Tendinopathy and Healing: Dealing with Tendon Pain

This is one of the most common issues that people come to see me about. Whether the complaint is in the lateral hip, Achilles tendon, shoulder rotator cuff muscles, especially supra spinatus muscle or elbow pain, pain in or around tendon.

Tendons attach muscle to bone. Tendons are designed to be strong and able to with stand a lot of tensile load. However in some situations the repeated load on tendons becomes greater than a load the tissue can repeatedly bear.

Over time a tendon’s structure can change with usually well aligned collagen/ protein fibres becoming more haphazard. This is called collagen disorganization. This is the case in Achilles Tendinopathy, when a lump may be felt in the substance of the tendon. There may also be small tears in the tendon.

There may be inflammatory ‘reactivity’ around the surface of the tendon, but the degenerative process inside the main tendon, is not thought to be inflammation.  So this is why I am calling tendon issues ‘ tendinopathy’ rather than  ‘ tendinitis’, as ‘itis’ denotes inflammatory reactions.

Ultrasound investigation can show tendon changes including infiltration of blood vessels into the degenerative tendon matrix. This is called ‘neovascularization’, but this does not consistently corelate with complaints of pain apparently. New research has shown that pain is thought to be related to in growth of small nerve fibres and other chemical substances into the tendon as it tries to heal and adapt.  (Ackermann PW, 2022; Wasker SVZ, 2023; Physio Meets Science FB post 27.12.25)

WHAT CAN WE DO ABOUT MANAGING TENDON PAIN AND DYSFUNCTION?

The key to rehab for tendon pain is choosing the right advice and exercise regime to carefully grade back to training and pain free daily function.

Tendons LIKE load that muscles put on them. However, it needs to be the RIGHT exercise and functional movement load. This involves ‘LISTENING’ to the tendon, to judge how it is reacting to certain exercises and daily and sport activities. Too much load or too little load can mean less  healing progress and continued pain, while ‘just the right’ load will give great results. Think of the ‘Goldie locks’ ‘just right’ sweet spot and progress loading exercises from there as the tendon adapts and heals.

Tendons DO NOT like stretch or Compression.

Sleeping positions can exacerbate pain on a sore, cranky lateral hip tendon with degenerative changes, associated bursitis or a tear in the tendon. Positions that are not recommended are

1. Lying on the sore hip, causing compression on the sore tendon or associated bursa or
2. Side lying with the leg hanging down across the midline of the body, causing Sustained stretch on the top lateral hip tendon

Sleeping with pillows that allow the thigh and leg  to remain in line with the top hip in side lying will give pain relief during the night.

Using just a small pillow between the knees with the foot unsupported does not give the leg the position that will protect and rest the lateral hip tendon. The whole thigh, knee and foot need to be aligned to prevent the leg from dropping in or rotating too much at the hip.

One of the defining symptoms of tendon pain is ‘ START UP PAIN’. This is pain and stiffness first thing in the morning when first getting up or after sitting for a length of time. Tendons then warm up as you move, but may become painful again if over loaded in appropriately during the day.

DOING THE DETECTIVE WORK

Your physio will be able to look at potential causes of tendon problems during daily and sporting situations. Does the foot alignment have an influence on your heel and Achilles tendon position?  Does the shoulder girdle and thoracic spine posture, put undue compression or stretch on your  shoulder tendons? What load is TOO much load, and how can you carefully grade back to your normal level of function.

REHAB PROCESS

Graded rehab exercises often start with static holds in relatively pain free  joint position. This Static or ‘isometric’ muscle hold is useful as a pain relieving strategy.. ‘panadol for the tendon’.

Exercises then progress from very light, to very heavy loads as the tendon is able to tolerate progressive increases in load. Tendons don’t like ‘shocks’ so sudden stretches or rapid increase in weights may cause exacerbation of pain and a slower recovery.

Work with your physio to judge the load progression to suit you. Discuss when it will be appropriate to progress exercises, and when to introduce the most appropriate progressions.

REMEMBER:

A common mistake is copying exercises from Instagram or YouTube.

What works for someone else’s body, injury, or dance/ sport  load may be completely wrong for yours.

• Generic exercises don’t consider timeline of your pathology
• Exercise Timing and load matter
• Technique errors can delay recovery

The real secret to long-term results is individualised programming with feedback and care.

• Medical conditions are always considered
• We aim to  empower you toward independence in injury management.
• You can work to reverse tendon damage and lead a pain free life.

Contact Activate Physio. Exercise Rehab to start your healing process.