Tendinopathy

The Tendinopathy Continuum

Cook and Purdam described a continuum of tendon pathology with three distinct stages. Understanding which stage your tendon is in is central to planning the right management. The continuum can progress if a tendon is continually overloaded, but with appropriate load management it can also reverse in the earlier stages.

1. Reactive Tendinopathy

Reactive tendinopathy is an acute response to a sudden increase in load — for example a rapid increase in training, a new activity, or a change in surface or footwear. The tendon thickens and becomes painful as it attempts to adapt. With appropriate load management, a reactive tendon can settle and return towards normal. This stage is more common in younger athletes.

2. Tendon Disrepair (Failed Healing)

If a reactive tendon is not managed and the load continues, the tendon enters a stage of disrepair. The collagen matrix begins to break down, with increased cellularity and ingrowth of new blood vessels. There are attempts at healing, but the matrix becomes disorganised and the tendon’s structure is progressively compromised.

3. Degenerative Tendinopathy

Degenerative tendinopathy is the chronic stage, characterised by significant collagen degeneration, cell apoptosis, matrix breakdown and neovascularisation. It is common in older athletes or those with long-standing tendon issues. Areas of degenerate tissue are unlikely to reverse, but function and capacity can still be substantially improved through appropriate rehabilitation.

Factors That Contribute to Tendinopathy

Tendinopathy rarely develops in isolation. A number of factors can place excessive or abnormal load on a tendon, and identifying these is a key part of your assessment at Physio Tullamore:

• Posture — Poor posture and alignment can alter the way load is distributed through tendons, placing excessive stress on specific structures over time.
• Poor biomechanical patterns — Movement faults, altered kinematics and poor movement quality place abnormal loads on tendons that they are not conditioned to absorb.
• Spikes in training load — Sudden increases in training volume, intensity or frequency overwhelm the tendon’s capacity to adapt. This is a primary driver of reactive tendinopathy.
• Insufficient recovery — Tendons need time to adapt and recover between loading sessions. Without adequate recovery, the tendon enters a negative adaptation cycle.
• Taking up new hobbies — Starting new activities, especially ones the tendon is not conditioned for, can rapidly expose tendons to unfamiliar loads — for example a runner taking up hill walking, or a sedentary person starting tennis.

Management — First Line Treatment at Physio Tullamore

Effective tendinopathy management is built around understanding the tendon, the loads placed upon it and the factors driving your symptoms. At Physio Tullamore, first line management typically includes:

• Exercise modification — Modifying the loads and activities that provoke the tendon. This is the cornerstone of management.
• Improving range of movement — Addressing any restrictions that may be contributing to altered tendon loading, such as ankle dorsiflexion or hip range.
• Motor control — Retraining movement patterns to reduce aberrant loading on the tendon.
• Local tendon capacity — Progressive tendon-specific loading programmes (isometric, isotonic, heavy slow resistance and plyometric progression) to rebuild the tendon’s capacity to handle load.
• Performance testing — We use performance testing to objectively assess tendon capacity and measure strength, power and load tolerance. This helps guide your progression through rehabilitation and informs safe decisions around return to activity and sport.
• General lower limb strength — Building overall lower limb strength to distribute loads more effectively and reduce demand on the affected tendon.
• Shockwave therapy — Extracorporeal shockwave therapy as an adjunct to stimulate healing and reduce pain.

• Injection therapy — In some cases, injection therapies may be considered as an adjunct when conservative management alone is insufficient — but always in conjunction with a rehabilitation programme, never as a standalone treatment.