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10 truths you should know about tendinopathies

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This infographic shows you the 10 most important things you must know about tendinopathies. The information has been kindly provided by Dr Peter Malliaras.

It says as follow…

1. Rest does not improve tendinopathy

Pain may settle, but will be back when returning to activity, because rest does not increase the tolerance of the tendon to load.

2. Exercise is the top treatment for tendinopathy

Exercise is the most evidence-based treatment for tendinopathy. In a vast majority of cases (but not all) tendinopathy will not improve without the vital load stimulus given by exercising.

3. Modifying load is very important

Load modification is important in settling tendon pain. This often involves reducing (at least in the short-term) abusive tendon load that involves energy storage and compression. Tendons need to be loaded progressively so that they can develop greater tolerance to the loads that an individual needs to endure in their day-to-day life.

4. Exercise needs to be individualised

This is based on the individual’s pain and function presentation. There should be progressive increase in load to enable restoration of goal function whilst respecting pain.

5. Tendinopathy responds very slowly to exercise

You need to have patience, ensure that exercise is correct and progressed appropriately, and try and resist the common temptation to accept ‘short cuts’ like injections and surgery. There are often no short cuts.

6. Tendinopathy rarely improves long term with only passive treatments

Such as massage, therapeutic ultrasound, injections, shock-wave therapy etc. Exercise is often the vital ingredient and passive treatments are adjuncts. Multiple injections in particular should be avoided, as this is often associated with a poorer outcome.

7. Tendinopathy is not considered a classic inflammatory response

Although there are some inflammatory biochemical and cells involved in tendinopathy, it is not considered to be a classic inflammatory response. Antiinflammatories may help if you have very high pain levels but it is unclear what effect they have on the actual cells and pathology.

8. The cause of tendinopathy can be multifactorial

The main factor is a sudden change in certain activities – these activities include 1) those that require the tendon to store energy (i.e. walking, running, jumping), and 2) loads that compress the tendon. Some people are predisposed because of biomechanics (e.g. poor muscle capacity or endurance) or systemic factors (e.g. age, menopause, elevated cholesterol, increased susceptibility to pain, etc). Predisposed people may develop tendon pain with even subtle changes in their activity.

9. Pathology on imaging does not equal pain

Pathology is common in people without pain. Also, if you have been told you have ‘severe pathology’ or even ‘tears’ this DOES NOT necessarily mean you will not get better or have a poorer outcome.

10. Pathology is not likely to reverse in most cases

We know that even with the best-intentioned treatment (exercise, injections, etc) the pathology is not likely to reverse in most cases. Therefore, most treatments are targeted towards improving pain and function, rather than tissue healing, although this still is a consideration.

Please, note that these are general principles and there are instances when adjuncts, including injections and surgery are very appropriate in the management of tendinopathy.

You can see the infographic made for this article here.


– Abate M, Gravare-Silbernagel K, Siljeholm C, et al.: Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Research and Therapy. 2009, 11:235.

– Cook J, Purdam C: Is compressive load a factor in the development of tendinopathy? British Journal of Sports Medicine. 2012, 46:163-168.

– Littlewood C, Malliaras P, Bateman M, et al.: The central nervous system–An additional consideration in ‘rotator cuff tendinopathy’and a potential basis for understanding response to loaded therapeutic exercise. Manual therapy. 2013.

– Malliaras P, Barton CJ, Reeves ND, Langberg H: Achilles and Patellar Tendinopathy Loading Programmes. Sports Medicine. 2013:1-20.

Spanish version

Foto del autor

Peter Malliaras

Dr. Peter Malliaras has been a respected and leading tendinopathy researcher and clinician for the last 15 years. He completed his PhD, in 2006, in tendinopathy identifying novel risk factors, and since has undertaken post doctoral research in the UK and Australia, and has co-authored over 55 peer review publications most relating to tendinopathy.