That Darn Tendon!

I’m seeing a trend towards chronic tendinopathies in the office that have “failed” conservative care elsewhere. This could be a product of my setting. I’m working in Austin, TX. This is a tech-heavy town with lots of weekend warrior athletes. This interesting dynamic, translates into a bunch of people that sit 40+ hours/week at a computer and in the car on the way to/from work and then kick a** and take names on the weekend with boot camps, Crossfit, high intensity interval training (HIIT) style workouts. I’m seeing more repetitive stress injuries now that before, when I was practicing in the suburbs of Chicago. These injuries include tennis elbow (lateral epicondylagia), golfers elbow (medial epicondylagia), rotator cuff tendinopathy (Swimmer’s shoulder), Achilles tendinopathy, patelllar tendinopathy (jumper’s knee), posterior tibial tendinopathy and plantar fasciopathy.

Several of these patients had injections (cortisone) that “failed”. The injections provided temporary relief but the pain and dysfunction came back. I’m no magician, but I feel like a majority of these cases can be improved however, the biggest change and the biggest thing I want to impart is PATIENCE!

True, chronic tendinopathies require progressive loading (exercise). Progressive loading takes time. Most good protocols for chronic tendinopathies are 4-12 months long. So here are some chronic tendinopathy tricks and funny things to tell your patients to set the stage for a successful recovery:

1. Slow Cook This Like Good Barbecue: Good cue is low and slow. 200 degrees for 12 hours to get that nice smoke ring and that smoke flavor. Consistent daily loading of 10-15 reps over weeks to months is encouraged.We typically recommend 1 set of 10-15 reps done slowly 4-6x daily.

2. Pain Scale for Tendinopathy Loading:

  • 1, 2, 3, 4 & “No More”: Pain during loading should be tolerable 1-4/10. So the saying here is 1-4 and “no more.”
  • 5 & “Staying Alive”: Pain at a level 5/10 is acceptable, but pay attention. If trending up from 5/10 then modify. If trending at 5/10 or down from 5/10 continue. So 5 is “staying alive.”
  • 6,7,8 = “I Hate”: 6-8+/10 is too much load. Asking a patient to consistently load the tissue at 6-8/10 for weeks to month often overloads the tissue and either: a) produces a painful, acute, reactive tendinopathy rather than a chronic degenerative one OR b). is a path to non-compliance by the patient. A non-compliant patient does not get a successful outcome. So 6-8 is “I hate.”
  • 9 & 10 = “Never Again”: Pain at a level of 9-10/10 is absurd. Re-investigate the diagnosis. Did you get the diagnosis right? Did you classify the patient’s type of pain correctly? Does the patient have red flags or yellow flags? If a patient does not have red flags and no apparent serious pathoanatomy (torn tendon) and is exercising (“loading the tendinopathy) and feels a 9-10/10 then consider a possible central or peripheral sensitization mechanism. So if pain is reproduced at 9-10/10 the saying is “never again.”

3. “Produce & No Worse“: Loading tendinopathies can produce pain but later (minutes to hours later) the pain should return to baseline. This is important because many patients and most exercise prescription should not produce pain, but tendinopathies have a tendency to be different. Pain (tolerable pain) is very likely with loading and loading is required for management and a successful outcome in many cases.

4. Watching Paint Dry: The paint will dry. It will just take time. Tendinopathy rehab isn’t sexy. It’s 1-2 exercises several times daily for months. Your tendinopathy if we assessed correctly will get better, it just will take time. Most protocols are 4-12 months long. I typically will say initial results can begin at 2-3 months but we won’t abandon the protocol until at least a 4 month trial.

5. Progressive Overload is Required to make the tendon “Bigger, Faster, Stronger and Harder to Kill”: I like starting simple and progressing. Isometrics — Concentrics — Eccentrics — Functional Task Loading. Throughout this process you may need to pump the breaks periodically or adjust and step on the gas depending on where a patient is in the process. Periodic evaluations are critical to get the correct dose of exercise to stimulate the adaptations required.

6. Biological, Neurological & Psychological Adaptations: The adaptations are both physical (biological), neurological and psychological. The patient’s tendon is stimulated to adapt to load and force often with the “good” (non-degenerated tissue) showing hypertrophy and better able to handle load and force. These adaptations are the biological adaptations mentioned. If we image via diagnostic ultrasound or MRI, we will see the degenerated “disorganized” tissue remain degenerated and disorganized with fatty infiltrates. So the good tissue, does better at handling more load and force while the “bad” tissue still looks bad.

The patient also learns the neurological trick of decreased sensitivity of local and central receptors & pathways. In other words, exposing yourself to a painful but positive stimulus has the net affect of reducing sensitivity of the nervous system and reducing the “alarm” signal that pain often generates.

The last major benefits come from psychological means. Coping, independence, self reliance, self efficacy, and resilience can be conferred through exercise and progressive loading in a controlled rehab program. Progressive loading via exercise rewires the body and brain.

7. Management: I’ll typically treat several visits with manual therapy or other tools (in past private practice) for pain control. In past private practice, modalities implemented included assisted soft tissue mobilization (IASTM), acupuncture/dry needling, heat, and ice. These modalities are temporary for short term symptom modification in chronic tendinopathies. These modalities may also be utilized for acute, reactive tendinopathies. The emphasis though should be on progressive home loading. My analogy is that manual therapy, manipulation and modalities are the appetizers. The main course is exercise. I tell patients “don’t get full on appetizers or else you’ll miss the main course.” 

Re-checking or re-evaluating baselines in office every 2-4 weeks for signs of progress is recommended initially. After that and with progress you can wean from care or push them further out till re-evaluation. A sample plan treatment plan would include:

  • 1st Month – 4-6 visits: 4-6 visits over a period of approx 1 month depending on the case to reduce pain reports via manual therapy, manipulation or other modalities if indicated.
  • 2nd Month – 1-2 Visits: I typically follow up in 2-4 weeks after the 1st month to check in and adjust dosing recommendations.
  • 3rd-4th Month – 1 visit/month: I typically follow up every 30 days until 3-4 months. Every 30 days, I’d like to adjust the dose of exercise and follow up to make sure the patient is making progress. These are often very quick and simple check ins.

Typically in 4 months I’m seeing them 6-10x total. The specific prescription is case by case depending on how the patient is progressing. Each reassessment hopefully you’ll modify the dose of exercise and progressively challenge them. If no progress at 4 months, stop the trial of care and reassess. If progress conferred, continue to wean from care and talk about discharge criteria. If plateaued game plan and problem solve (adjust loading, refer for yellow flags or consider ortho biological agent or other injection). Orthobioligics include PRP (platelet rich plasma), stem cell, prolotherapy or other options.

8. Slow Healing Tendinopathies: Find out what’s pumping the break.

  • Metabolic Concerns = Functional Medicine Work Up. Does the patient have diabetes, high cholesterol, high blood pressure or autoimmune disease that is impacting tissue regeneration and adaptation at a cellular level. A referral may be required to help take the foot off the brake.
  • Yellow Flags/Psych = Issue Yellow Flags and Make Appropriate Referral or Recommendations. Psychosocial issues can impact the patient’s ability to recover. The dominant pain mechanism can change from one day to the next. What could look like mechanical, nociceptive (tissue driven) pain can morph into other forms. When you peel back the layers underlying concerns may show up that weren’t evident initially. Be willing to continue the investigation if you are not getting the desired outcome.
  • Long Standing Tendinopathies that have improved but plateaued = Consider additional loading or orthobiologic/regenerative medicine referral. Some modifications include changing the loading strategy with sets, reps or dose. You can also change the exercise prescribed. An ancillary strategy of current debate is orthobiological treatment like PRP (platelet rich plasma) or stem cell injections. There is mixed information of effectiveness of orthobiological agents in chronic tendinopathies. Here’s a nice little video that discusses the state of of orthobioligical research and applications (

So there you have it. There’s my 2 cents (ok way more than 2 cents) on tendinopathy rehab. The above information is based on the current literature by authors like Cook, Khan, Alfredson, Silbernagel and more. I hope these PEARLs can help you and help your patients with stubborn tendinopathies. If you’d like some additional information or need to see some of this information in video format, please click on this tendinopathy link (