Tendon Tissue & Load-induced Tendinopathy

Tendon injuries and reports of tendon pain are common presentations to The Injury Clinic Physiotherapy. We have found there is a lot of confusion and a few misconceptions surrounding tendon injuries and the most appropriate course of action in their management.

Tendons are comprised of strong, fibrous collagen tissue (collagen is the main structural protein of connective tissue) and are responsible for attaching muscle to bone. Tendon tissue has an essential role in transmitting contractile forces to bone to generate movement. Tendons are designed to withstand considerable loads and are capable of adapting to changes in loading (mechanical loading results in increased strength), however repetitive use often results in injury.

Tendon injuries are referred to as Tendinopathy or Tendinosis and are characterized by pain during activity, localized tenderness on palpation and impaired performance. Historically, the term ‘tendinitis’ was used to describe pain referring to a symptomatic tendon, implying that there is an inflammatory process. However, treatment aimed at modulating inflammation has limited success in tendon presentations. The proposed mechanism of injury that leads to a tendinopathy is that there are one or more ‘weak links’ in the tendon structure that result in a pathological response.

Tendon pathology has in recent years been described as degenerative or failed healing as opposed to inflammatory. However recent research conducted by Jill Cook and Craig Purdam in 2009 outlines a model that considers tendon pathology as a continuum.

Tendon Pathology
  • Generally follows a period of acute overload (i.e. burst of unaccustomed physical activity)
  • Non-inflammatory response
  • Adaptive thickening in an attempt to reduce tissue stress


  • Greater breakdown/disorganisation of tendon matrix
  • Neovascularisation may be present on imaging
  • Apparent in chronically overloaded tendons


  • Large areas of tendon matrix disorganisation and breakdown
  • More commonly seen in older client/athlete





As a general rule, clinical treatments directed at effecting change in tendon structure or pathology are the way to go. Treatment approach should vary depending on what stage of the continuum your tendon presentation is consistent with. Loading a reactive tendon will not be beneficial and resting a degenerative tendon will not promote the much needed cell activity and reorganization of the tendon matrix.


  • Load management will allow your tendon time to adapt and tendon cells to become less reactive. A reduction in load is also likely to have a positive impact on pain.
  • Assessment and modification of the intensity, duration and frequency of load is the key clinical intervention.
  • Tendon load without energy storage and release such as cycling or strength based weight training can be maintained and should be considered in regards to injury prevention measures.
  • High load elastic or eccentric loading, particularly with little recovery time will tend to aggravate tendon cells at this stage.


  • Treatments that simulate cell activity, increase protein production and restructure the matrix are most appropriate.
  • Eccentric exercise has been shown to affect both tendon structure and pain and to increase collagen in abnormal tendons.
  • Eccentric exercise has also been shown to be an effective pain relief treatment.
  • Other, more invasive treatment options (Extracorporeal Shock Wave Therapy; Prolotherapy (ABI; PRP); Cortisone Injections; Surgery) exist, however the most appropriate choice is dependent on the individual tendon, person and response to conservative management.


So, gathering the right information and determining at what stage your tendon tissue may be (it can be also be a combination; i.e. a tendon in late dysrepair can become reactive) is the best place to start. This will ensure that the best management plan is set and that treatment is targeted to both the needs of the tissue, and the person. As with any injury, it is also important that any predisposing factors be both identified and addressed (i.e. training errors, biomechanics etc.).



Cook, J. & Purdam, C. 2009. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409-416.

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