For years, we were taught about the inflammatory response, which was thought to be the origin of our patient’s (PT’s) pain. The cardinal signs are all there: the tendon seems swollen or thickens, the PT is tender to palpation, the tendon may feel warmer along with a sudden onset of pain, etc. The usual thinking is that, collectively, these symptoms are an “itis” – tendinitis! Though research has found that all such inflammatory agents are indeed present, at least in the acute stage, it is not clear that they are the sole cause of the nociceptive signal. 

In turn, over the last 10 years, tendon researchers such as Jill Cook have re-branded this condition as TendinoPATHY! Even though their findings have shown great validity and positive results, the amount of clinicians and doctors that still diagnose “TendinITIS” is shocking. One fact is clear to us now: your patient’s tendon pain is directly related to load. 

Interesting, but what does “load” mean? It refers to the work done by the tendon during a specific activity. That load was not received well and provoked a negative response of the tendon. As a result, the upset tendon is just telling us that it is unhappy with that load. The more we can increase our PT’s load-bearing capacity, the happier their tendon is going to be. Keep in mind, though, that not every load and tendon is created equal. Having great capacity in tensile load does not mean that we are prepared to sustain an increase in friction or compression load. 

Below I will share some key concepts and thoughts on how to understand tendon pain: 

Invest Time in a Thorough History 

In most tendinopathy scenarios, the PT has undergone a specific loading pattern that started the negative response. When reflecting on possible injury causes, it is absolutely crucial to ask the right questions and dig deep to understand what may have been the primary trigger. 

Here are two example scenarios:  

a. Return from Injury or Vacation/Off Season

The PT has gone through a low loading period and therefore reduced their tendon’s load-bearing capacity. For example, even if the PT is returning from a hip issue, their patella tendon might now be suffering due to a sudden increase in running, jumping, or another activity creating similar biomechanical stress. 

b. Dorsiflexion Loading

The PT has been running outdoors, but to challenge herself, she has recently started running on mountain trails. The abrupt increase in uphill running may now be a new trigger for the Achilles tendon.  

Types of Loads 

Once you have put your finger on the provoking load, it is key to understand each type of load: tensile, compressive, and friction – or a combination. 

Example A above represents a tensile load (overloading the spring-like mechanism), whereas example B represents a compressive load (overloading while the tendon is compressed against bone in dorsiflexion). Friction loads are often associated with paratenon irritation, as low but repetitive loads like poor biking mechanics can irritate the tendon sheath.

Removing the Provoking Load and Educating the Patient 

Our main goal with tendinopathy is to manage pain and improve function, as those are the reasons the PT is coming to us. Remove the provoking load in order to start the recovery process. This does NOT mean that we tell our PT to rest, ice, massage, cup, and elevate! Remember the more they rest, the more their load bearing capacity decreases. 

Active intervention through a specific loading program is the most effective way to reduce the PT’s pain and start re-establishing function. Passive interventions like injections, walking boots, massages, heel lifts, and stretching methods – though helpful as complementary tools – have been shown to be ineffective treatment methods in addressing tendon pathology and function. 

Finally, we must always educate our PT. Often, we might find an apprehension to loading because the PT is in pain – or because the doctor told them they have a “partial thickness tear.” Spend time educating your PT about the load and capacity relationship to get buy-in. 

Thank you all for reading. Please share your thoughts or questions, and keep an eye out for Part 2, where I will address the different types of loads, the stages of tendinopathy, and the components of the rehabilitation process. 


* Information from this blog series was drawn from the Barça Innovation Hub Course – Lower Limb Tendinopathy merged with my personal experience on tendinopathy Return To Play.