Tendons, muscles, and ligaments are commonly injured, especially in active adults and athletes. Because they present similarly, it’s important to see a specialist who can confirm a diagnosis and get you started on your recovery. Tendinosis treatment requires accurate diagnosis and very specific types of intervention.

In this article, we will look at the differences between tendon injuries, different types of tendon pain, and tendonitis treatment for active adults and athletes.

What is a Tendon?

A tendon is a strong cord of connective tissue that is made from collagen fibers. Tendons play a large role in every movement since they connect muscles to bones.

Although the tendons themselves are made up of several parts, the most important one is known as a tenocyte. Tenocytes respond to stressors placed upon the tendon and transmit the force to the bone to which it’s connected.

The Difference Between Tendinitis, Tendinosis, and Tendinopathy

Injuries to tendons are characterized by several factors. Generally speaking, there are three categories of tendon injuries, ranging from mild to severe in nature.

Out of the three types of tendon injuries, tendinitis is the mildest in nature and refers to inflammation of the tendon. With tendinitis, there is potential for small micro-tears within the tendon but these rarely cause concern. Luckily, tendinitis has a predictable recovery, and most people with Achilles tendinitis or similar conditions will completely recover with physical therapy and activity modification.

With tendinitis, you may exhibit mild changes, like increased signal intensity, on an MRI. These changes show up as white discoloration around the injured area. Doctors may use this finding to distinguish between tendinitis and more severe tendon injuries like tendinosis or tendinopathy.

Tendinitis that fails to respond to treatment can become tendinosis, a chronic condition that is complex in nature and difficult to diagnose. Sometimes, an MRI is warranted for diagnosis but not always helpful in providing definitive answers. At this time, research shows there is no correlation between the findings on an MRI with pain or function.

If you’ve had untreated or poorly managed tendinitis for several weeks or months, you’re probably dealing with tendinosis or tendinopathy. The most severe category of tendon injuries is referred to as tendinopathy. This diagnosis usually means some sort of degenerative process has begun and any problems observed during tendinosis have worsened. People with tendinopathy, especially Achilles tendinopathy, are highly sensitive to any activities that involve the tendon and are likely to experience more issues over time.

There are three stages of tendinopathy that basically describe the health of the tendon on a cellular level. While it’s not often that you’ll hear your healthcare provider refer to these stages, you should know that each one will affect the way the tendon heals and your overall recovery.

Occasionally, tendinopathy can be mistaken for a partial tear in the tendon. While this does not necessarily mean that you need surgery, a full full-thickness tear almost always does.

The timeframe for recovery from tendinosis or tendinopathy will vary. Recovery occurs on a continuum, which means there are different stages to tendon pain and, therefore, healing. Tendinosis or tendinopathy recognized at an early stage can take six to 10 weeks to recover; however, chronic tendinosis can last anywhere from three to nine months.

When it comes to recovery, there’s a reason for such a wide range of timeframes. Improving the health and strength of the tendon takes time, which is one of the reasons why it can take months to see improvements.

Where Can You Get Tendinosis?

woman with runners knee looking for tendinosis treatment

Have you ever experienced “growing pains” as a teenager? If so, you probably were experiencing pain with at least one of your tendons.

Any tendon in the body can potentially develop tendinitis, tendinosis, or tendinopathy. Here is a list of common tendons that are prone to injury:

  • Rotator cuff tendons (4 total)
  • Golfer’s elbow
  • Tennis elbow
  • Glute tendons
  • Hip adductor tendons
  • Patellar tendon
  • Hamstring tendons
  • Quadriceps tendon
  • Achilles tendon
  • Plantar fascia

As you can see, almost every area of the body is vulnerable to tendon problems. Most tendon problems start when the area becomes less tolerable to stressors (forces) that are placed on it. As for the exact mechanism behind why it happens, researchers are not quite sure.

However, there are a few theories as to how tendons can be injured, and they are summarized below.

  1. Cellular components of the tendon, mainly collagen, shrink or sustain damage. This ultimately decreases the strength of the tendon and affects the way it works.
  2. Small amounts of inflammation in the tendon may, in fact, be normal. Therefore, pain associated with a tendon injury may be originating elsewhere. The exact mechanisms behind this theory are not clear, but research shows that inflammation does not necessarily equal pain when it comes to tendon injuries.
  3. Tendon injuries may have something to do with loading, similar to the mechanisms behind osteoporosis. Like bones, tendons require individual amounts of loading, aka force, to work properly. Excessive loading can result in injury whereas small loads are not enough to maintain the tendon’s strength, thus making it vulnerable to injury.

The Relationship Between Tendon Injuries and Pain

man receiving rotator cuff tendinosis treatment

Before we discuss tendon pain, it’s important to know how pain is interpreted. It’s thought that pain originates from nerves in the body that send warning signals to the brain. There, the brain is tasked with interpreting the signals as a painful sensation and determining the next course of action.

Sensitivity and pain that gradually develop are characteristic of tendon pain. It’s also possible that the overused tendon has been sending pain signals for longer than you may have realized. Frequent pain signals can cause sensitivity in the injured area, thus the reason why you may feel fine today but in pain tomorrow.

Interestingly enough, partial tendon tears are not always associated with pain. This may be due to the fact that there is no nerve in the deeper part of the tendon. Others who feel pain with partial tendon tears may have problems with the outer layers of the tendon where nerve fibers are located.

Signs and Symptoms of Tendon Pain

One clue to diagnosing a tendon injury, regardless of its severity, is pain with stretching and direct loading of the tendon. This means that pain is triggered when the tendon is pulled, stretched, or loaded.

Other signs and symptoms of tendon pain include:

  • Pain during or after exercise
  • Pain near the tendon; may have a noticeable bump on larger tendons (like the Achilles tendon)
  • Sharp, burning, or aching sensations

Depending on the level of irritation, tendon pain can occur at various times. Mild tendon irritation can cause pain after exercise. For example, those who do CrossFit may not have shoulder pain during a pull-up but will notice it afterward. Moderate tendon irritation may cause pain both during and after exercise whereas severe tendon irritation tends to cause pain at rest, even when the tendon is not being used.

A tip from the experts: Tendon pain can be triggered by returning to physical activity after a period of rest. However, understand that pain doesn’t necessarily refer to damage to the tendon but rather increased sensitivity to use.

Tendinosis Treatment and Management in Active Adults and Athletes

Recall that tendon injuries occur on a continuum that is based upon stages. Therefore, treatment will also follow a staged approach.

Mild tendon injuries, like rotator cuff tendinitis treatment, respond to rest, ice, and exercises to unload and strengthen the area. Activity modification is a crucial part of tendinitis treatment because continued overuse places you at risk for tendinosis or tendinopathy.

Tendinosis and tendinopathy are managed quite differently than tendinitis. The main focus of tendinosis treatment is teaching you how to progressively load the tendon. This involves showing you how to manage your pain and safely use the injured tendon without triggering high levels of pain.

One way to do this is to use a 2-point pain rule in which you stop any activity that increases your pain more than two points from baseline. When this happens, you may need to modify something in your workout routine, like the number of repetitions, sets, or rounds you’re completing. Other ways to alter your routine may be to decrease the speed of movement, amount of weight lifted, or change your body mechanics.

Understanding how to manage the amount of weight, or load, on the injured tendon is important. If the tendon is constantly overloaded, healing will be almost impossible. On the other hand, unloading the tendon doesn’t enable it to heal, either. Treatment for tendinosis uses progressive tendon loading methods to improve the tendon’s ability to manage an external load.

Here’s a general example of progressive tendon loading:

  • Start with isometric exercises that transmit minimal force through the tendon.
  • Progress to concentric exercises and eccentric exercises that create movement with tendon loading.
  • Add in sport-specific exercises, plyometrics, and jumping

athlete having patellar tendinosis treatment done

What stimulates healing in the tendon, and how does it become less sensitive with treatment? While we have some understanding of these questions, most of the answers are unknown at this time. Some believe that certain treatments, like dry needling, realign the fibers within the tendon itself whereas others think that manual treatment with progressive loading techniques stimulates healing. It’s likely that the answer is a combination of all of the above.

It’s also important to strengthen the muscles surrounding the injured tendon. After identifying the cause of the injury, like overuse or compensation for a weakness elsewhere in the body, the focus of treatment should also include those areas as well. For example, stiff ankles can contribute to tendon problems in the knee or hip due to compensation patterns. Complex cases such as these often require the expertise of a specialist to recover properly.

You may be surprised to hear that cortisone, a high dose of anti-inflammatory medication, is not effective if you have tendinosis or tendinopathy. This is because anti-inflammatory treatments target irritation which is typically seen in someone with tendinitis.

Tendinosis Treatment and Pain Relief in Columbus, Ohio

There was a ton of information in this post, so let’s take a moment to break it down.

  • If you’ve had tendon pain for a long time, it’s probably not tendinitis which is inflammation of the tendon. You’re likely past that stage, and that’s why anti-inflammatory treatments might not be working for you.
  • Tendon injuries may be diagnosed with the help of an MRI, but this doesn’t always match your pain or disability. However, MRIs can be helpful in distinguishing between tendinitis, tendinosis, and tendinopathy. Don’t panic if the MRI shows a partial tear in the tendon since this doesn’t necessarily mean you’re destined for surgery.
  • Chronic tendon injuries or pain may be a sign that you’re dealing with tendinosis or tendinopathy. A physical therapist can show you how to improve your sensitivity to tendon loading using a progressive tendon loading protocol and activity modification. Tendinosis treatment can last anywhere from six weeks to a few months.

Treatment for tendinosis or tendinopathy requires a highly trained specialist. The value of coming to a specialist at Peak Physiotherapy and Performance is the deeper understanding of progressive loading, activity modification, and identifying your specific stage of healing. Don’t delay contacting P3, where Dr. Junak can set you on the right path to recovery. Plus, for a limited time, he is offering free phone consultations for his physical therapy clinic in Columbus.

About the Author

Dr. Andrew Junak is a Doctor of Physical Therapy and Board-Certified Orthopedic Specialist. Dr. Junak received his Doctorate of Physical Therapy from Walsh University and completed his Orthopedic Specialist training at the Cleveland Clinic Orthopaedic Residency Program. He is the owner of Peak Physiotherapy and Performance, a physical therapy clinic in Canal Winchester, Ohio where he serves the local communities of Lancaster, Reynoldsburg, Grove City, Pickerington, and Columbus. In his practice, Dr. Junak helps clients with jaw pain, neck pain, and headaches find relief without resorting to medications, injections, or surgery.

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