Management of Tendon disease or Tendinopathy: We still have much to learn

  • Friday 12 September 2014

Tendon problems are relatively common in the sports medicine community. They can be divided into two groups: overuse tendon disease called tendinopathy and tendon tears. The tendons most commonly affected include Achilles, Patella, tennis elbow, golfer's elbow, shoulder tendons and high hamstring tendons; but most tendons of the body can be affected.

I've had the privilege to work with the best practitioners in the area of tendon disease. I'm also involved in research on tendon and attend conferences to discuss the latest research. In fact, I've published papers with the eminent Professor Hakan Alfredson, who is arguably the best in the business. Although we've come leaps and bounds in our understanding of tendon disease, I'm still amazed at how little we know.

Contrary to what many people think, we have very little in the way of 'hard science' to support our management of tendon disease. Many 'experts' lecture on treatments based on extrapolation of simple basic science rather than hard clinical evidence. Although I think we need to keep an open mind about treatments, I suggest we need to be skeptical of when so called 'experts' lecture on the perfect exercise or injection. What we need is good clinical studies and we just don't have it yet.

Nevertheless, I think we are slowly getting there. I like discussing basic principles rather than specifics. I think my patients are better served at using general principles to guide treatment rather than relying on specific prescriptive programs.

So what are these principles of tendinopathy management? I think we should separate treatment into five distinct areas:

Reduce load but avoid complete rest

We know that complete rest of the tendon is detrimental. But we also know that excessive load and in particular high energy load (such as jumping and hopping) is also detrimental. The key is to get the right balance between two.

Load load load! and keep loading

I take the approach of graduating tendon loading starting with heavy slow loading and introducing faster loading (hopping and skipping as examples). I don't think there is a big difference between eccentric and concentric loading. I also used heavy isometric loading for acute tendon pain.

Avoid compression

There is increasing evidence that compression of a tendon is detrimental to tendon health. Therefore, a rehabilitation program should actively avoid compression at least in the early stages. Examples include wearing a heel raise for Achilles and avoiding stretching (yes you heard it, stretching could be detrimental to a swollen tendon)


Injections should be reserved for cases that fail an exercise program. The aim of an injection is to provide a pain-free period for further loading. It should NOT be used as the only treatment.


There is certainly a role for surgery in tendinopathy. However, like injection therapy, surgery should be reserved for cases that fail a conservative program. SURGERY SHOULD ONLY BE OFFERED IF A COMPREHENSIVE REHABILITATION PROGRAM HAS FAILED. Previously, surgeon used to 'cut out' the thickened tendon and stitch the remaining 'good' tendon. Success of this operation is poor operation (less than 50% return to their original sport). Recently, Professor Hakan Alfredson has pioneered a new innovative surgical procedure. This procedure is performed as a day case under local anaesthesia and involves scraping the undersurface of the tendon to destroy abnormal vessels. This procedure can be performed for Achilles and Patella tendons and success is about 80% with a 2-3 month recovery.

Tags: tendontendinopathy

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