Tendon Pain Resolution
Updated: Oct 21
This article should be helpful for the common areas affected by tendon pain including the Achilles (lower calf), front of the knee (in the “patellar” tendon) or back of the knee (in the “distal” hamstring tendon), high or “proximal” hamstring, shoulder/rotator cuff (See this article for more), wrist (the term of the outdated term “repetitive strain injury” or “R.S.I.”), and gluteal or “lateral” hip pain.
How do you know you have tendon pain?
Pain, stiffness, a dull or sharp ache, or “awareness” is felt in a pinpoint area of the tendon or around the end of a muscle where it attaches to the bone.
Symptoms are felt when stretched under load, such as strength exercise, running, hopping, or jumping (ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology).
Bruising or swelling is uncommon with tendon pain.
Symptoms might decrease during exercise but return later in the day or tomorrow, or remain constant during most movements in very irritable tendons.
Often, tendon pain, if not managed well within days/weeks of first symptoms, can linger for months to years.
Often occurs gradually over time with increased exercise (Couch to 5km) or after beginning any tendon-loading activities following prolonged periods (Talking Tendons with Ebonie Rio).
How long does tendon pain take to improve?
Suppose tendon pain does not resolve after the first couple of weeks from when symptoms start (Revisiting the continuum model of tendon pathology). In that case, complete resolution of tendon pain is more likely to occur within months rather than weeks or days of seeking care. Most of the time, you should expect improvement in pain and function after 2-3 months when completing a high-quality tendinopathy management program (The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up). However, strong or definite time-based opinions about complete tendon pain improvement should be considered sceptically (Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols).
Some can still do everything right and have pain linger for longer. However, that does not mean people with a longer duration of tendon pain are less likely to improve once undertaking high-quality management. Many individuals can still experience improvement even after years of tendon symptoms. The duration of tendon pain does not predict delayed recovery, despite intuition (Persistent Tennis Elbow Symptoms Have Little Prognostic Value).
Tendon pain can recur after years of resolution, which shouldn't be interpreted as being back to square one (Recurrence of Achilles tendon injuries in elite male football players is more common after early return to play). Flare-ups are a regular part of the process. Good tendon management just reduces the frequency and intensity of these flare-ups. Complete, permanent resolution is not realistic for anyone (How To Rehab Tendon Injuries & Pain (Exercises & Education for Tendinitis, Tendinosis, Tendinopathy)). Properly guided exercise and education can reduce the suffering and confusion inherent in thoughts of “flare-ups equals tendon health worsening” and decrease the medical costs associated with desperate treatment-seeking behaviour aimed at “fixing” pain ("It's disappointing and it's pretty frustrating, because it feels like it's something that will never go away." A qualitative study exploring individuals' beliefs and experiences of Achilles tendinopathy + Beyond the tendon: Experiences and perceptions of people with persistent Achilles tendinopathy).
Common reasons tendon pain does NOT improve:
Unhelpful beliefs.
Too much rest. Tendon pain, when persistent, cannot be “rested better.” Progressive tendon strengthening and gradual return to running or jumping movements is recommended for everyone (Which treatment is most effective for patients with Achilles tendinopathy? + Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy).
Stopping your valued activities because of the belief that “pain is bad for my tendon” (Explanation for symptoms and biographical repair in a clinic for persistent physical symptoms) or exercise (Physical Activity as a Central Pillar of Lifestyle Modification in the Management of Chronic Musculoskeletal Pain) because we're not improving is not suitable for tendon health long term. Excessive but well-intended pain behaviour, such as stopping all movement when the tendon is painful or avoiding all potentially painful movements, and pain beliefs such as “my pain is because of old age”, “my pain is due to weakness”, or “this tendon pain will never go away”) isn’t helpful long-term. This is either because of the direct tendon health worsening effect of negative thoughts (Which Psychological and Psychosocial Constructs Are Important to Measure in Future Tendinopathy Clinical Trials?) or how these thoughts influence decreased physical activity, sleep and other healthy habits (What are Psychosocial Factors, and Why You Need to Know- Greg Lehman). Discuss these thoughts and behaviours that feel helpful with your healthcare professional to reframe your thoughts to be more optimistic (Looking beyond the tendon in tendinopathy – the emerging role of psychosocial factors?).
“My tendon might rupture with painful exercise.” A painful tendon actually decreases the risk of tendon ruptures. Many are concerned that painful exercise might increase the risk of extensive tendon injuries, but having pain is likely protective (Achilles tendon ruptures: Rehab & recovery with Prof. Peter Malliaras).
Focusing on “inflammation”. “Tendonitis” and “tendinosis” are inaccurate terms for tendon pain, and inflammation does not explain tendon pain symptoms fully (Time to abandon the "tendinitis" myth + Overuse tendon conditions: time to change a confusing terminology). We do not know why tendons become painful or why symptoms resolve with high-quality management (How Does Tendinopathy Develop? (youtube.com) + Adaptation of Tendon Structure and Function in Tendinopathy With Exercise and Its Relationship to Clinical Outcome). However, attempting to “reduce inflammation” with ice, rest, or medication is often not helpful for long-term tendon pain. A clinician who uses these descriptions is a red flag for you that you might be speaking to a “dinosaur” who, despite good intentions, is out of date.
Relying only on temporary pain-relief methods such as braces (Physical therapies for Achilles tendinopathy), oral medication (No Additive Clinical or Physiological Effects of Short-term Anti-inflammatory Treatment to Physical Rehabilitation in the Early Phase of Human Achilles Tendinopathy) + Oral Ibuprofen Interferes with Cellular Healing Responses), manual therapy like massage (Comparative Efficacy and Safety of Nonsurgical Treatment Options for Enthesopathy of the Elbow: 2019 + Comparative Efficacy and Tolerability of Nonsurgical Therapies for the Treatment of Midportion Achilles Tendinopathy), or any needling type (Intramuscular stimulation vs sham needling + Acupuncture Is All Placebo and Here Is Why + Overestimating “success rates” (for dry needling)), without progressive tendon exercise is unhelpful. Even one dose of an injection like corticosteroids can “feel” helpful in the short term but harmful in the long term (Talking Tendons: Steroid injection for Achilles tendinopathy? on Apple Podcasts + Evidence-informed approach to managing chronic tennis elbow: injections, physiotherapy or wait it out?). Platelet-rich plasma injection has also not been shown yet to be significantly better than an expensive placebo for tendons. (Effect of Platelet-Rich Plasma Injection vs Sham Injection + Even experts cannot agree on the optimal use of platelet-rich plasma in lateral elbow tendinopathy + Platelet Rich Plasma for tendinopathy? + No effects of PRP on ultrasonographic tendon structure and neovascularisation in chronic midportion Achilles tendinopathy). Be sceptical of a clinician exaggerating any benefit of these options. Ask them what they will profit from you receiving these options.
Focusing on strength or thoughts of “I have pain because I am weak.” Increased strength does not consistently explain why tendon pain resolves, even though weekly strengthening exercises are helpful (Can we really say that getting stronger makes your tendon feel better? No current evidence). Think of weakness more like a consequence than a cause of persistent pain.
When it comes to strength training, many believe pain will increase with higher loads. However, tendon pain is often not proportional to the force transmitted through a tendon (see graphs below). Don’t assume more weight will equal more pain, as it didn’t in this article (Achilles tendon forces and pain during common rehabilitation exercises).
The top graph shows the progressive exercise, with the semi-predictable progressive force measured in the tendon. The bottom graph shows progressive exercise along the chart, illustrating the unpredictable pain response to each movement, despite being “more forceful” (Achilles tendon forces and pain during common rehabilitation exercises).
Focusing on flexibility or stretching. Range-of-motion capacity or stretching is unlikely to reliably prevent or predict the initiation or resolution of tendon pain (Do physical tests have prognostic value?). Additionally, prioritising full range of motion strength training will improve flexibility, if desired, while offering more secondary health benefits than stretching alone (The Case for Retiring Flexibility as a Major Component of Physical Fitness).
Well-intended healthcare providers offering unhelpful advice. Ironically, the advice of outdated healthcare professionals, including Physios and Doctors, may have included some of the unhelpful beliefs described above, which we now know can be unhelpful and contribute to continued unhelpful behaviour (Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation).
Unmanaged medical conditions such as depression, anxiety (Individualising treatment for Achilles tendinopathy), diabetes (Differences in Recovery of Tendon Health Explained by Midportion Achilles Tendinopathy Subgroups), being overweight (Explaining Variability in the Prevalence of Achilles Tendon Abnormalities + Inflammatory mechanisms linking obesity and tendinopathy), and having cardiovascular disease (Clinical Impact of Metabolic Syndrome on Eccentric Exercises for Chronic Insertional Achilles Tendinopathy) reduce the rate of recovery from tendon pain. Sometimes, these factors can be targeted individually to resolve tendon pain.
Receiving imaging without a reasonable explanation and reassurance of what the range of normal findings can look like. Relying on imaging for diagnosis or to validate pain is not useful (Imaging and its role in tendinopathy). Your tendon should never be compared to idealised “flawless anatomical drawings.” Tendon findings can be abnormal and stay abnormal despite no pain (Significance of Asymptomatic Tendon Pathology in Athletes + Treat the donut, not the hole: The pathological Achilles and patellar tendon has sufficient amounts of normal tendon structure) or tendon pain resolution (Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols). Most high-quality tendon pain guidelines do not recommend using imaging to diagnose tendon pain, but it is often offered by time-poor, well-meaning clinicians without considering downstream negative effects of unnecessary imaging (Imaging Myths - E3 Rehab).
Receiving imaging increases the risk of being offered unnecessary surgery to change “imaging results” and pain. Although there are rare times where surgery is helpful, 1) sham surgery has been shown to be just as helpful as real surgery and (How does surgery compare to sham surgery or physiotherapy as a treatment for tendinopathy? + Surgical Treatment of Lateral Epicondylitis), 2) we have already discussed that imaging changes do not need to occur for your tendon symptoms to resolve so is unlikely to be the mechanism to explain why surgery could be helpful (Surgery, The Ultimate Placebo: A surgeon cuts through the evidence).
Relying on unproven nutritional strategies for tendon health.
This is especially true for collagen, which is unlikely to be very helpful for tendons because:
The size of tendon changes blamed on tendon pain are so small that you would need to consume only a tiny amount of collagen to be helpful, which would be easy to prove, but unfortunately it hasn’t (Collagen Protein: What It Is and Does It Work? + Collagen Protein and Tendinopathy | Barbell Medicine). Collagen supplements are theoretically more helpful for much larger injuries, which might explain why protein intake is helpful for recovery from large traumatic injuries (Effect of oral nutritional supplementation on outcomes in older adults with hip fractures and factors influencing compliance).
As mentioned already tendon changes occurred probably long before the pain symptoms, and we still have plenty of healthy tissue around “abnormal” tendon changes in painful tendons (Treat the donut, not the hole: The pathological Achilles and patellar tendon has sufficient amounts normal tendon structure), and these changes, even when great exercise programs are followed, are not associated with predictable tendon symptoms or resolution (Adaptation of Tendon Structure and Function in Tendinopathy With Exercise and Its Relationship to Clinical Outcome). Therefore, aiming to change the tendon with collagen supplements would not predict recovery anyway.
Collagen supplementation does not increase collagen turnover in tendons (Collagen Protein Ingestion during Recovery from Exercise Does Not Increase Muscle Connective Protein Synthesis Rates).
You still need an exercise stimulus to make sure collagen is placed in the right area around the tendon. The tendon cell decides how to adapt based on exercise stresses it experiences (The impact of loading, unloading, ageing and injury on the human tendon), not what nutritional substances it has access to.
Be careful with “snake oil” supplements for tendon health, but more optimistic nutritional advice —even about collagen —might still be helpful for some (5 Nutritional Strategies To Enhance Tendinopathy Rehab — Physio Network).
To wrap up, speak to any of our staff at Method Health if you have tendon pain and want to receive up-to-date advice about a progressive exercise program for improving your tendon symptoms.
More resources on common tendon pain sites and recovery:
Achilles/lower calf tendon pain
Exercise Progression to Incrementally Load the Achilles Tendon
Clinical Pearls on Tendinopathy from Dr Jill Cook - Physio Network (physio-network.com)
Achilles Tendinopathy - E3 Rehab + Achilles Tendinopathy / Tendinitis / Tendinosis | Heel Pain Rehab (Education, Myths, Exercises) (youtube.com)
Tendinopathy Rehabilitation - YouTube
Knee/ “patellar” tendon pain
Hamstring tendon pain - can be either pain around the lower (“distal”) or upper/high “proximal” tendons of the hamstrings.
Shoulder/rotator cuff tendon pain
Elbow tendon pain
Wrist tendon pain (often still unhelpfully called the outdated term “repetitive strain injury” or RSI)
Gluteal tendon pain or “lateral” hip pain.
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