscles working with the corresponding tendon are the best-studied tool. The eccentric exercises for the calf muscles proposed by H. Alfredson have become a classic of Achilles tendinopathy treatment (Alfredson et al., 1998). Later, a randomised trial showed that heavy slow strength exercises give a comparable result and are better tolerated by patients (Beyer et al., 2015).
For prevention, general strength and movement control are also important: strengthening the muscles of the hip and pelvis for knee and Achilles problems, the muscles of the scapula and rotator cuff for shoulder problems, landing technique in jumping sports.
Finally, it is worth remembering the factors that weaken tendons: taking fluoroquinolones, corticosteroids, anabolic steroids, as well as metabolic conditions. During treatment with fluoroquinolones, for example, it is sensible to limit intense loads and inform the doctor about doing sport.
- gradual increase in volume and intensity;
- regular strength exercises for the corresponding muscles;
- control of technique and equipment;
- rest days between the hardest jumping or sprinting workouts;
- caution while taking drugs that affect tendons.
Diagnosis: examination, ultrasound, MRI
The diagnosis of tendinopathy is made predominantly clinically — on the basis of complaints and examination. The doctor establishes how and when the pain appeared, how it relates to load, which drugs the patient is taking. During the examination they palpate the tendon and assess swelling, thickening, strength and pain during specific loaded tests.
Ultrasound examination allows one to see thickening of the tendon, disruption of its structure, areas of increased blood flow, partial tears. The advantage of ultrasound is its accessibility and the possibility of a dynamic examination during movement.
MRI is ordered when the diagnosis is unclear, there is a suspicion of a partial tear, bone damage or other structures of the joint. At the same time it is important to understand: changes on images are not always linked to pain. Structural changes are often found in people without symptoms, so one treats the patient, not the picture.
Blood tests in typical tendinopathy are usually not needed. They are ordered if there are signs of systemic inflammation, a suspicion of gout, a rheumatological disease or infection, or if the tendinopathy is multiple and atypical.
| Method | What it shows | When appropriate |
|---|---|---|
| Clinical examination | Location of pain, function, loaded tests | Always |
| Ultrasound | Structure, thickness, blood flow, partial tears | For confirmation and monitoring |
| MRI | Detailed anatomy, bone, adjacent structures | Atypical course, suspicion of a tear |
| Blood tests | Inflammation, uric acid, rheumatological markers | Multiple or atypical cases |
Principles of treatment and the pain-monitoring model
The basis of treatment for most tendinopathies is load management and progressive strength exercises. Complete rest is usually not recommended: without load a tendon weakens. Instead, the most provocative types of activity (jumps, sprints) are reduced and strength work is gradually built up.
For self-monitoring, a pain-monitoring model is often used, which was tested in a randomised trial in Achilles tendinopathy. Patients were allowed to continue activity if the pain during it did not exceed 5 out of 10 and the pain and stiffness did not increase the next morning; the results were not inferior to a group with active rest (Silbernagel et al., 2007).
Corticosteroid injections give quick but often short-lived relief; for some tendinopathies long-term outcomes after them are worse, and injections directly into the tendon are not recommended (Coombes et al., 2010). Other methods — shockwave therapy, injections of platelet-rich plasma — have a heterogeneous evidence base and are considered by a doctor individually.
Recovery usually takes weeks or months. Patience and regularity in performing the exercises are more important here than the search for a "magic" method.
When to see a doctor
You should see a doctor or physiotherapist if tendon pain lasts more than two or three weeks despite reduced load, if it interferes with normal walking, sleep or work, and also if the problem keeps coming back again and again.
You need to seek help urgently in case of sudden sharp pain with a feeling of a blow or "snap", after which weakness or an inability to perform a movement appeared — for example, to stand on tiptoe. This may indicate a tendon rupture, and the time to treatment affects the outcome.
Urgent examination is also required for redness, warmth and swelling in the tendon area with an elevated body temperature — this may be a sign of infection. Separately, one should immediately inform the doctor about pain in the tendons during or after taking fluoroquinolones.
During the visit, honestly tell about all medications and drugs, including anabolic steroids or injections you received earlier. This directly affects the assessment of rupture risk and the choice of treatment.
Editorial conclusions
Early signs of tendinopathy — local pain that decreases after a warm-up and intensifies the next morning — require correction of load at the very first stage.
The best prevention and at the same time the basis of treatment is gradual load and progressive strength exercises, not complete rest or injections.
The diagnosis is usually clinical, with ultrasound and MRI refining the picture; sudden pain with loss of function is a reason for an urgent visit because of the risk of rupture.
We also recommend reading our materials on the causes of tendinitis, on tendon ruptures and on the role of collagen and vitamin C in the recovery of connective tissue.
References
- Scott A, Squier K, Alfredson H, et al. ICON 2019: International Scientific Tendinopathy Symposium Consensus: clinical terminology. Br J Sports Med. 2020;54(5):260–262.
- Alfredson H, Pietilä T, Jonsson P, et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360–366.
- Beyer R, Kongsgaard M, Hougs Kjær B, et al. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2015;43(7):1704–1711.
- Silbernagel KG, Thomeé R, Eriksson BI, et al. Continued sporting activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35(6):897–906.
- Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751–1767.
- Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409–416.
Andriy Melnyk
A strength-sports coach and author of programs for beginner and intermediate levels. Writes about training planning.
