27 Tendinopathy

Rehabilitation for Tendon Pain

Tendinopathy is the preferred term for persistent tendon pain and loss of function related to mechanical loading (Scott et al., 2020).

  • Patellar tendinopathy is the preferred term for persistent patellar tendon pain and loss of function related to mechanical loading.
  • Achilles tendinopathy is the preferred term for persistent Achilles tendon pain and loss of function related to mechanical loading.
  • Peroneal (fibularis) tendinopathy is the preferred term for persistent peroneal (fibularis) tendon pain and loss of function related to mechanical loading.
  • Persistent tendon pain and loss of function related to mechanical loading of the medial or lateral elbow tendons should be referred to as medial or lateral elbow tendinopathy.


The presentation of pain in a tendon, does not always mean that the tendon is the primary contributor to pain. The multifactorial model of tendinopathy suggests that an impaired motor system, local tendon pathology, and changes in the pain/nociceptive system contributes to the complex clinical picture of tendon pain.


A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient Specific Functional Scale
  • Brief Pain Inventory (BPI)
  • Visual Analog Scale (VAS)



Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. There may be times that focal irritability (i.e., nerve irritation, trigger points, nervous system sensitization) co-exists with tendon pain. Gently stretching the muscles, neurovascular structures, and investing fascia activates endogenous pain modulating systems that help to modulate neuro-immune responses. 

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as hydrotherapy, relative rest, and strengthening exercises may be useful for people with tendon pain.

Tendinitis, Tendinosis, Tendinopathy? Exercise is the best medicine for tendon pain.


Multimodality options self-care techniques such as exercise therapy, relative rest, activity modifications should be considered as the first line treatment of tendon pain (Irby et al., 2020). Clinicians managing tendon pain should be thoughtful and skilled in managing the load on the tendons and supporting structures through a number of rehabilitation considerations including, but are not limited to manual therapy, education on psychosocial factors such as fear avoidance, and remedial loading programs.

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for tendon pain based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

Bayer, M. L., Magnusson, S. P., Kjaer, M., & Tendon Research Group Bispebjerg (2017). Early versus Delayed Rehabilitation after Acute Muscle Injury. The New England journal of medicine, 377(13), 1300–1301. doi:10.1056/NEJMc1708134

Bayer, M. L., Bang, L., Hoegberget-Kalisz, M., Svensson, R. B., Olesen, J. L., Karlsson, M. M., … Kjaer, M. (2019). Muscle-strain injury exudate favors acute tissue healing and prolonged connective tissue formation in humans. FASEB journal: official publication of the Federation of American Societies for Experimental Biology, 33(9), 10369–10382. doi:10.1096/fj.201900542R

Berrueta, L., Muskaj, I., Olenich, S., Butler, T., Badger, G. J., Colas, R. A., … Langevin, H. M. (2016). Stretching Impacts Inflammation Resolution in Connective Tissue. Journal of cellular physiology, 231(7), 1621–1627. doi:10.1002/jcp.25263

Best, T. M., Gharaibeh, B., & Huard, J. (2013). Stem cells, angiogenesis and muscle healing: a potential role in massage therapies?. British journal of sports medicine, 47(9), 556–560. doi:10.1136/bjsports-2012-091685

Bojsen-Møller, J., & Magnusson, S. P. (2019). Mechanical properties, physiological behavior, and function of aponeurosis and tendon. Journal of applied physiology (Bethesda, Md. : 1985), 126(6), 1800–1807. doi:10.1152/japplphysiol.00671.2018

Bove, G. M., Harris, M. Y., Zhao, H., & Barbe, M. F. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Journal of the neurological sciences, 361, 168–180. doi:10.1016/j.jns.2015.12.029

Bove, G. M., Delany, S. P., Hobson, L., Cruz, G. E., Harris, M. Y., Amin, M., … Barbe, M. F. (2019). Manual therapy prevents onset of nociceptor activity, sensorimotor dysfunction, and neural fibrosis induced by a volitional repetitive task. Pain, 160(3), 632–644. doi:10.1097/j.pain.0000000000001443

Brasure, M., Nelson, V.A., Scheiner, S., Forte, M.L., Butler, M., Nagarkar, S., Saha, J., Wilt, T.J. (2019). Treatment for Acute Pain: An Evidence Map [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US).

Cardoso, T. B., Pizzari, T., Kinsella, R., Hope, D., & Cook, J. L. (2019). Current trends in tendinopathy management. Best practice & research. Clinical rheumatology, 33(1), 122–140. https://doi.org/10.1016/j.berh.2019.02.001

Challoumas, D., Clifford, C., Kirwan, P., & Millar, N. L. (2019). How does surgery compare to sham surgery or physiotherapy as a treatment for tendinopathy? A systematic review of randomised trials. BMJ open sport & exercise medicine, 5(1), e000528. https://doi.org/10.1136/bmjsem-2019-000528

Cholok, D., Lee, E., Lisiecki, J., Agarwal, S., Loder, S., Ranganathan, K., … Levi, B. (2017). Traumatic muscle fibrosis: From pathway to prevention. The journal of trauma and acute care surgery, 82(1), 174–184. doi:10.1097/TA.0000000000001290

Clifford, C., Challoumas, D., Paul, L., Syme, G., & Millar, N. L. (2020). Effectiveness of isometric exercise in the management of tendinopathy: a systematic review and meta-analysis of randomised trials. BMJ open sport & exercise medicine, 6(1), e000760. https://doi.org/10.1136/bmjsem-2020-000760

Docking, S. I., & Cook, J. (2019). How do tendons adapt? Going beyond tissue responses to understand positive adaptation and pathology development: A narrative review. Journal of musculoskeletal & neuronal interactions, 19(3), 300–310.

Dubois, B., & Esculier, J. F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British journal of sports medicine, 54(2), 72–73. https://doi.org/10.1136/bjsports-2019-101253

Duchesne, E., Dufresne, S. S., & Dumont, N. A. (2017). Impact of Inflammation and Anti-inflammatory Modalities on Skeletal Muscle Healing: From Fundamental Research to the Clinic. Physical therapy, 97(8), 807–817. doi:10.1093/ptj/pzx056

Dunn, S. L., & Olmedo, M. L. (2016). Mechanotransduction: Relevance to Physical Therapist Practice-Understanding Our Ability to Affect Genetic Expression Through Mechanical Forces. Physical therapy, 96(5), 712–721. doi:10.2522/ptj.20150073

Edwards, W. B. (2018). Modeling Overuse Injuries in Sport as a Mechanical Fatigue Phenomenon. Exercise and sport sciences reviews, 46(4), 224–231. doi:10.1249/JES.0000000000000163

Gracey, E., Burssens, A., Cambré, I., Schett, G., Lories, R., McInnes, I. B., Asahara, H., & Elewaut, D. (2020). Tendon and ligament mechanical loading in the pathogenesis of inflammatory arthritis. Nature reviews. Rheumatology, 16(4), 193–207. https://doi.org/10.1038/s41584-019-0364-x

Hamilton, B., Alonso, J. M., & Best, T. M. (2017). Time for a paradigm shift in the classification of muscle injuries. Journal of sport and health science, 6(3), 255–261. doi:10.1016/j.jshs.2017.04.011

Hunt, E. R., Baez, S. E., Olson, A. D., Butterfield, T. A., & Dupont-Versteegden, E. (2019). Using Massage to Combat Fear-Avoidance and the Pain Tension Cycle. International Journal of Athletic Therapy and Training, 24(5), 198-201.

Hunt, E. R., Confides, A. L., Abshire, S. M., Dupont-Versteegden, E. E., & Butterfield, T. A. (2019). Massage increases satellite cell number independent of the age-associated alterations in sarcolemma permeability. Physiological reports, 7(17), e14200. doi:10.14814/phy2.14200

Hsu, J. R., Mir, H., Wally, M. K., Seymour, R. B., & Orthopaedic Trauma Association Musculoskeletal Pain Task Force (2019). Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury. Journal of orthopaedic trauma, 33(5), e158–e182. doi:10.1097/BOT.0000000000001430

Irby, A., Gutierrez, J., Chamberlin, C., Thomas, S. J., & Rosen, A. B. (2020). Clinical management of tendinopathy: A systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments. Scandinavian journal of medicine & science in sports, 30(10), 1810–1826. https://doi.org/10.1111/sms.13734

Laumonier, T., & Menetrey, J. (2016). Muscle injuries and strategies for improving their repair. Journal of experimental orthopaedics, 3(1), 15. doi:10.1186/s40634-016-0051-7

Magnusson, S. P., & Kjaer, M. (2019). The impact of loading, unloading, ageing and injury on the human tendon. The Journal of physiology, 597(5), 1283–1298. doi:10.1113/JP275450

McGorm, H., Roberts, L. A., Coombes, J. S., & Peake, J. M. (2018). Turning Up the Heat: An Evaluation of the Evidence for Heating to Promote Exercise Recovery, Muscle Rehabilitation and Adaptation. Sports medicine (Auckland, N.Z.), 48(6), 1311–1328. doi:10.1007/s40279-018-0876-6

Millar, N. L., Murrell, G., & Kirwan, P. (2020). Time to put down the scalpel? The role of surgery in tendinopathy. British journal of sports medicine, 54(8), 441–442. https://doi.org/10.1136/bjsports-2019-101084

Miller, B. F., Hamilton, K. L., Majeed, Z. R., Abshire, S. M., Confides, A. L., Hayek, A. M., … Dupont-Versteegden, E. E. (2018). Enhanced skeletal muscle regrowth and remodelling in massaged and contralateral non-massaged hindlimb. The Journal of physiology, 596(1), 83–103. doi:10.1113/JP275089

Moseley, G. L., Baranoff, J., Rio, E., Stewart, M., Derman, W., & Hainline, B. (2018). Nonpharmacological Management of Persistent Pain in Elite Athletes: Rationale and Recommendations. Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine, 28(5), 472–479. doi:10.1097/JSM.0000000000000601

Ng, J. L., Kersh, M. E., Kilbreath, S., & Knothe Tate, M. (2017). Establishing the Basis for Mechanobiology-Based Physical Therapy Protocols to Potentiate Cellular Healing and Tissue Regeneration. Frontiers in physiology, 8, 303. doi:10.3389/fphys.2017.00303

Rice, S. M., Gwyther, K., Santesteban-Echarri, O., Baron, D., Gorczynski, P., Gouttebarge, V., … Purcell, R. (2019). Determinants of anxiety in elite athletes: a systematic review and meta-analysis. British journal of sports medicine, 53(11), 722–730. doi:10.1136/bjsports-2019-100620

Rio, E., Moseley, L., Purdam, C., Samiric, T., Kidgell, D., Pearce, A. J., … Cook, J. (2014). The pain of tendinopathy: physiological or pathophysiological?. Sports medicine (Auckland, N.Z.), 44(1), 9–23. doi:10.1007/s40279-013-0096-z

Rio, E., & Docking, S. I. (2018). Adaptation of the pathological tendon: you cannot trade in for a new one, but perhaps you don’t need to?. British journal of sports medicine, 52(10), 622–623. doi:10.1136/bjsports-2016-097325

Sato-Suzuki, I., Kagitani, F., & Uchida, S. (2019). Somatosensory regulation of resting muscle blood flow and physical therapy. Autonomic neuroscience: basic & clinical, 220, 102557. doi:10.1016/j.autneu.2019.102557

Schleip, R., Gabbiani, G., Wilke, J., Naylor, I., Hinz, B., Zorn, A., … Klingler, W. (2019). Fascia Is Able to Actively Contract and May Thereby Influence Musculoskeletal Dynamics: A Histochemical and Mechanographic Investigation. Frontiers in physiology, 10, 336. doi:10.3389/fphys.2019.00336

Scott, A., Squier, K., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., … Zwerver, J. (2020). ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. British journal of sports medicine, 54(5), 260–262. https://doi.org/10.1136/bjsports-2019-100885

Stern, B. D., Hegedus, E. J., & Lai, Y. C. (2020). Injury prediction as a non-linear system. Physical therapy in sport: official journal of the Association of Chartered Physiotherapists in Sports Medicine, 41, 43–48. https://doi.org/10.1016/j.ptsp.2019.10.010

Thompson, W. R., Scott, A., Loghmani, M. T., Ward, S. R., & Warden, S. J. (2016). Understanding Mechanobiology: Physical Therapists as a Force in Mechanotherapy and Musculoskeletal Regenerative Rehabilitation. Physical therapy, 96(4), 560–569. doi:10.2522/ptj.20150224

van der Vlist, A. C., Winters, M., Weir, A., Ardern, C. L., Welton, N. J., Caldwell, D. M., Verhaar, J., & de Vos, R. J. (2020). Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials. British journal of sports medicine, bjsports-2019-101872. Advance online publication. https://doi.org/10.1136/bjsports-2019-101872

Vicenzino, B., de Vos, R. J., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B. K., … Zwerver, J. (2020). ICON 2019-International Scientific Tendinopathy Symposium Consensus: There are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi study of healthcare professionals and patients. British journal of sports medicine, 54(8), 444–451. https://doi.org/10.1136/bjsports-2019-100894

Waters-Banker, C., Dupont-Versteegden, E. E., Kitzman, P. H., & Butterfield, T. A. (2014). Investigating the mechanisms of massage efficacy: the role of mechanical immunomodulation. Journal of athletic training, 49(2), 266–273. doi:10.4085/1062-6050-49.2.25


Icon for the Creative Commons Attribution-NonCommercial 4.0 International License

Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

Share This Book