YOUR THERAPIST IS LYING TO YOU! A blog on ‘tendonitis’

YOUR THERAPIST IS LYING TO YOU! A blog on ‘tendonitis’

A topic I present on with some frequency is tendinopathy.

Ever been diagnosed with a tendinitis or a tendinosis? Well these terms are now officially outdated with the preferred term being tendinopathy.

Other then trying to confuse you, the real reason for the name change is tha ‘tendonitis’ and ‘tendinosis’ are both inaccurate.   That’s right, both terms are just plain wrong.

You see ‘…itis’ in medical speak means inflammation. Think prostatitis, or bursitis. And ‘…..osis’ means degeneration.

For the longest time there has been a back and forth by researchers in terms of tendon injuries on what the actual issue is. When we thought inflammation caused the problem, we called them ‘tendonitis’, when we thought they were degenerative in nature we thought we were super smart and quickly changed the term to ‘tendinosis’.

While this argument continues, to simplify things we are now meant to use an umbrella term….tendinopathy. This is to denote more of a ‘failed healing response’. You see after a short period of time there is minimal (if any) inflammation in your disturbed tendon. And just because your tendon has hurt for some time does not necessarily mean it has degenerated.

To patients this distinction means very little. For therapists, the name change is reflective of a fairly dramatic shift in our understanding of tendons, the pathology causing perceived tendon injury, and the preferred approach to rehab.

Some astute readers will note I said “perceived tendon injury”. One of the biggest issues with tendon injuries is the complete lack of correlation between pain and tendon damage. You can have little to no damage to your actual tendon and have fairly tremendous pain, or conversely you could have dramatic tendon damage and have no pain at all.

Don’t believe me? Been taught that damage = injury? There are literally too many studies to cite that prove this point but my favorite statistic is that 97% of all achilles tendon ruptures had severe degenerative tendinopathy (meaning advanced damage) prior to rupture but a full 2/3rds of these people had no pain at the time of rupture.

While this lack of correlation between pain and injury is certainly a problem, a second (and equally as confounding) issue with tendon injury is the lack of correlation between imaging findings and pain. In fact, I will suggest that at times diagnostic imaging does more harm then good for tendon injuries as often it will show ‘damage’ to a tendon that does little more then reinforce the ‘injury mindset’ to the individual. In truth, this tendon ‘damage’ may have already been present before the injury and if you did the same imaging on the other side it may be present there as well even though there is no pain. Even worse, you can have complete ‘resolution’ of your pain and have no change on imaging findings with a follow-up ultrasound. In tendon consensus statements, the top researchers in the world literally state that they DO NOT recommend serial follow up imaging as it simply does not matter.

We do have a general framework for what causes tendon injuries. When you apply too much loading (meaning a dramatic increase in activity/stress/load) to a tendon too quickly, it is likely to react with injury. Sounds simple, and in reality it is. We can take a couple of key learnings from this statement:

  • Your best ‘preventative’ strategy to avoid tendon injuries is to make sure you stay active and consistently load your tendons. At our clinic we go as far as saying that chronically under-loading your tendon is as bad as acutely overloading your tendon as it relates to injury.
  • Even this is relative to the individual. Regardless of your activity level and athletic prowess, you have to take a progressive approach to increasing activity. In fact, the most popular blog we have written to date is a short one specifically on this concept (

So where does that leave us? Confused!!! This is an injury that has poor correlation with both pain and imaging. Therefore as clinicians (that like to follow research) our best practice is to trust the accepted guidelines and science created by individuals far smarter then we are.

And here is where an issue surfaces. WE ARE LYING TO OUR PATIENTS! In fact, I propose we lie frequently during tendon injuries and it starts right from the first visit. Here are just 2 examples.

  • We tell the person their tendon is ‘damaged’ and ‘inflamed’ (usually untrue)
  • We tell the person we can ‘fix’ their tendon in as little as 2-6 weeks (always untrue) So untrue in fact that we have a whole second blog just on this topic!

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