Tendinopathy

The tendon that won't heal

You've rested it. You've iced it. You've taken anti-inflammatories. And yet that tendon still hurts. If this sounds familiar, you're dealing with tendinopathy — and the reason it's not getting better is that the problem isn't what most people think it is.

Tendinopathy is not tendinitis. The suffix "-itis" implies inflammation, and while there may be an inflammatory component early on, chronic tendon pain is primarily a degenerative problem. The tendon's internal structure has broken down — the collagen fibers become disorganized, the normal architecture is disrupted, and the tissue loses its ability to handle load. Rest and anti-inflammatories don't fix disorganized collagen. Progressive loading does.

Where it shows up

Tendinopathy can affect any tendon, but some are far more common than others:

Achilles tendinopathy. Pain in the back of the ankle, especially in runners, walkers, and people who've suddenly increased their activity. It can affect the mid-portion of the tendon or the insertion at the heel — these are actually two different conditions with different treatment approaches.

Lateral epicondylitis (tennis elbow). Pain on the outside of the elbow from degeneration of the common extensor tendon origin. Despite the name, it's more common in people who type, use tools, or carry heavy objects than in tennis players.

Rotator cuff tendinopathy. Degeneration of the supraspinatus or infraspinatus tendon, causing shoulder pain with overhead activity. Often coexists with impingement — the biomechanical component is important to address.

Patellar tendinopathy (jumper's knee). Pain at the front of the knee just below the kneecap. Common in sports that involve jumping and landing — basketball, volleyball, running.

Gluteal tendinopathy. Pain on the outside of the hip, often misdiagnosed as trochanteric bursitis. It's the primary cause of greater trochanteric pain syndrome and is especially common in women over 40.

Plantar fasciitis. Though technically a fascia, the plantar fascia behaves like a tendon, and plantar fasciitis is essentially a form of enthesopathy — degeneration at the insertion.

Why rest doesn't work

Tendons need load to heal. Not excessive load, not sudden load, but progressive, controlled mechanical stress that stimulates the tendon to lay down new collagen in an organized pattern. Complete rest actually makes tendons weaker — the collagen fibers lose their alignment and the tendon becomes less tolerant of load when you return to activity.

This is the most important concept in tendon rehabilitation: the treatment is graduated loading, not rest.

How we approach it

Progressive loading programs. Eccentric exercises — where the muscle lengthens under load — have the strongest evidence base for tendinopathy. For Achilles tendinopathy, that's slow heel drops. For tennis elbow, that's wrist extension with resistance. We start where you are and build systematically.

Shockwave therapy. Extracorporeal shockwave therapy delivers acoustic energy to the tendon, stimulating blood flow, collagen remodeling, and pain modulation. It's one of the best-studied treatments for chronic tendinopathy, with consistent evidence across Achilles, plantar fascia, lateral epicondyle, and rotator cuff tendinopathy. It works particularly well for tendons that have failed to improve with exercise alone.

Ultrasound-guided PRP injections. Platelet-rich plasma concentrates the growth factors from your own blood and delivers them directly to the degenerative tissue. Under ultrasound guidance, we can target the exact area of tendon pathology. PRP shows the most promise in tendons with partial tears or significant structural disorganization.

OMM addresses the biomechanical factors that are overloading the tendon. An Achilles tendon that's being stressed by a stiff ankle, a weak calf, and poor pelvic mechanics won't heal no matter how many injections or shockwave sessions you do. We treat the chain, not just the link.

The role of imaging

Ultrasound is our primary imaging tool for tendons. It shows us the tendon in real time — the thickness, the internal architecture, areas of degeneration, partial tears, and calcification. It's dynamic, fast, and done in the office. MRI is reserved for cases where we need more detail about surrounding structures.

When to seek care

If you have tendon pain that's been present for more than four to six weeks, if it's getting worse rather than better, if it's limiting your activity, or if you've tried rest and it hasn't helped, come in. The earlier we intervene in tendinopathy, the better the outcome. Chronic tendinopathy that's been present for months or years is harder to reverse — but still treatable.

What you can do right now

Start loading the tendon — gently. If you have Achilles pain, slow eccentric heel drops off a step. If you have tennis elbow, slow wrist extensions with a light weight. The exercise should produce some discomfort (3 to 4 out of 10) but not sharp pain. Progressively increase the load over weeks.

Stop taking NSAIDs for chronic tendon pain. Anti-inflammatories may help acute tendinitis, but for chronic tendinopathy they can actually impair tendon healing by interfering with the remodeling process.

Be patient. Tendon remodeling takes time — typically 12 weeks or more for a structured loading program to produce meaningful change. The improvement is gradual but durable.