Chronic tendinopathy: a hybrid approach
Tendinopathy is tendon pain tied to load, often with structural change inside the tendon. It is slow to settle, and the most dependable treatment is a loading program that is dosed correctly.
What the options have been shown to do
Progressive loading
Isometric, eccentric and heavy slow resistance programs all have trial support. The best choice depends on the tendon, how irritable it is and what you need to do.
Shockwave and other physical treatments
May help some people alongside loading. They are add-ons, not replacements for it.
Injections
Corticosteroid can reduce pain for a short time but is not a long-term fix. Platelet-rich plasma has mixed trial results. A physician can explain where each fits for you.
Cellular therapies
In refractory cases, cellular therapies may be evaluated by our medical team. They are an optional adjunct, the evidence is limited, and they never replace loading.
Why dosed load comes first is explained in the page on mechanotransduction. Achilles tendinopathy has its own midportion and insertional plans. Where a physician is also involved, see physical therapy and physician-led regenerative care. A plan from our sports rehabilitation team sets the dose and the tests. The shoulder is a common example, covered in rotator cuff rehab.
How a tendon plan is sequenced
Select a stage to see the rehab focus and the physician’s role.
Rehab focus
Reduce the provoking load, not all load. Isometric holds can ease pain while you keep training elsewhere.
Physician’s role
Confirm the diagnosis, rule out other causes, and review medications and health factors that affect tendons.
Rehab focus
Progress to eccentric or heavy slow resistance work, with weights raised as the tendon tolerates them.
Physician’s role
Review progress at set points. Discuss any further option and its evidence honestly, including doing nothing more.
Rehab focus
Add the speed, impact and volume of your sport or job, in steps, with testing.
Physician’s role
Close the loop: what helped, what did not, and what to do if symptoms return.
About the clinical team behind this page
Author
Dr. Angel Williams, PT, DPT, OCS, FAAOMPT
Director of Orthopaedic Rehabilitation & Biomechanical Recovery
Dr. Angel Williams is a board-certified Orthopaedic Clinical Specialist and a Fellow of the American Academy of Orthopaedic Manual Physical Therapists. Dr. Williams has served as a supervising physical therapist at Nova and designs rehabilitation programs built on progressive loading, manual therapy and dry needling for tendon, ligament and post-surgical recovery. Where a physician prescribes a cellular therapy alongside rehabilitation, Dr. Williams builds the loading program that goes with it.
- NPI 1174844872 (CMS registry)
- GA license PT012751, verify with the Georgia State Board of Physical Therapy
- Board-Certified Orthopaedic Clinical Specialist (OCS), American Board of Physical Therapy Specialties (ABPTS)
- Fellow of the American Academy of Orthopaedic Manual Physical Therapists (FAAOMPT)
Dr. Michael D. Schreiber is an osteopathic physician. He applies osteopathic principles to musculoskeletal diagnosis and rehabilitation, looking at the whole kinetic chain when judging how a joint or tendon problem developed, and advises on how physician care and physical therapy fit together. He is a graduate of the Chicago College of Osteopathic Medicine of Midwestern University, class of 1992.
Medical disclaimer: The information on this site is for education and does not replace a consultation, diagnosis or treatment. Full credentials are on our physicians and clinical governance page.
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Individual results vary and no outcome is guaranteed. This page is general information, not medical advice.