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What’s the Difference Between Tendonitis and Tendinopathy?
Though often used interchangeably, tendonitis and tendinopathy are not the same thing.
Tendonitis refers to acute inflammation of a tendon, usually due to overuse or a sudden increase in activity.
Tendinopathy is a broader term that includes degeneration of the tendon tissue without significant inflammation—typically from chronic overuse or poor recovery.
Common sites of tendon injuries include the Achilles tendon, patellar tendon, rotator cuff, tennis (lateral) & golfer’s (medial) elbow, and gluteal tendons.
Continuum Model of Tendon Pathology (Cook, 2016)
Tendon injuries don’t happen all at once—they usually follow a gradual process. The continuum model of tendon pathology, developed by leading tendon researcher Dr. Jill Cook, explains how tendons break down over time and guides how we should treat them.
Stage 1 – Reactive tendon: The tendon becomes sensitive due to a sudden increase in activity or load. At this point, the structure of the tendon is still mostly healthy, and with the right activity modifications—such as reducing load—it can settle quickly.
Stage 2 – Dysrepair: If the stress continues without enough recovery, the tendon moves into the disrepair stage, where the collagen structure begins to change and weaken.
Stage 3 – Degeneration: With continuous stress and overload the tendon may reach the degenerative stage, where permanent structural changes occur, making the tendon thicker, weaker, and more prone to pain and, potentially, rupture.
Clinically, tendon pain presentations fall into two categories in the continuum model:
- Reactive tendon with a first presentation of tendon pain following acute overload
- Reactive-on-degenerative tendon pathology
Physiotherapy Management of Tendon Injuries and Tendinopathy
Physiotherapy management of tendon injuries including tendinopathy should be client-centered, taking into consideration severity, pain and duration of symptoms, functional limitations and, ultimately, the client’s goals.
Pain Management
Effective pain management in tendinopathy isn’t about stopping movement—it’s about loading the tendon in a way that encourages healing without flaring up symptoms. One of the most reliable approaches to treating tendinopathy involves gradual strengthening exercises, particularly progressive tendon loading, which help improve tendon structure and reduce pain over time.
Hands-on techniques like manual therapy, including soft tissue work and joint mobilization, can also help reduce pain and stiffness in the early stages. These approaches will support better movement and make active rehab more effective.
Tendon loading: How much load is enough (and when is it too much too soon)?
Overall, the key is to find the right level of load that the tendon can tolerate, then gradually build from there. Pain is monitored throughout—not to avoid all discomfort, but to guide safe progression. Long-term success depends on consistency and progressively challenging the tendon to rebuild its strength and resilience.
For individuals in significant discomfort, isometric exercises—where muscles are tensed without changing joint position—can offer immediate pain relief and restore some function without provoking symptoms.
After initial pain management, exercise is targeted at improving tendon strength through gradual loading, followed by functional rehabilitation and return-to-sport training. Eccentric exercises—where the muscle lengthens under tension, such as lowering a weight slowly—have been considered the gold standard for tendinopathy rehabilitation for many years. More recently, isometric and heavy slow resistance (HSR) exercises have also shown potential in pain reduction and functional improvement.
What appears to be crucial in tendinopathy recovery is not the type of exercise—but the amount and progression of load applied to the tendon. Appropriate loading is necessary to create optimal tendon adaptation and muscle strength changes. Many therapists use the so-called “10% rule” as a safe way to increase exercise load—meaning you shouldn’t add more than 10% additional load each week compared to the previous week. Although this is a useful general guideline, the “safe” amount of load depends on the individual and is often symptom guided.
It’s important to recognize that some pain and discomfort is normal with exercise. Tendons often feel better with activity but may worsen the next day, so it’s important to monitor symptoms 24 hours after loading. An easy rule-of-thumb is: if you are worse tomorrow, you’ve done too much.
Tendon Rehab: Take Home Message
Successful tendon rehabilitation relies on consistency with the exercise program and patience: muscles and tendons change slowly and can take 3-4 months to respond. On average, the general expectation is at least 12 weeks of rehab. There is no quick fix for tendons!
Further, the optimal physiotherapy approach is holistic and tailored to each individual. This means taking into consideration the entire kinetic chain: strength of adjacent muscles, tissue flexibility, joint mobility, movement control and overall biomechanics. Addressing these areas supports optimal tendon loading and functional movement.
Throughout this process, interventions must remain aligned with the tendon’s current condition, level of pain and, ultimately, the individual’s goals of rehab.
References:
Canosa-Carro L, Bravo-Aguilar M, Abuín-Porras V, Almazán-Polo J, García-Pérez-de-Sevilla G, Rodríguez-Costa I, López-López D, Navarro-Flores E, Romero-Morales C. Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice. Dis Mon. 2022 Oct;68(10):101314. doi: 10.1016/j.disamonth.2021.101314. Epub 2022 Jan 4. PMID: 34996610.
Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? Br J Sports Med. 2016 Oct;50(19):1187-91. doi: 10.1136/bjsports-2015-095422. Epub 2016 Apr 28. PMID: 27127294; PMCID: PMC5118437.
If you or someone you know is suffering from a tendon injury or tendinopathy, professional care combined with thorough assessments and manual therapy can help you get back to moving comfortably. At The Physio Approach North York, our team is dedicated to creating a personalized treatment plan tailored to your individual needs. We are committed to supporting you with expert care and consistent feedback to ensure your treatment is effective and successful every step of the way. Book an appointment or a free 10 minute consultation with us today!