Tendonitis: Treating Overuse Injuries Effectively

Condition/Diagnosis

Tendonitis is notorious for its ability to sideline even the most seasoned athletes and active individuals. It doesn’t just affect performance; it disrupts daily life, making simple tasks like gripping a cup or climbing stairs a frustrating challenge. Whether you’re treating patients or managing your own recovery, let’s dive into what tendonitis is, what science says about effective treatment, and the practical tools that make a difference.

Tendonitis is the inflammation of a tendon, typically caused by repetitive motion, overloading, or microtears in the tissue. Common signs and symptoms include localized pain and tenderness, stiffness or decreased range of motion, swelling, and a burning sensation around the affected tendon. Activities like gripping, lifting, or repetitive motions often worsen these symptoms. Left untreated, chronic inflammation can lead to tendinosis—a degenerative condition where the tendon’s collagen begins to break down.

🔬 What the Science Says

Tendonitis involves both inflammatory and degenerative changes in tendon structure, making treatment complex. Studies show that eccentric exercise plays a pivotal role in tendon rehabilitation by promoting collagen synthesis, tendon neovascularization, and structural remodeling.¹ In contrast, prolonged immobilization can lead to tendon matrix degradation, increased proteoglycan content, and impaired healing.² Research indicates that isometric exercises not only reduce pain but also improve tendon stiffness and mechanotransduction, which are critical for tendon remodeling.³

A key component of tendon pathology is the disruption of tenocyte function, which leads to disorganized collagen fibers and increased levels of inflammatory cytokines such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α).⁴ In chronic cases, excessive production of matrix metalloproteinases (MMPs) degrades extracellular matrix proteins, further weakening the tendon.⁵ This degenerative aspect is why anti-inflammatory treatments alone are insufficient, and mechanical loading through targeted rehabilitation is necessary for recovery.⁶

Recent research suggests that growth factors such as insulin-like growth factor-1 (IGF-1) and transforming growth factor-beta (TGF-β) play an essential role in tendon healing, stimulating fibroblast proliferation and collagen deposition.⁷ Additionally, oxidative stress and mitochondrial dysfunction have been implicated in chronic tendinopathies, reinforcing the need for treatments that address both mechanical and biochemical factors.⁸ Understanding these mechanisms has led to more targeted interventions such as platelet-rich plasma (PRP) therapy and red light therapy (a.k.a. low-level laser therapy, LLLT), which aim to modulate cellular activity and promote tissue regeneration.⁹

🎯 Treatment

For most cases of tendonitis, rehabilitation should focus on controlled movement, pain management, and progressive loading rather than complete rest. Here are some of the most effective treatment strategies:

• Counterforce Straps (Braces)? Those straps that go around the forearms that are used for golfer's elbow and tennis elbow are so common but do they work? The idea is that they reduce strain on the affected tendon during movement. Research on their effectiveness is mixed but generally supports their role in symptom management rather than long-term healing. A study by Struijs et al. found that counterforce braces reduced pain and improved grip strength in patients with lateral epicondylitis (tennis elbow) compared to a control group.¹⁰ Another study by Wadsworth et al. suggested that while braces provided short-term relief, they were most effective when combined with eccentric exercise and other rehabilitation strategies.¹¹ The key takeaway is that braces can offload stress from the tendon and provide pain relief, but they should not replace active rehabilitation protocols.

• Eccentric Strengthening: Slow, controlled lengthening contractions are a gold standard for tendon rehab, as they stimulate collagen synthesis and tendon remodeling. Exercises like heel drops for Achilles tendonitis, wrist extensions for tennis elbow, or slow squats for patellar tendonitis should be incorporated early and progressed gradually.¹⁰

• Isometric Exercises: Holding static contractions at low to moderate intensity can reduce pain and build tendon resilience, making isometrics a great starting point for patients with acute inflammation.¹¹ Examples include wall sits for patellar tendonitis or sustained wrist flexion holds for golfer’s elbow.

• Soft Tissue Mobilization & Cross-Friction Massage: Targeted manual therapy techniques help break up adhesions, improve circulation, and stimulate healing. Deep friction massage, Graston technique, or instrument-assisted mobilization can be particularly effective for chronic cases where stiffness and thickening are present.¹²

• Kinesiology Taping: Taping provides proprioceptive feedback, mild support, and offloads stress on the tendon during movement.¹⁵

• Load Management & Activity Modification: Tendons respond to gradual, progressive loading, but overuse must be addressed first. Reducing aggravating movements while maintaining alternative forms of activity (such as aquatic therapy, cycling, or modified lifting techniques) can keep patients active while avoiding setbacks.

• Ergonomic & Phone Use Retraining: Poor biomechanics often contribute to tendonitis. Identifying faulty movement patterns, improper lifting mechanics, or inefficient running gait can prevent re-injury. A simple workstation adjustment, awareness and strategies around phone use, or cues to modify grip mechanics can make all the difference in chronic cases.

➡️ Advanced Treatments

• Platelet-Rich Plasma (PRP) Injections: PRP delivers a concentrated dose of growth factors directly to the injured tendon to promote tissue repair. Some studies suggest PRP improves healing outcomes, particularly in cases of chronic tendinopathy.¹⁶

• Low-Level Laser Therapy (LLLT)/Red Light Therapy: Red light therapy enhances mitochondrial function and collagen synthesis, aiding in tendon healing. Research suggests it reduces inflammation and supports tissue regeneration.¹⁷ Red light therapy is quickly becoming a go-to tool for many because of its wide-ranging benefits.

• Extracorporeal Shock Wave Therapy (ESWT): High-energy sound waves stimulate healing in chronic tendon injuries by promoting blood flow and cellular repair. Systematic reviews suggest ESWT is beneficial for calcific tendinopathies.¹⁸

• Nitric Oxide Patches: These patches increase local circulation and collagen synthesis, supporting tendon repair. While still being studied, early evidence suggests they may reduce pain and improve function in tendonitis.¹⁹

• Collagen Supplementation & Nutritional Support: Tendons require adequate collagen, vitamin C, and protein for repair. Emerging research suggests collagen supplements combined with exercise may enhance tendon remodeling and strength.²⁰

🚧 Common Challenges and Solutions

• Patient Non-Compliance: Simplify the exercise program and provide clear, written instructions with visuals to ensure understanding and adherence.

• Pain During Therapy: Reduce intensity, range of motion, or resistance in exercises or techniques to minimize discomfort while maintaining progress.

• Chronic Tendonitis: Use advanced modalities like ESWT or collaborate with a multidisciplinary team for persistent cases that don’t respond to traditional methods.

• Overuse Despite Pain: Educate patients about activity modification and the risks of prolonged overuse to encourage healthier habits.

💡 The Therapist’s Role

When treating tendonitis, your role goes beyond symptom management—it’s about identifying and addressing the root cause. Are your patients overloading specific muscle groups? Are they ignoring proper warm-ups or recovery protocols? Educate them on load management and provide a roadmap for progressive return to activity.

• Educate: Explain the importance of adherence to rehab exercises and activity modification. A well-informed patient is more likely to stay consistent.

• Monitor Progress: Regularly assess pain levels, range of motion, and strength to ensure they’re on track for recovery.

• Integrate Functional Goals: Tailor exercises to mimic real-life or sport-specific activities to ensure a smooth transition back to daily life or competition. Example: For a tennis player, design drills that include grip strengthening, wrist mobility, and rotational control to reduce recurrence.

📊 Assessments & Measurements

• Pain Scales: Use tools like the Visual Analog Scale (VAS) or Numeric Pain Rating Scale (NPRS) to track pain levels over time.

• Range of Motion (ROM) Testing: Measure joint mobility using a goniometer or inclinometer to determine baseline function and progress.

• Grip Strength Tests: For tendonitis affecting the upper extremity, assess grip strength with a dynamometer to gauge improvement.

• Tendon Palpation and Thickening: Assess for tenderness, swelling, or changes in tendon thickness as a marker of inflammation or healing.

• Functional Movement Tests: Evaluate activities that replicate real-life or sport-specific motions to ensure the patient’s readiness to return to activity. Examples include single-leg calf raises for Achilles tendonitis or wrist extension tests for tennis elbow.

• Outcome Measures: Use validated tools like the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire to measure the impact of tendonitis on daily activities and overall quality of life.

🌀 My Take

Tendonitis is about the long game. If you ignore it and keep pushing through, it’ll get worse. If you baby it too much, your tendon gets weaker. The real key? Smart rehab that loads the tendon the right way. Your body needs a signal to heal, and that signal is movement. But not just any movement—controlled, progressive, intentional movement.

I see too many people jumping from one treatment to another, hoping for a magic fix. There isn’t one. Eccentric exercises, isometrics, proper nutrition, and load management—these aren’t just buzzwords, they’re the blueprint for real recovery. Tendons don’t heal overnight, so consistency is everything. If you’re dealing with tendonitis, treat it like a long-term project, not a quick repair. Respect the healing timeline, listen to your body, and trust the science.

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References

1. Alfredson, H., et al. "Eccentric calf muscle training in chronic Achilles tendinosis." The American Journal of Sports Medicine, 1998.

2. Kannus, P., "Structure of the tendon connective tissue and basic science of tendon healing." Scandinavian Journal of Medicine & Science in Sports, 2000.

3. Rio, E., et al. "Isometric exercise induces analgesia and reduces pain in tendinopathy patients." British Journal of Sports Medicine, 2015.

4. D’Addona, A., et al. "Tendon injuries: pathophysiology, therapeutic approaches and role of inflammation." International Journal of Immunopathology and Pharmacology, 2017.

5. Riley, G., "Tendon and ligament biochemistry and pathology." The Royal Society of Medicine Press Limited, 2004.

6. Malliaras, P., et al. "Achilles and patellar tendinopathy loading programs: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness." Sports Medicine, 2013.

7. Kaux, J. F., et al. "Eccentric training in chronic tendinopathy: mechanisms, effects and clinical applications." Clinical Biomechanics, 2011.

8. Heinemeier, K. M., & Kjaer, M., "Tendon structure and metabolic activity in response to exercise." Journal of Musculoskeletal & Neuronal Interactions, 2011.

9. Andia, I., et al. "Platelet-rich plasma therapies for musculoskeletal soft tissue injuries: a systematic review." British Medical Bulletin, 2018.

10. Struijs, P. A., et al. "Brace treatment in patients with tennis elbow: a randomized clinical trial." The Journal of Bone and Joint Surgery, 2004.

11. Wadsworth, C. T., et al. "Effects of counterforce bracing on forearm and wrist muscle performance." The Journal of Orthopaedic and Sports Physical Therapy, 1989.

12. Mafi, N., et al. "Eccentric exercise in chronic Achilles tendinopathy." The American Journal of Sports Medicine, 2001.

13. Rio, E., et al. "Isometric contractions reduce pain and improve function in tendinopathy." Sports Medicine, 2017.

14. Smidt, N., et al. "Effectiveness of physical therapy for lateral epicondylitis." The Cochrane Database of Systematic Reviews, 2002.

15. Thelen, M. D., et al. "Kinesiology tape effect on performance and pain in individuals with patellar tendinopathy." Journal of Orthopaedic and Sports Physical Therapy, 2008.

16. Maffulli, N., et al. "Platelet-rich plasma injections in tendon conditions: clinical and research perspectives." Sports Medicine, 2019.

17. Tumilty, S., et al. "Low level laser therapy for tendinopathy: systematic review of randomized controlled trials." Physical Therapy Reviews, 2010.

18. Rompe, J. D., et al. "Shock wave therapy for chronic tendinopathy." British Journal of Sports Medicine, 2007.

19. Paoloni, J. A., et al. "Topical nitric oxide application in the treatment of chronic tendinopathy: a randomized, double-blinded, placebo-controlled clinical trial." The American Journal of Sports Medicine, 2003.

20. Shaw, G., et al. "Vitamin C-enriched gelatin supplementation before intermittent activity augments collagen synthesis." The American Journal of Clinical Nutrition, 2017.