Introduction

Tendinopathies are a group of clinical disorders characterized by chronic, localized tendon pain and impaired function that worsen with mechanical loading. They result primarily from repetitive tendon overuse, failed tendon healing, and degenerative changes rather than acute inflammation alone. Tendinopathies may present as acute or chronic conditions and commonly affect the rotator cuff, Achilles tendon, patellar tendon, lateral epicondyle (tennis elbow), medial epicondyle (golfer's elbow), and wrist tendons.

Current evidence indicates that chronic tendinopathy is largely a degenerative disorder (tendinosis), characterized by collagen disorganization, neovascularization, and altered cellular activity, rather than persistent inflammatory cell infiltration.

Epidemiology

• Common among athletes and physically active individuals.

• Frequently affects middle-aged adults.

• More common in occupations involving repetitive movements.

• Incidence increases with obesity and metabolic disorders.

• Achilles, patellar, and rotator cuff tendons are among the most frequently affected.

Etiology

Most cases result from repetitive mechanical overload exceeding the tendon's capacity for repair.

Common causes include:

• Repetitive overuse

• Sudden increase in physical activity

• Sports injuries

• Poor training technique

• Occupational repetitive movements

• Direct trauma

• Poor biomechanics

Predisposing factors

• Increasing age

• Obesity

• Diabetes mellitus

• Hypercholesterolaemia

• Rheumatoid arthritis

• Chronic kidney disease

• Corticosteroid exposure

• Fluoroquinolone use

• Muscle weakness

• Joint instability

• Poor flexibility

Classification

According to duration

Acute tendinopathy

Symptoms lasting less than 6 weeks.

Chronic tendinopathy

Symptoms persisting for more than 6 weeks, usually associated with degenerative tendon changes.

According to anatomical site

• Rotator cuff tendinopathy

• Achilles tendinopathy

• Patellar tendinopathy

• Gluteal tendinopathy

• Lateral epicondylitis

• Medial epicondylitis

• De Quervain tenosynovitis

• Biceps tendinopathy

Pathophysiology

Tendinopathy develops when repetitive mechanical loading exceeds the tendon's ability to repair microscopic injuries. Recurrent overload disrupts collagen fibres and stimulates an ineffective healing response. Instead of regenerating normal tendon tissue, tenocytes produce disorganized collagen with increased ground substance and abnormal neovascularization. Over time, the tendon becomes thicker, weaker, and less able to tolerate mechanical stress. In chronic tendinopathy, inflammatory cells are generally absent or minimal, and pain is thought to result from mechanical dysfunction, biochemical mediators, and ingrowth of sensory nerves accompanying new blood vessels.

Clinical presentation

Patients commonly present with:

• Localized tendon pain

• Pain on palpation of the affected tendon

• Pain during tendon loading or resisted movement

• Pain that improves with rest

• Morning stiffness

• Reduced strength

• Reduced functional performance

• Swelling in acute cases

• Tender tendon thickening in chronic disease

Associated findings include:

• Muscle spasm

• Muscle weakness

• Abnormal movement patterns

• Reduced flexibility

• Joint stiffness

• Altered biomechanics

Diagnostic criteria

Diagnosis is primarily clinical.

Diagnosis is supported by:

• Localized tendon pain reproduced by palpation

• Pain during resisted contraction of the involved muscle

• Pain during stretching of the affected tendon

• Symptoms aggravated by mechanical loading

• Functional limitation

• Imaging findings when clinically indicated

Investigations

Imaging is reserved for uncertain diagnoses, persistent symptoms, or pre-operative assessment.

Laboratory investigations

Routine laboratory tests are usually unnecessary unless inflammatory, infectious, or systemic disease is suspected.

Imaging

Ultrasound (greyscale or colour Doppler)

First-line imaging for most superficial tendons.

Typical findings include:

• Tendon thickening

• Loss of normal fibrillar architecture

• Hypoechoic areas

• Neovascularization on Doppler imaging

• Partial tendon tears

MRI

Preferred for:

• Deep tendons

• Rotator cuff tendinopathy

• Persistent symptoms

• Suspected tendon tears

• Surgical planning

MRI findings include:

• Tendon thickening

• Increased signal intensity

• Partial or complete tendon tears

• Peritendinous oedema

Differential diagnosis

• Tendon rupture

• Bursitis

• Ligament injury

• Osteoarthritis

• Rheumatoid arthritis

• Septic arthritis

• Stress fracture

• Referred cervical or lumbar radiculopathy

• Peripheral nerve entrapment

Management

Treatment aims to:

• Relieve pain

• Restore tendon function

• Improve strength

• Correct biomechanical abnormalities

• Prevent recurrence

• Enable return to normal activities

Non-pharmacological management

Conservative treatment is the cornerstone of management.

Recommended measures include:

• Physiotherapy with progressive loading exercises

• Eccentric strengthening exercises where appropriate

• Stretching exercises

• Activity modification

• Correction of biomechanical abnormalities

• Gradual return to activity

• Ice therapy during the acute phase

• Heat therapy for chronic tendinopathy

• Joint mobilization

• Deep friction massage where indicated

• Ergonomic modification

• Appropriate footwear and orthoses when required

Pharmacological treatment

Pain management (acute phase)

Ibuprofen

• 400 mg orally immediately, then 200 mg orally every 8 hours.

OR

Diclofenac sodium

• 50 mg orally every 8 hours for 7–14 days.

OR

Meloxicam

• 7.5–15 mg orally every 12–24 hours for 7–14 days.

OR

Tramadol + paracetamol

• 550 mg orally every 8 hours for 7–14 days.

OR

Paracetamol + ibuprofen

• 900 mg orally every 8 hours for 7–14 days.

Topical analgesics

These may be added for severe localized pain.

Diclofenac gel

• Apply every 12 hours.

OR

Ketoprofen gel

• Apply every 12 hours.

Gastroprotection

Patients with a history of peptic ulcer disease or those receiving NSAIDs for two weeks or longer should receive gastroprotective therapy.

Options include:

Omeprazole

• 20 mg orally once daily.

OR

Pantoprazole

• 40 mg orally once daily.

Corticosteroid therapy

Prednisolone

• 40 mg orally once daily for 3 days, followed by gradual tapering over 2–4 weeks.

OR

Betamethasone (intralesional)

• 12 mg per injection.

• Repeat every 2–12 weeks if necessary.

• Maximum of four injections per year for up to two years.

OR

Triamcinolone (intralesional)

• 40 mg per injection site.

• Administer once weekly if required.

• Maximum dose: 40 mg/day.

• Maximum of three injections per year with intervals of 1–3 weeks between injections.

Surgical management

Surgery should be considered only after failure of comprehensive conservative treatment.

Indications include:

• Persistent symptoms despite at least 6 months of physiotherapy and medical treatment

• Significant functional impairment

• Partial tendon tears progressing despite treatment

• Complete tendon rupture requiring repair

Surgical options include:

• Open tendon debridement or repair

• Arthroscopic (laparoscopic) tendon surgery where appropriate

Rehabilitation

Rehabilitation is essential for recovery and prevention of recurrence.

It includes:

• Progressive tendon-loading programme

• Eccentric strengthening exercises

• Muscle strengthening

• Flexibility training

• Neuromuscular retraining

• Balance and proprioception exercises

• Gradual return-to-work programme

• Sport-specific rehabilitation

Monitoring and follow-up

Patients should be reviewed regularly to assess:

• Pain severity

• Functional improvement

• Tendon strength

• Range of motion

• Adherence to rehabilitation

• Medication adverse effects

• Return to work or sport

Persistent symptoms after 3–6 months should prompt reassessment and consideration of advanced imaging or referral to an orthopaedic or sports medicine specialist.

Complications

• Chronic pain

• Tendon rupture

• Persistent weakness

• Reduced athletic performance

• Functional limitation

• Recurrent tendinopathy

• Muscle atrophy

• Joint stiffness

Prognosis

The prognosis is generally favourable with early diagnosis, activity modification, and structured rehabilitation. Most patients improve with progressive exercise therapy and correction of biomechanical factors. Recovery may require several months, particularly in chronic tendinopathy. Delayed treatment, continued tendon overloading, and metabolic comorbidities increase the risk of persistent symptoms, tendon rupture, and recurrence.