Treatment Guideline Chart

Tendinopathy is a clinical syndrome characterized by tendon thickening persistent localized tendon pain, swelling, and impaired performance.

It is usually is a temporary condition if treated early but may also be recurrent or chronic, with symptoms lasting over 3 months.

Principles of therapy include identification and elimination of the cause of tendinopathy, behavior modification to minimize or eliminate sources of continuing irritation, and specialist referral for appropriate follow-up care.

Goal of therapy is to reduce pain and to return function.


Tendinopathy Diagnosis


  • Diagnosis of tendinopathy is made based on medical history and clinical findings; imaging is useful in ruling out other conditions
  • Lab tests are not indicated unless other potential causes (eg systemic, inflammatory, or metabolic disease) need to be ruled out
Common Types of Tendinopathy

Achilles Tendinopathy
  • Common in both competitive and recreational athletes (eg runners, football, tennis and basketball players) as well as sedentary individuals
    • Incidence increases with age
  • Caused by tight or weak calf muscles, anatomic misalignment, improper technique, uneven training surfaces and improperly fitted shoes
  • Pain or stiffness is experienced at the posterior heel proximal to the tendon insertion
  • Physical exam may show thickened, tender and palpable nodules
    • Observe for anatomic deformities (eg heel varus, forefoot, excessive pes planus or foot pronation)
    • Assess functional status (eg hop and heel-raise endurance tests) and evaluate impairment (eg range of motion, strength and endurance, static arch height, forefoot alignment, pain with palpation)
  • Plain film radiography may show calcific tendinopathy, calcaneal avulsion fracture and soft-tissue swelling
  • May also affect other tendons of the ankle (ie posterior tibialis, peroneus longus and peroneus brevis tendons)
Biceps Tendinopathy
  • Causes pain in the anterior shoulder, occasionally radiating to the elbow and forearm
  • There is worsening of pain when flexing the shoulder or elbow and supinating the forearm (eg lifting, pulling, repetitive overhead activity)
  • Yergason’s test
    • Done with patient’s arm fully pronated and elbow flexed to 90°
    • Patient is asked to supinate his arm against resistance applied by the examiner
    • Positive test if pain is elicited in the long biceps tendon
  • Speed’s test
    • Patient forward flexes the shoulder about 30° against resistance applied by the examiner, while keeping the elbow fully extended and the arm fully supinated
    • Positive test if pain is elicited in the anterior shoulder
Elbow Tendinopathy
  • Most common in patients >40 years of age
  • Lateral epicondylitis or tennis elbow
    • More common than medial epicondylitis
    • Common in persons who play racket sports or manual laborers whose activities involve repetitive wrist extension or squeezing the hands with forearm in prone position
    • Patient experiences insidious lateral or outer elbow pain aggravated by wrist supination or extension activities (eg grasping and twisting)
    • Physical exam reveals tenderness over or 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 with the left hand while the right hand pulls the patient’s 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 and 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 with wrist flexion and pronation
    • Physical exam reveals tenderness over the medial epicondyle near the insertion of the wrist flexor tendons
  • Imaging modalities:
    • Magnetic resonance imaging (MRI) shows degenerative thickening of the tendons, fibrovascular proliferation and mucoid degeneration
    • Increased signal at the common extensor origin is commonly observed on T2-weighted/fat suppression MRI image
Iliotibial Band Syndrome
  • Common in cyclists, dancers, long-distance runners, football players and 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 with knee flexed
  • Renne test
    • Knee is flexed while standing with weight on affected knee
    • Positive test if pain is elicited at approximately 30° of flexion
  • Ober test
    • Patient lies down with unaffected side down and unaffected hip and knee at a 90° angle
    • If iliotibial band is tight, patient will experience difficulty in adducting the leg beyond midline and may experience pain at the lateral aspect of the knee
Patellar Tendinopathy
  • Also known as jumper’s knee
  • Common in those who engage in jumping sports (eg basketball, high jumping, volleyball) and running
  • Characterized by insidious onset of localized anterior knee pain
  • Pain is exacerbated when changing position (eg going up and down the stairs, sitting to standing)
  • Physical exam reveals pain at the inferior pole of the patella with 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 with chronic degenerative changes of the tendon as well as other detailed anatomic information of the knee joint  
  • Ultrasonography shows tendon thickening, decreased echogenicity and tendon calcification  
Rotator Cuff Tendinopathy  
  • Often involves damage to the supraspinatus tendon
  • Common in athletes who throw repetitively and in persons with history of participating in overhead activities (eg painting, swimming)
  • Pain on top of the shoulder and upper arm that is usually worsened when reaching, pushing, pulling or lifting the arm above the shoulder and when lying on the affected side
  • May elicit point tenderness over the greater tuberosity
  • Shoulder Pain and Disability Index (SPADI) or the Western Ontario Rotator Cuff Index (WORC) may be used in clinical evaluation
  • Jobe’s test
    • A resistance test to assess the supraspinatus function
    • Patient’s straight arm placed at 90° abduction and 30° forward flexion followed by internal rotation of the shoulder
    • Weakness or presence of pain is suggestive of supraspinatus tendinopathy
  • Hawkin’s Test
    • Test for rotator cuff tendinopathy or subacromial impingement
    • Elicits pain with forcible internal rotation with 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 with full forward flexion between 70° and 120°
Calcific Tendinopathy
  • Deposition of calcium hydroxyapatite crystals in or around the rotator cuff tendons
  • 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
    • Usually positive results in Hawkin’s and Neer’s test
  • Physical exam reveals point tenderness over the greater tuberosity
  • Plain film radiography confirms evidence of calcification in or around the rotator cuff tendons


  • Elicit the following in the history:
    • History of repetitive stress (eg changes or increase in sports or other recreational activities, work activities, changes in workplace) either recent or over several weeks/months and type of activity or training
    • History of infectious disease
    • Use of tendinopathic medications (eg fluoroquinolones, glucocorticoids, statins, aromatase inhibitors) or other systemic illness
  • Pain is the most common symptom
    • Initial pain during activity is short-lived and subsides after a period of warm-up but later on presents with gradual increase of intensity and duration of pain that may persist even at rest
    • May be described as sharp, stabbing, insidious, localized pain aggravated by activity, or as a dull ache after activity and during rest period


Plain Film Radiography

  • Indicated if a history of trauma is present
  • Not useful in showing tendons and other soft tissue changes but helpful in excluding other joint or bone abnormalities (eg osteoarthritis, tendon calcification, joint degeneration, fracture)

Magnetic Resonance Imaging (MRI) and Ultrasound

  • Reserved for when the diagnosis is uncertain, in cases of recalcitrant pain despite adequate conservative management and for preoperative evaluation
  • MRI can show damage to bones and soft tissues (eg tendon tears or rupture, tendon thickening, degenerative changes)
    • 95% sensitive and specific for the detection of chronic tendinopathy, cuff tears and 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
    • Tendon thickening and heterogeneous echogenicity on ultrasound is seen in Achilles and elbow tendinopathy
  • Imaging findings do not necessarily correlate with clinical symptoms of tendinopathy
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