"Tendinitis" or "tendonitis" is the word almost everyone uses, but in most cases it's not the most accurate term: the more appropriate clinical name is tendinopathy. In this guide you'll find what it is, why it happens, how it's diagnosed with a clinical examination and ultrasound, and what the science says about exercise, laser, Tecar, shockwave therapy, injections and anti-inflammatory medicines.
In everyday language people almost always say "tendinitis" or "tendonitis", as if tendon pain were always inflammation. It almost never is. The correct clinical term is tendinopathy: persistent pain and reduced tendon function related to mechanical load2. A true inflammatory process (tendinitis in the strict sense) is rare in the chronic overuse form, the most common in athletes; it may play a limited role only in the early stages or in the tissue around the tendon (paratendinopathy)1.
This is not just a matter of words: it's one of the reasons why complete rest and anti-inflammatory medicines alone often don't solve the problem, while progressive loading exercise is the treatment with the strongest scientific support.
A tendon can show obvious changes on ultrasound without any pain, and typical pain can occur with an almost normal scan1. That's why the diagnosis of tendinopathy is mainly clinical: it's based on the examination and the history of the pain, with ultrasound used to confirm it and rule out other causes. How the diagnosis is made →
The most common cause is a mismatch between the load placed on the tendon and its capacity to tolerate it at that moment, not the movement itself1. The strongest risk factor is having had tendinopathy in the same place before; then come a too-rapid increase in training load (volume, intensity, a change of surface or footwear, returning after a break), age, and deficits in strength or mobility in nearby joints.
The more recent view also adds systemic factors: high blood sugar, high cholesterol, hormonal changes and cellular ageing can alter collagen quality and reduce the tendon's tolerance to load, regardless of the sport played3. These are worth considering especially when tendinopathy doesn't respond to treatment as expected.
The typical symptom of tendinopathy is pain well localised to a precise point on the tendon, which appears or worsens with load and improves with rest. Whatever the tendon involved, the clinical picture has some fairly constant features1:
Pain at rest, at night, spreading along the whole limb, or unrelated to load is less typical of tendinopathy and deserves a clinical assessment to rule out other causes, such as a joint, nerve or inflammatory problem. How the diagnosis is made →
Some situations are not typical of overuse tendinopathy and should be assessed without waiting:
The most frequent tendinopathies involve the Achilles tendon, the patellar tendon, the rotator cuff of the shoulder, the elbow tendons (tennis elbow and golfer's elbow), the proximal hamstring tendon, the groin adductors and the plantar fascia. Each site has a characteristic pain pattern, useful during the examination1.
Common in runners and in sports with repeated jumping. Painful stiffness in the first steps of the morning is typical, usually easing within about thirty minutes. There's a mid-portion form and an insertional form near the heel bone, which may also involve the retrocalcaneal bursa and — sometimes — the plantaris tendon when it runs close to the Achilles.
Very common in volleyball, basketball and athletics, sports with repeated jumping. The pain is at the lower tip of the kneecap, typically with discomfort after sitting for a long time, for example in the car. It worsens on take-off and landing and on the way down in a squat.
Common in sports with repeated overhead arm movements — volleyball, swimming, tennis, handball — but also for age-related degenerative reasons. People often call it shoulder tendonitis or "swimmer's shoulder". The most characteristic symptom is night pain, often bad enough to stop you sleeping on that side.
Tennis elbow (lateral epicondylitis) affects the outside of the elbow and worsens when gripping objects or lifting with the palm down; golfer's elbow (medial epicondylitis) affects the inside and worsens with wrist-bending movements. Both are common in people who don't play those sports, typically in repetitive manual work or long hours using a computer mouse.
It often affects sprinters, hurdlers, dancers and anyone doing repeated sprints. The pain is deep, at the top of the back of the thigh near the buttock, typically uncomfortable when sitting on a hard chair. It's among the hardest tendinopathies to treat, often with long recovery times even with a well-run loading programme4.
Common in football, hockey and sports with changes of direction and repeated kicking. Pain when turning over in bed or getting in and out of the car is typical. Groin pain has many possible causes — it can also involve the abdominal wall, the pubic symphysis or the hip — which is why a clinical and ultrasound assessment is particularly useful here.
Plantar fasciopathy (plantar fasciitis) is not a tendon in the strict sense but shares the same overload mechanism. The pain is under the heel, worst in the first steps of the morning, easing with walking and returning at the end of the day. Common in runners, people who stand for many hours, or who train on hard surfaces.
The diagnosis is first of all clinical: it's based on the history — where the pain is, when it gets worse, how it behaves with load — and on tests that reproduce the pain by loading the tendon progressively during the examination. Imaging is not always needed for the diagnosis, but it helps to confirm it, to rule out other causes and to guide any injections1.
Ultrasound is the first-choice imaging test: quick, dynamic — it lets you watch the tendon as it moves — and ideal for comparing the painful side with the healthy side in the same session. It assesses thickness, collagen structure, calcifications and any associated bursitis. MRI remains useful in more complex cases: a suspected significant partial tear, atypical pain, or when ultrasound is not conclusive.
Structural tendon changes are often seen in people with no symptoms at all, and typical pain can occur with an almost normal scan1. A report should therefore always be interpreted together with the clinical picture, never on its own.
At the clinics where I work, in Italy and in Lisbon, the examination and the ultrasound scan are done in the same session. If you live far away, the clinical diagnosis and the exercise plan can also be done in an online consultation →
Of all the options available, progressive loading exercise is the treatment with the strongest scientific support for tendinopathy1. The idea is simple, even if it feels counter-intuitive when you're in pain: the tendon doesn't heal by avoiding load, but by gradually adapting to tolerate it again. Complete rest reduces pain in the short term, but as soon as you return to activity the symptoms tend to come back, often worse, because the tendon hasn't been trained to handle that load.
Static contractions, with no joint movement. Useful especially in the most painful phase: in many people they give pain relief that can last several hours, while maintaining some of the tendon's strength.
Exercises with increasing resistance, performed with slow, controlled movement. This is where the tendon's real load capacity is built, with progression based on individual tolerance, not a fixed calendar.
Faster movements that require the tendon to store and release energy — small hops, changes of pace — are gradually introduced, only if the previous stage was tolerated without the pain getting worse over the following 24 hours.
The typical movements of your sport — sprints, jumps, changes of direction — are reintroduced, with load increasing until it matches what training and competition demand.
The right load for each stage is not a fixed scheme: it must be set according to the real condition of the tendon, assessed through the clinical examination and ultrasound. Severity, irritability of symptoms and any associated components (bursitis, paratendinopathy) determine the starting point and the pace of progression. That's why an individual assessment works better than a generic exercise plan found online.
Live far away, in another city or abroad? I can set up and follow your loading programme by video call too, in English, with a physiotherapist near you or through telerehabilitation: online consultation and telerehabilitation →
There's a very wide range of supporting therapies for tendinopathy, and they generate many of the questions I get in clinic. In short: none of these therapies replaces progressive loading exercise, which remains the treatment with the strongest scientific support; some may help as a complement for pain control. Therapy by therapy, here's what the available evidence says:
Laser, Tecar therapy, therapeutic ultrasound. These are among the most common questions in clinic ("will laser help?", "does Tecar work?"). They're widely used for pain control, but high-quality evidence for their specific effect on tendinopathy is weak or insufficient. They may play a complementary role in managing pain, particularly in the acute phase, but not as a stand-alone treatment and never instead of progressive loading.
Ice can give temporary pain relief after heavy loading, but it doesn't change the structure of the tendon or speed up healing: think of it as occasional symptom relief, not a cure. Heat has no proven specific role in tendinopathy.
Studies on non-steroidal anti-inflammatory drugs (such as ibuprofen) in chronic tendinopathy give conflicting results and, overall, don't support routine use1. Since the main mechanism is not inflammatory, they may reduce pain in the short term but don't act on the cause; some preclinical data also suggest they might interfere with the tendon's normal adaptation to load.
They reduce pain in the short term, but studies comparing them with exercise show worse results in the medium to long term, and repeated injections have been linked to a higher risk of tendon rupture1. They're generally not the first choice in chronic overuse tendinopathy; they may have a role in selected clinical situations, assessed case by case.
The evidence is moderately in favour for Achilles, proximal hamstring and gluteal tendinopathy, while the available studies are against its use for patellar tendinopathy1. It should always support a loading programme, never be used alone; if there's no benefit after 3-5 sessions, the advice is to stop.
The most methodologically robust systematic reviews currently find insufficient evidence to recommend routine use in chronic tendinopathy1: some studies show a benefit, others no significant difference from placebo. It's an option only for selected cases, not a first-line treatment.
A thin needle is inserted into the damaged tendon tissue under ultrasound guidance to apply a small electric current at the precise site of the change. It's not a first-choice treatment: it's reserved for selected cases of tendinopathy that haven't responded to a well-run programme of progressive loading exercise combined with supporting therapies, and should always be performed by a professional experienced in the technique.
A common mistake is thinking a painful tendon needs to be "stretched out". In fact, stretching increases compression of the tendon against nearby structures, especially near bony attachments, and can make the pain worse rather than better1. A guided progressive loading programme is preferable to stretching on its own.
In short: the treatment with the strongest scientific support remains progressive loading exercise, matched to the condition of the tendon. Supporting therapies can help manage pain along the way, but none replaces it.
In most cases you can keep training and playing with tendinopathy. The decision is based on how intense the pain is and how it affects performance: pain reaching up to a moderate level during activity is generally acceptable, as long as it stays stable over time and doesn't change your technique (for example, making you limp). A tendon-specific loading programme should continue alongside, adjusting sports volume so as not to stack up excessive loads1.
When a break has been needed, the return to sport follows objective criteria — strength compared with the healthy side, tolerance of increasingly explosive loads, stable symptoms — rather than a set calendar5. Rushing the stages is one of the most common causes of relapse.
The progression back to sport can also be followed remotely, with check-ins by video call: how the online consultation works →
Most tendinopathies resolve with conservative treatment: an accurate diagnosis, progressive loading and, where useful, supporting therapies. Surgery remains an option for a minority of cases, when a well-performed exercise programme carried out for several months doesn't bring enough improvement1. Modern techniques are often minimally invasive and ultrasound-guided, with shorter recovery times than traditional tendon surgery.
Recognising tendinopathy
In everyday language "tendinitis" (or "tendonitis") is the most common term, but scientifically it's hardly ever accurate: "tendinitis" means inflammation, whereas chronic overuse tendon pain is now called tendinopathy, the clinical term for persistent pain and reduced function related to mechanical load. It's not just about the name: the main mechanism in chronic tendinopathy is not inflammatory, and this shapes treatment choices. Read more →
Tendinopathy is the umbrella clinical term for tendon pain and loss of function. Tendinosis is a more technical term for the structural tissue changes visible on imaging (disorganised collagen, increased blood vessels). Tendinitis, strictly speaking, means an inflammatory process: it's a rare mechanism in chronic overuse tendinopathy, although it may play a role in the earliest phase or in the tissue around the tendon.
The most characteristic sign is pain precisely localised to one point on the tendon, which appears or worsens with load — running, jumping, lifting, depending on the tendon — and often improves during the warm-up only to come back, the same or worse, the next day or at the end of activity. Painful stiffness in the morning or after keeping still for a long time is also common. A definite diagnosis still requires a clinical assessment, with ultrasound if needed. Read more →
No, almost never, at least in the chronic form. The most accepted model describes tendinopathy as a problem of tissue adapting to a load that exceeds its capacity at that moment, with changes in collagen structure rather than true widespread inflammation. Some inflammation-like signalling may appear in the earliest or reactive phases, but it's different from classic inflammation, and it's one of the reasons why anti-inflammatory medicines alone give limited results.
They're two different problems. Tendinopathy affects the tendon, usually comes on gradually and gives well-localised pain that appears with load and improves with rest. A muscle injury (a "pulled muscle") affects the muscle belly, comes on suddenly during effort — typically a sprint or a change of direction — often with a "pop" and an immediate inability to carry on. Treatment is different too. The muscle injury guide →
Causes and risk factors
The main cause is a mismatch between the load placed on the tendon and its capacity to bear it at that moment: a too-rapid increase in training volume or intensity, a change of surface or technique, or returning after a period of inactivity are the most typical situations. Individual factors also count, such as age, a previous tendinopathy in the same place and, according to more recent evidence, metabolic conditions such as diabetes, high cholesterol and hormonal changes, which can make the tendon less tolerant of load. Read more →
The strongest are a previous tendinopathy in the same place and a too-rapid increase in training load. Age, sex, some local biomechanical factors and — according to the most recent literature — systemic factors such as diabetes, high cholesterol, hormonal changes and cellular ageing also contribute, by altering collagen quality and the tendon's tolerance of load.
They can contribute, yes. Recent studies show that high blood sugar, high cholesterol and age-related hormonal changes alter collagen structure and the tendon's response to load, increasing the risk of tendinopathy and sometimes making it more resistant to treatment. They're not the sole cause in most sports cases, but they should be considered especially when tendinopathy doesn't respond to treatment as expected.
Some can. Fluoroquinolone antibiotics are associated with an increased risk of tendinopathy and tendon rupture, particularly of the Achilles tendon, and the risk rises further if they're taken together with corticosteroids. If tendon pain appears during or just after a course of these medicines, tell the doctor who prescribed them and don't push the load.
Diagnosis and scans
The diagnosis is mainly clinical: it's based on the history of the pain — where it is, when it gets worse, how it behaves with load — and on specific pain-provocation tests during the examination. Ultrasound is not always essential for the diagnosis, but it helps confirm the picture, assess the state of the tendon and rule out other causes of pain in the same area. Read more →
It's very useful but not always essential for the diagnosis, which remains clinical. Ultrasound helps confirm that the tendon is involved, assess its thickness and structure, spot any associated bursitis or inflammation around the tendon, and rule out other causes of pain in the same area. It's also the reference tool for guiding injections precisely.
No. Structural tendon changes are often found in people with no symptoms, and conversely a tendon with clinically typical pain can look almost normal on imaging. That's why ultrasound must always be interpreted together with the clinical picture, never alone: a "clean" scan isn't enough to rule out tendinopathy if the history and examination are typical.
For most tendinopathies ultrasound is the first-choice test: it's quick, dynamic — it lets you assess the tendon as it moves — and ideal for comparison with the healthy side. MRI is reserved for more complex cases, suspected significant partial tears or when ultrasound isn't conclusive.
Outlook
There's no fixed time: it depends on the tendon involved, how long symptoms lasted before diagnosis and how well the progressive loading programme is followed. The most recent reviews indicate that, without active treatment, symptoms tend to persist for months in many tendinopathies, such as Achilles, patellar or elbow tendinopathy: one reason why a structured loading programme, started early, is better than passively waiting.
It may partly improve, but the available evidence indicates it rarely resolves completely within a few weeks if left alone: several tendinopathies, such as elbow, patellar and Achilles tendinopathy, tend not to resolve fully within 12-16 weeks without active treatment. A structured exercise programme speeds up and improves recovery compared with waiting.
Treatment and exercise
The cornerstone treatment, with the strongest scientific support, is progressive loading exercise: you start with isometric exercises or heavy slow loads, then gradually introduce more explosive movements and finally sport-specific movements, adjusting intensity to how the tendon responds over the following 24 hours. Other therapies — medicines, injections, shockwave, physical therapies — play a supporting role and don't replace exercise. Read more →
No. Complete rest reduces pain in the short term but doesn't train the tendon to tolerate load again: as soon as you return to activity, symptoms tend to come back, often worse than before. The best-supported approach is a targeted, temporary reduction of the most provocative load — not total inactivity — together with a progressive exercise programme.
In many cases yes, with pain considered acceptable in clinical practice up to a moderate level during activity, provided the pain the next morning isn't worse than the day before and symptoms stay stable over time. The decision to continue, modify or temporarily stop your sport should still be made after an assessment of the site, the severity and the demands of your sport. Read more →
Generally no, especially in the painful phase: stretching can increase compression of the tendon against nearby structures, particularly near bony attachments, and make the pain worse rather than better. A progressive loading programme guided by a professional is preferable to stretching alone.
The five most common mistakes are: prolonged complete rest, which reduces pain but leaves the tendon unprepared for returning to activity; persistent stretching in the painful phase, which increases tendon compression; relying only on passive therapies without a loading programme; increasing load abruptly as soon as the pain eases, a frequent cause of relapse; and repeated cortisone injections into the tendon, linked to worse long-term outcomes.
It's a common worry but uncommon in practice. Ruptures usually happen in tendons with degenerative changes built up over time, often in people who had no previous symptoms, rather than as a direct progression of a well-managed painful tendinopathy. Repeated corticosteroid injections into the tendon and fluoroquinolone antibiotics increase the risk. A painful tendon treated with appropriate progressive loading is not a tendon "about to snap".
In most cases, yes. Treatment is based on progressive loading exercise, which can be set up and followed by video call, in English, with a physiotherapist near you or through telerehabilitation. If the pain isn't clear or doesn't improve, you need a visit with ultrasound, which can be done at a clinic near home. Online consultation →
Supporting therapies
Laser and other machine-based physical therapies (Tecar, therapeutic ultrasound) are widely used for pain control, but the scientific evidence for their specific effect on tendinopathy is weak or insufficient, and they can't replace a progressive loading programme. They may play a complementary role in managing pain in the acute phase, never as a stand-alone treatment. Read more →
As with other machine-based physical therapies, high-quality evidence for Tecar therapy in tendinopathy is limited. It can be used to support pain management, but the treatment with the strongest scientific support remains progressive loading exercise, which Tecar can't replace.
Ice can give temporary pain relief, especially after heavy loading, but it doesn't change the structure of the tendon or speed up healing: see it as occasional symptom relief, not a cure. Heat has no proven specific role in tendinopathy.
The evidence on their use in chronic tendinopathy is conflicting and, overall, doesn't support routine use: since the main mechanism isn't inflammatory, they may temporarily reduce pain but don't act on the cause, and some preclinical studies suggest they might interfere with the tendon's normal adaptation to load.
Corticosteroid injections into the tendon can reduce pain in the short term, but studies show worse results in the medium to long term compared with exercise, and repeated injections have been linked to a higher risk of tendon rupture. For this reason they're generally not the first choice in chronic tendinopathy, and should be reserved for specific situations assessed case by case.
It depends on the site: the evidence is moderately in favour of shockwave for Achilles, proximal hamstring and gluteal tendinopathy, while the available studies are against its use for patellar tendinopathy. It should support a loading programme, never be used alone, and if there's no benefit after 3-5 sessions it's best to stop.
The most robust systematic reviews currently find insufficient evidence to recommend routine use in chronic tendinopathy: some studies show benefits, others no difference from placebo. It's a therapy to consider only in selected cases, not as a first choice.
It's a technique in which a thin needle is inserted into the damaged tendon tissue under ultrasound guidance to apply a small electric current at the precise site of the change. It's not a first-choice treatment: it's reserved for selected cases of tendinopathy that haven't responded to a well-run programme of progressive loading combined with supporting therapies, and should be performed by a professional experienced in the technique.
Massage can give temporary relief, especially for tight muscles around the painful area, but it doesn't change the structure of the tendon or increase its load capacity. It's a supporting therapy, useful for comfort at some stages, that doesn't replace the progressive exercise programme.
It depends on the site. In insertional Achilles tendinopathy a heel raise can reduce compression of the tendon against the heel bone and ease symptoms, which is useful early on. For the patellar tendon, by contrast, straps and taping reduce pain in the short term but in studies haven't proved more effective than placebo. In general they're temporary aids for managing symptoms, not a cure.
The evidence for collagen or similar supplements in tendinopathy is still preliminary and doesn't allow them to be recommended as treatment. What does make sense, where present, is correcting the metabolic factors that can reduce the tendon's tolerance of load — high blood sugar, abnormal blood lipids, nutritional deficiencies — as part of an overall medical assessment. No supplement replaces progressive loading exercise.
Surgery and return to sport
Only in a minority of cases, when a well-run progressive loading programme carried out for several months hasn't brought enough improvement. Modern techniques are often minimally invasive and ultrasound-guided, with shorter recovery times than traditional tendon surgery. Read more →
There's no standard time: returning to sport is based on a staged loading progression, from isolated tendon strengthening up to sport-specific movements, with objective criteria of strength, load tolerance and symptom stability checked at each step — not just the absence of pain or the time that has passed.
Where to be seen
Tendinopathy is managed by musculoskeletal specialists: sports medicine doctors, orthopaedic specialists and rehabilitation physicians. What matters most, more than the specialty itself, is that the assessment combines the clinical examination with ultrasound, to establish which structure is really involved and how to set the progressive load, together with the physiotherapist who follows the exercise programme.
In person in Italy (Modena, Maranello, Casalecchio di Reno and Carpi) and in Lisbon. If you live far away, you can have an online consultation by video call, in English, and get a loading programme built for you. Online consultation →
The content of this page is based on the scientific literature cited below. The main reference for the clinical framework and the treatment approach was the tendinopathy guide published by Barça Innovation Hub, one of the most comprehensive consensus documents available on managing tendinopathy in athletes.
Video consultation in English, with an exercise programme built around your tendon, to follow with a physiotherapist near you or through telerehabilitation. Near Modena or Lisbon, also in person, with examination and ultrasound in the same session.
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