Tendinopathy is a clinical syndrome characterized by tendon thickening and localized tendon pain, swelling or impaired performance.
It usually is a temporary condition if treated early but may also be recurrent or chronic.
Principles of therapy include: ddentification & elimination of the cause of tendinopathy, behavior modification to minimize or eliminate sources of continuing irritation, specialist referral for appropriate follow up care and to reduce pain & to return function


Tendinopathy Diagnosis


Common Types of Tendinitis
Achilles Tendinopathy
  • Common in runners, football, tennis & basketball players; incidence increases w/ age
  • Caused by tight or weak calf muscles, anatomic misalignment, improper technique, uneven training surfaces & improperly fitted shoes
  • Pain is experienced at the posterior heel proximal to the tendon insertion
  • Physical exam may show thickened, tender & palpable nodules
    • Observe for anatomic deformities (eg heel varus, forefoot, excessive pes planus or foot pronation)
  • Magnetic resonace imaging (MRI) is useful for showing partial tendon tears, tendon thickening & chronic degenerative changes
  • Ultrasonography shows tendon thickening & heterogeneous echogenicity
  • Plain film radiography may show calcific tendinopathy, calcaneal avulsion fracture & soft-tissue swelling
Bicipital Tendinopathy
  • Causes pain in the anterior shoulder & radiates to the elbow & forearm
  • There is worsening of pain when flexing the shoulder or supinating the forearm
  • Yergason’s test
    • Done w/ patient’s arm fully pronated & elbow flexed to 90°. Patient is asked to supinate his arm against resistance applied by the examiner
    • Considered positive test if pain localized to the long biceps tendon is elicited
  • Speed’s test
    • Patient forward flexes the shoulder about 30° against resistance applied by the examiner, while keeping the elbow fully extended & the arm fully supinated
    • Considered positive if pain is elicited in the anterior shoulder
Calcific Tendinopathy 
  • Deposition of Ca hydroxyapatite crystals in or around the tendons of the rotator cuff
  • Affects any of the rotator cuff tendons but has a predilection for the supraspinatus
  • Has been postulated to be related to continuous microtrauma
  • Symptoms are similar to those of an impingement syndrome
  • Physical exam reveals point tenderness over the greater tuberosity
  • Plain film radiography confirms evidence of calcification in or around the rotator cuff tendons
Elbow Tendinopathy
  • Equally affects men & women; most common in patients >40 years of age
  • Lateral epicondylitis or tennis elbow
    • More common than medial epicondylitis
    • Common in persons who play racquet sports or manual laborers whose activities involve repetitive wrist extension
    • Patient experiences insidious lateral or outer elbow pain aggravated by wrist supination or extension activities (eg grasping & twisting)
    • Physical exam reveals tenderness over or just distal to the lateral epicondyle where the extensor tendons insert
    • Cozen test
      • Patient is asked to keep his fist clenched while extending the wrist. The examiner grasps the forearm w/ the left hand while the right hand pulls the patients hand toward flexion against the patient’s resistance
      • Positive test if pain is elicited at the lateral epicondyle
  • Medial epicondylitis or golfer’s elbow
    • Common in golfers, bowlers, carpenters & other manual laborers whose activities involve repetitive wrist flexion
    • Can result from microtrauma at the site of the insertion of the flexor carpi radialis on the medial epicondyle
    • There is medial or inner elbow pain exacerbated w/ wrist flexion & pronation
    • Physical exam reveals tenderness over the medial epicondyle near the insertion of the wrist flexor tendons
  • Imaging modalities:
    • MRI shows degenerative thickening of the tendons, fibrovascular proliferation & mucoid degeneration
    • Ultrasonography shows tendon thickening & heterogeneous echogenicity, which are common findings in elbow tendinopathy
Iliotibial Band Syndrome
  • Common in cyclists, dancers, long-distance runners, football players, military recruits
  • Pain is observed after completion of a run or several minutes into a run
  • Pain is exacerbated by running down hills, lengthening stride or sitting for long periods w/ knee flexed
  • Positive Renne test
    • Knee is flexed while standing w/ weight on affected knee resulting in pain at approx 30° of flexion
  • Ober test
    • Patient lies down w/ unaffected side down & unaffected hip & knee at a 90° angle
    • If iliotibial band is tight, patient will experience difficulty in adducting the leg beyond midline & may experience pain at the lateral aspect of the knee
Patellar Tendinopathy or Jumper’s Knees
  • Common in those who engage in jumping sports (eg basketball, high jumping, volleyball) & running
  • Characterized by insidious onset of localized anterior knee pain
  • Pain is exacerbated when changing position (eg going up & down the stairs, sitting to standing)
  • Physical exam reveals pain at the inferior pole of the patella w/ the leg fully extended using resisted leg extension
  • Decline squat test
    • Pain is reproduced when placing greater load on the patellar tendon than a squat performed on level ground
  • MRI is useful for showing changes consistent w/ chronic degenerative changes of the tendon as well as other detailed anatomic information of the knee joint
    • Has a 78% sensitivity & 86% specificity
  • Ultrasonography shows tendon thickening, decreased echogenicity & tendon calcification
    • More specific (94%) than sensitive (58%)
Rotator Cuff Tendinopathy (Supraspinatus Tendinopathy)
  • Common in athletes who throw repetitively & in persons w/ history of participating in overhead activities (eg painting, swimming)
  • Pain on top of the shoulder & upper arm; usually worsened when reaching, pushing, pulling or lifting the arm above the shoulder & when lying on the affected side
  • May elicit point tenderness over the greater tuberosity
  • Jobe’s test
    • A resistance test to assess the supraspinatus function
    • W/ both arms abducted to 90°, held slightly in front of the body & arms fully pronated, comparative resistance is placed on both arms to compare strength & presence of pain
    • Weakness or presence of pain is suggestive of supraspinatus tendinopathy
  • Hawkin’s Test
    • Test for rotator cuff tendinopathy or subacromial impingement
    • Elicits pain w/ forcible internal rotation w/ the patient’s arm passively flexed forward at 90°
  • Neer’s Test
    • Test for impingement of the rotator cuff tendons under the coracoacromial arch
    • Elicits pain w/ full forward flexion between 70° & 120°
  • MRI is 95% sensitive & specific for the detection of chronic tendinopathy, cuff tears & degeneration
  • Ultrasonography is useful for detecting moderate to full thickness tears
    • Has limited ability to detect small tears but may show tendon changes of chronic tendinopathy


  • Diagnosis is based on medical history & careful physical exam
  • Elicit the following in the history:
    • History of repetitive stress (eg changes in sports or other recreational activities, work activities, changes in workplace) either recent or over several weeks/months; determine the type of activity or training
    • History of infectious disease, fluoroquinolone therapy or other systemic illness
  • Pain is the most common symptom
    • May be described as sharp, stabbing, insidious, localized pain aggravated by activity, or as a dull ache after activity & during rest period
    • Initially, pain is present during activity but subsides after a period of warm-up. Later, there is gradual increase in pain intensity & duration, & may be present at rest

Physical Examination

  • Inspection of muscle for atrophy, asymmetry, erythema, swelling, & joint effusions
    • Atrophy is usually observed in chronic conditions & gives information on the duration of the tendinopathy
    • Asymmetry, erythema & swelling are common in abnormal tendons
    • Joint effusions are infrequent w/ tendinopathy & more suggestive of intra-articular problems
  • Search for signs of deformity, trauma
  • Palpation
    • Localized tenderness along the involved tendon or its sheath
  • Motor evaluation such as active & passive range of motion, strength
  • Physical maneuvers
    • Support the diagnosis by simulating tendon loading & reproducing patient’s pain
  • Important to determine the source of pain, whether articular (w/in the joint capsule) or periarticular (around the joint capsule), to narrow down the diagnosis


  • Plain film radiography
    • Indicated if a history of trauma is present
    • Not useful in showing tendons & other soft tissue changes but helpful in excluding other joint or bone abnormalities (eg osteoarthritis)
  • Magnetic resonance imaging (MRI) & Ultrasound
    • Can show damage to bones & soft tissues (eg tendon tears, tendon thickening, degenerative changes)
    • Reserved for when the diagnosis is uncertain, in cases of recalcitrant pain despite adequate conservative management, & for preoperative evaluation
    • Changes seen do not necessarily correlate w/ clinical symptoms
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Rheumatology digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
01 Dec 2020
Tetanus toxoid 5 Lf, diphtheria toxoid 2 Lf, pertussis toxoid 2.5 mcg, filamentous haemagglutinin 5 mcg, fimbriae types 2 and 3 5 mcg, pertactin 3 mcg
Dr. Hsu Li Yang, Dr. Tan Thuan Tong, Dr. Andrea Kwa, 08 Jan 2021
Antimicrobial resistance has become increasingly dire as the rapid emergence of drug resistance, especially gram-negative pathogens, has outpaced the development of new antibiotics. At a recent virtual symposium, Dr Hsu Li Yang, Vice Dean (Global Health) and Programme Leader (Infectious Diseases), NUS Saw Swee Hock School of Public Health, presented epidemiological data on multidrug-resistant (MDR) gram-negative bacteria (GNB) in Asia, while Dr Tan Thuan Tong, Head and Senior Consultant, Department of Infectious Diseases, Singapore General Hospital (SGH), focused on the role of ceftazidime-avibactam in MDR GNB infections. Dr Andrea Kwa, Assistant Director of Research, Department of Pharmacy, SGH, joined the panel in an interactive fireside chat, to discuss challenges, practical considerations, and solutions in MDR gram-negative infections. This Pfizer-sponsored symposium was chaired by Dr Ng Shin Yi, Head and Senior Consultant of Surgical Intensive Care, SGH.
Jairia Dela Cruz, 23 hours ago
Spending too much time sitting cannot be good for the body, and rising to one's feet breaks up such a behaviour and yields small, but meaningful, reductions in certain cardiovascular disease (CVD) risk factors, according to the results of a meta-analysis.
5 days ago
Daily intake of cow’s milk formula in early life helps prevent the development of cow’s milk allergy later on without competing with breastfeeding, a recent study has found.