Understanding Tendinopathy: Why Rest Alone Isn’t Enough

Kieran Cummins
Jun 27
7 min read

Updated: Jul 23

What is Tendinopathy? Understanding the Inflammation vs. Degeneration Debate

Tendinopathy refers to a disorder of the tendon that causes pain and impaired function. Unlike acute tendonitis, which implies inflammation, chronic tendinopathy is primarily a degenerative condition of the tendon tissue nice.org.uk. During tendinopathy, the collagen fibers in the tendon become disorganized, leading to chronic degeneration instead of a classic inflammatory healing response nice.org.ukinspiredhealthchiropractic.com. While some inflammatory molecules may be present, the tendon is generally not swollen with inflammation like in an acute injury inspiredhealthchiropractic.com. Instead, it undergoes wear-and-tear changes due to overuse or repetitive stress. This results in a failed healing response, leading to weak or disordered tendon tissue.

Understanding the difference between inflammation and degeneration is crucial. This knowledge helps explain why treating tendinopathies is not as simple as taking anti-inflammatories or resting until pain subsides. Conditions like Achilles tendinopathy or patellar tendinopathy (jumper’s knee) are common lower-limb tendon issues where studies have shown that the tendon tissue is degenerated. It exhibits micro-tears and a loss of normal collagen structure, often with only a minimal inflammatory component nice.org.uk. Even gluteal tendinopathy, felt as pain on the outside of the hip (known as greater trochanteric pain syndrome), follows a similar pattern of chronic tissue degeneration due to overload. Recognizing that tendinopathies are primarily degenerative elucidates why a different treatment approach is required compared to acute injuries like sprains.

Why Rest Alone Can Make Tendinopathy Worse

When tendons become painful, the natural instinct is to rest completely until the pain subsides. While short-term relative rest (reducing high-impact activities) can help calm an irritated tendon, complete rest is not a good long-term solution for tendinopathy. The adage “use it or lose it” holds true for tendons. Prolonged rest leads to a decrease in load on the tendon, causing it to lose even more of its load-bearing capacity over time. If all activity stops, the tendon and associated muscles become weaker and less tolerant of strain. Although pain may lessen during rest, a return to activity often results in the tendon flaring up again, as it hasn’t adapted or improved—actually making it less prepared to handle stress than before.

Clinical experts increasingly warn against complete immobilization or long periods of inactivity for tendinopathy. Research has shown that exercise-based therapies and progressive loading strategies are superior to rest for treating tendinopathies natafoundation.org. Simply resting fails to address the underlying degeneration or increase the tendon’s tolerance to stress.

Modifying Activities for Effective Recovery

Instead of complete inactivity, a better approach is to modify activities to reduce excessive strain on the tendon. Gradually reintroducing and building up loads in a controlled manner is vital for rehabilitation. This gradual loading allows the tendon to adapt without being overwhelmed.

The Importance of Progressive Loading

Progressive loading—gradually increasing the stress placed on the tendon through exercise—is the cornerstone of rehabilitating tendinopathy. Tendons are living tissues that adapt to applied loads. Proper mechanical loading encourages tendon cells to produce new collagen and align fibers, aiding tissue remodeling and strengthening natafoundation.org. Exercise is recognized as the most evidence-based treatment for chronic tendinopathies. Without this essential load stimulus, most tendinopathies will not improve.

How Progressive Loading Works

Rehabilitation programs typically begin with gentle or isometric exercises (muscle contractions without joint movement) to load the tendon in a pain-free manner. They then progress to heavier or eccentric exercises (lengthening contractions) and, finally, plyometric or sport-specific loads. This graded approach enables the tendon to build tolerance and strength over weeks or months. Research on conditions like patellar and Achilles tendinopathy shows that structured exercise programs—such as eccentric heel drops for Achilles tendinopathy or decline squats for patellar tendon—lead to enhanced pain and function by improving the tendon’s load capacity natafoundation.orgnatafoundation.org. Essentially, the tendon must be retrained to handle stress. Progressive loading achieves this by balancing rest and activity effectively.

Patients are often guided by pain levels using a “pain-monitoring model” to ensure the loading remains therapeutic without causing excessive flare-ups natafoundation.org. This method helps transform a degenerative and weak tendon into one that is stronger and healthier, capable of meeting daily life or sports demands.

Evidence for Exercise-Based Therapy (Physiotherapy)

Considering the degenerative nature of tendinopathy, it’s not surprising that passive quick fixes rarely solve the problem. Physiotherapy focusing on exercise and load management shows the strongest evidence for improving tendinopathy outcomes. Clinical guidelines consistently endorse an active rehabilitation approach as first-line treatment. A recent consensus indicates that exercise-based therapies and progressive loading methods are more effective than rest or passive modalities (like ultrasound or braces) in managing patellar tendinopathy natafoundation.org.

Types of Exercises

For Achilles tendinopathy, the exercise-based rehabilitation approach has the highest efficacy, promoting tendon remodeling, reducing pain, and enhancing muscle function in the calf and leg. Typical exercises involve:

Isometric exercises: Essentially static holds to help reduce pain while gently loading the tendon.
Eccentric exercises: Controlled lengthening contractions like the Alfredson protocol of heel drops for Achilles tendinopathy or decline squats for patellar tendon, both historically studied and effective at stimulating tendon adaptation natafoundation.orgnatafoundation.org.
Heavy Slow Resistance training: Slow, heavy weight exercises through the tendon’s full range (combining eccentric and concentric work) have shown long-term pain reduction and functional improvements, sometimes comparable to eccentric-only routines natafoundation.org.
Plyometric and sport-specific drills: Introduced later in rehabilitation, these prepare the tendon for the demands of rapid energy storage and release, crucial for athletes.

Physiotherapy typically includes education and load management advice. This helps identify and modify activities that overload the tendon, such as reducing running frequency or changing training intensity natafoundation.org.

Importance of Active Rehabilitation

This is generally a selective rest strategy, offloading the tendon just enough to ease symptoms while enabling active rehabilitation, rather than complete rest. While treatments like manual therapy or stretching may offer symptomatic relief, they do not address degeneration's core issue.

It's worth noting that corticosteroid injections, although they may provide short-term pain relief, do not heal the tendon. Repeated injections could even impair tendon health long-term. The primary focus should stay on progressive exercise as the best-supported recovery route in managing tendinopathy. Patients can expect a structured exercise regimen over several months, yielding better functional outcomes and pain relief compared to passive treatments.

Shockwave Therapy: An Adjunct Option

What about therapies such as Extracorporeal Shockwave Therapy (ESWT)? This non-invasive treatment delivers high-energy sound waves to the injured tendon, aiming to stimulate healing. Shockwave therapy has gained traction for stubborn tendinopathies, such as plantar fasciitis, Achilles, and patellar tendinopathies, particularly when patients do not fully respond to exercise alone. However, the evidence for shockwave therapy is mixed and still developing.

Assessing Effectiveness

The UK’s National Institute for Health and Care Excellence (NICE) has reviewed ESWT for various tendon conditions: for Achilles tendinopathy, they found no major safety concerns but deemed current evidence on its effectiveness as inconsistent and limited in qualitynice.org.uk. Some studies show benefits, while others do not. Consequently, NICE recommends using ESWT under special arrangements (with experienced practitioners and outcome audits) for Achilles issues nice.org.uk.

Expectations vs. Reality

Regarding patellar tendinopathy, research findings are similarly uncertain. A recent 2023 review highlighted a lack of compelling evidence that shockwave significantly reduces pain or enhances function for patellar tendinopathy, recommending a multifaceted approach with exercise at its core rather than relying solely on ESWT natafoundation.org. Shockwave can be tried as an adjunct therapy, but patients should have realistic expectations—it is not guaranteed to be a cure.

Some patients report relief after several shockwave sessions (typically administered weekly over 3–6 weeks), possibly due to enhanced blood flow and tendon cell activity. However, results can differ because treatment protocols vary, and a significant placebo effect has been observed in studies nice.org.uk.

Bottom line: Shockwave therapy is generally safe and can be considered, especially for chronic cases not responding to exercise therapy. Some guidelines, including NICE, endorse its use for chronic Achilles and plantar fasciitis but stress that evidence for its efficacy remains limited nice.org.uknice.org.uk. Most specialists treat ESWT as an adjunct to physiotherapy, often providing pain relief or facilitating healing when combined with continued loading exercises and rehabilitation.

Managing Expectations in Tendinopathy Recovery

A vital message for patients is that tendon healing takes time and requires active engagement. Tendinopathies (in areas like the Achilles, knee, or hip) often arise after many weeks or months of overload and typically necessitate months of consistent rehabilitation to achieve significant improvement. Recovery is usually gradual, with many patients seeing slow progress in pain and function over a 3-6 month exercise program therapy jospt.orgnatafoundation.org.

Understanding Pain Levels

During rehabilitation, experiencing some pain during exercise is generally acceptable (and expected), provided it remains manageable and does not spike significantly post-activity. Learning to interpret pain as a guide is key; being entirely pain-free early on may not be realistic, but consistently decreasing pain over time signals progress.

Patients should also recognize that flare-ups are possible. If a tendon is overstressed too quickly—such as resuming high-level activities without sufficient buildup—symptoms might return. This doesn’t indicate that rehab was ineffective; it merely reflects the tendon exceeding its current capability. The typical solution involves adjusting loads temporarily and then resuming a controlled progressive loading strategy.

The Key to Successful Recovery

Consistency is crucial. Following prescribed exercises and adhering to the rehabilitation plan yield the best outcomes. In contrast, relying on passive remedies—like complete rest or painkillers—often results in recurrent issues since they do not address underlying tendon weakness.

Understanding the pathology of tendinopathy—that the tendon is inherently different and weaker, rather than merely “inflamed”—empowers patients to appreciate the structure of their rehabilitation plan. Progressive loading may be slower than achieving immediate pain relief through injections, but it effectively tackles the root cause of tendon issues. Our clinic prioritizes this evidence-based practice: educating patients, setting achievable timelines, and employing research-backed treatments (like individualized exercise programs and adjunct techniques such as shockwave, when appropriate) for long-lasting recovery. By integrating patient education with proven interventions, we aim to rehabilitate the tendon while empowering each individual to manage their tendon health over the long term.

Sources: Recent clinical guidelines and research on tendinopathy rehabilitation and treatments were used to inform this discussion, including NICE interventional procedure guidance on Achilles tendinopathy nice.org.uk and plantar fasciitis, as well as consensus findings on exercise therapy effectiveness natafoundation.orgnatafoundation.org. These evidence-based sources reinforce that while rest and anti-inflammatories alone are inadequate for tendinopathy, progressive loading and rehabilitation are key, with therapies like shockwave playing a supportive role when necessary nice.org.uknatafoundation.org. The primary goal remains to strengthen the tendon and improve its capacity—the most effective path to overcoming chronic tendon pain.