Tendinopathy

What it is

How the term is defined

The 2019 International Scientific Tendinopathy Symposium consensus made tendinopathy the preferred name for lasting tendon pain and loss of function linked to mechanical loading¹. The editorial introducing it said the terms for tendon problems had never been agreed, and were used inconsistently¹.

A 2021 review describes tendinopathy as a complex disorder of a tendon, marked by pain, falling function and lower tolerance of exercise⁹. The Dutch Achilles tendinopathy guideline calls local tendon pain with tendon-loading activities tendinopathy, by current consensus¹⁰. A 2016 review of its burden found that the definition varies, which makes cases hard to record².

The 2021 review also lists the commonest overuse tendinopathies as those of the rotator cuff, inner and outer elbow, patellar, gluteal (buttock) and Achilles tendons⁹. The same review lists tissue features such as disorganised collagen, covered on the tendon page⁹.

Competing models of how it develops

Reviews have put forward several models of how tendinopathy develops^11,12,13:

• A continuum: a 2009 review proposed that tendon changes run along a continuum, as neither degeneration nor failed healing fully explained how varied tendinopathy is¹².
• Failed healing: a 2010 review proposed three stages: an injury, failed healing, then symptoms, which the authors call clinical presentation¹³. In this model tendinopathy is not an overuse injury as such, though overuse may trigger it¹³.
• Three families: a 2016 review groups models by what each puts first: collagen tearing, inflammation, or the tendon cell’s response¹¹. It says there are arguments for and against all of them¹¹.

The same 2016 review adds that staging tendinopathy by tendon structure has been challenged, since it is mainly a pain condition¹¹.

Pain and what scans show

A 2014 review says painless tendons can be badly worn, and scans do not always match symptoms¹⁴. The 2016 continuum review suggests structural change inside a tendon is best seen as a risk factor for tendinopathy, not the condition itself¹¹.

A 2014 review says painless tendons can be badly worn, and scans do not always match symptoms.

A meta-analysis (a study that pools earlier studies) looked at pain-free Achilles and patellar tendons, mostly in sporting groups¹⁵. Changes on ultrasound (a sound-wave scan) went with at least four times the risk of later tendinopathy¹⁵. Its authors add that factors beyond tissue structure are also involved¹⁵.

Who it affects

Where it has been counted

A 2016 review included 132 studies: 42 in athletes, 36 in workers, 35 in the general population and 19 in people with other conditions². It reports these figures for prevalence, the share of people with a condition at a given time²:

Group	What the 2016 review reports
Adult athletes	Patellar tendinopathy in about 17%, Achilles in 12.5%2
Adolescent athletes	Patellar tendinopathy in 5.6%, Achilles in 7.8%2
Athletes, largest studies	Rotator cuff tendinopathy in 23.7% of volleyball players, elbow tendinopathy in 13.1% of climbers2
Workers	Almost always in the arm, mostly the outer elbow: 2–3%, up to 18% in spine surgeons and 41% in coal miners2
Adults in general	Rotator cuff tendinopathy in 2% to 3.8%, and 5–7% in older people2

The same review notes that dancers more often have Achilles tendinopathy, and rowers rotator cuff or elbow tendinopathy². It calls the patellar tendon the most studied, and arguably the most often affected, in the leg². Gluteal tendinopathy, by contrast, has been described as the most common leg tendinopathy^16,17.

New cases in health records

In 25 years of Hong Kong public-hospital records, the 10 tendinopathies studied had about 15.5 new cases per 100,000 people a year³. Lateral elbow tendinopathy (pain where the forearm tendons attach at the outer elbow) had the highest rate, at 8.84 per 100,000³.

A registry study of one Danish general practice, with 8,836 patients, found a prevalence of leg tendinopathies of 16.6 per 1,000 patients¹⁸. Its incidence, the count of new cases, was 7.9 per 1,000¹⁸. That study counted plantar heel pain (pain under the heel) as a tendinopathy, and it made up 39% of them¹⁸.

Studies that used imaging found higher incidence, as scans also pick up tendons without symptoms². The 2016 review says up to two thirds of cases may go unreported².

Age and sex: the sources differ

The 2016 review found no clear trend by sex among athletes². It concluded that age and sex did not seem to be factors across the groups it reviewed². Other sources report patterns^3,4:

• Hong Kong records: people aged 40–59 had higher rates of most tendinopathies, but patellar and Achilles tendinopathy mainly affected younger people³. Women had higher rates of several, and men of patellar tendinopathy³.
• Under-18s: a review of 17 studies found leg tendinopathy in 8.2% to 33.3%, rising with age up to 18⁴. In studies reporting by tendon, it was more common in boys⁴.

What studies found

How it changes over time

A meta-analysis pooled the wait-and-see groups of six randomised trials, covering 518 people with tendinopathy¹⁹. Pain and function improved without intervention¹⁹. Yet rotator cuff tendinopathy had not fully recovered at one year¹⁹. Lateral elbow, patellar and Achilles tendinopathy had not fully resolved within 12–16 weeks¹⁹.

The 2009 continuum review notes that some tendons recover with simple measures, while others resist every approach tried¹². For the Achilles tendon, the Dutch guideline says most people recover, but symptoms may persist¹⁰. In 23–37%, symptoms were still present at least up to 10 years later¹⁰.

Exercise and loading

A large 2023 evidence synthesis, drawing on 204 studies, found exercise for tendinopathy safe and beneficial, with patients generally satisfied²⁰. Its evidence was generally low or very low quality²⁰. On that evidence, exercise may help most when combined with another non-surgical approach²⁰. The same synthesis found combining concentric (shortening) and eccentric (lengthening) work may help more than eccentric work alone²⁰.

Two earlier reviews of reviews, both from 2020, read the eccentric evidence differently^21,22. One, of 25 systematic reviews, found eccentric exercise the most common and most consistently effective approach²¹. The other, an umbrella review (a review of systematic reviews) of 40 reviews, found only qualitative support for it²².

A 2023 network meta-analysis covered 68 randomised trials in Achilles tendinopathy, patellar tendinopathy and greater trochanteric pain syndrome (outer hip pain)⁵. Its findings⁵:

• No convincing evidence that any added approach, alone or with exercise, beat exercise alone⁵.
• Every clear difference between approaches rested on low- or very-low-strength evidence⁵.
• Heavy slow resistance (slow, heavy strength exercise) alone ranked second for medium- and long-term Achilles scores⁵.
• The one trial of heavy slow resistance against eccentric work found no difference at 12 weeks or a year⁵.
• Three trials compared one isometric (joint-still) bout with one isotonic (moving) bout in young athletes with patellar tendinopathy⁵. Their results conflicted, and pooled, the difference was not significant⁵. No trial reported medium- or long-term results⁵.

Injections

A systematic review of 41 randomised trials (2,672 people) studied injections for tendinopathy²³. Corticosteroid (a drug that copies a hormone the body makes) injections eased pain in the short term, but the effect reversed later on²³. For lateral elbow tendinopathy, pooled trials found a large short-term pain benefit over no intervention²³. At 26 and 52 weeks, no intervention did better²³. A 2020 review of reviews agrees: some short-term pain benefit, but not long-term²¹.

The 2010 injection review found effects varied between tendons, and cautioned against generalising from one site to another²³. In trials that reported harms, one of 991 people given corticosteroid had a serious harm, a tendon rupture²³.

Reviews of platelet-rich plasma (part of a person’s own blood with extra platelets) point both ways^6,7:

• A 2017 meta-analysis of 16 trials against control injections found a moderate pain benefit⁶. It declared funding from DePuy Synthes Mitek Sports Medicine⁶. That company’s research department is among its author affiliations, and it declared no competing interests⁶.
• A 2021 meta-analysis of 13 trials found it no better than placebo for pain or function at 4–6, 12 or 24 or more weeks⁷.
• A 2014 Cochrane review (one done to the Cochrane Collaboration’s standards) of 19 small trials found the evidence very low quality⁸. It judged it insufficient to support use in soft-tissue injuries, tendinopathies among them⁸.
• A 2025 meta-analysis of 27 trials against corticosteroid covered rotator cuff, outer elbow, plantar fascia and tenosynovitis (swollen tendon lining) trials²⁴. It found platelet-rich plasma did better in the medium term²⁴. Its long-term effect still needs confirming²⁴.
• The 2020 review of reviews called the evidence inconclusive²¹.

Shockwave and laser

A 2026 network meta-analysis of 65 trial reports (3,921 cases) studied shockwave therapy (pulses of sound energy aimed through the skin)²⁵. Its authors concluded that limited evidence suggests it eased pain and severity against control groups in several tendinopathies²⁵. They added that the effect may vary by type, and it did not beat placebo in patellar tendinopathy²⁵. It rated the evidence against placebo moderate, mainly because some trials were not blinded²⁵.

One 2020 review of reviews found low-level laser therapy (light from a low-power laser, shone on the skin) and shockwave therapy moderately effective²¹. The 2020 umbrella review found moderate-quality evidence that may support both²².

Surgery

A systematic review of 12 randomised trials, mostly of the shoulder and outer elbow, compared surgery with other approaches²⁶. Surgery did better than no intervention or placebo, but was similar to sham (pretend) surgery in the medium term²⁶. Physiotherapy was as effective as surgery in the medium and long term²⁶. The review rated two trials good, four moderate and six poor²⁶. It was funded by the Medical Research Council UK and Versus Arthritis²⁶.

Return to sport and how trials measure outcomes

A review looked at midportion Achilles tendinopathy, more than 2 cm above where the tendon attaches to the heel bone²⁷. It notes this can cause long absence from sport and often recurs²⁷. Across its 35 studies, definitions of return to sport varied widely²⁷.

Connections

The tendon page covers the tissue itself⁹. The 2020 umbrella review urged caution, because tendinopathy may differ from one region to another²². A review of how healthy tendons adapt to load found studies only of the Achilles and patellar tendons²⁸. Each tendon page covers its own tendinopathy^10,29,30:

• Achilles tendon: tendinopathy there is split into insertional, near the heel bone, and midportion¹⁰.
• Patellar tendon: jumper’s knee is another name for patellar tendinopathy^29,30.
• Gluteal tendons: bursa (fluid-filled sac) changes alone are uncommon in outer hip pain, though they may come with tendon changes¹⁷.
• Rotator cuff tendons: a Dutch guideline counts tendinosis (tendon wear) of the supraspinatus, a cuff muscle atop the shoulder blade, within subacromial pain syndrome³¹.
• Common extensor tendon: a cadaver (donated body) study suggested lateral elbow pain comes more from the shared tendon origin³².
• Proximal hamstring tendon: a review of 12 studies found no high- or moderate-quality evidence for any intervention³³.
• Distal biceps tendon: in a review, low-level evidence prevented pooling of outcomes³⁴.

A Danish general practice study counted plantar heel pain among leg tendinopathies¹⁸. The 2025 corticosteroid comparison included plantar fascia trials²⁴. In one trial of 58 people with mid-portion Achilles tendinopathy, the eccentric heel drop and heavy slow resistance gave equally good gains in symptoms³⁵. A 2020 review in patellar tendinopathy found no overall short-term effect from adding another approach to the decline squat, on low- to very-low-certainty evidence³⁶.

Sources

1. Zwerver J, Mc Auliffe S, Rio EK, Scott A, Vicenzino BT, Weir A (2020). ICON 2019-international scientific tendinopathy symposium: building an ICONic tendon tower-launching a new era in clinical tendinopathy research.. British Journal of Sports Medicine. doi:10.1136/bjsports-2019-101214 PMID 31666219
2. Hopkins C, Fu SC, Chua E, Hu X, Rolf C, Mattila VM, Qin L, Yung PS, Chan KM (2016). Critical review on the socio-economic impact of tendinopathy.. Asia-Pacific journal of sports medicine, arthroscopy, rehabilitation and technology. doi:10.1016/j.asmart.2016.01.002 PMID 29264258
3. Lau KKL, Ng JP, Ling SKK, Ong MTY, Yung PSH, Lui PPY (2026). Incidence rates of tendinopathies and non-traumatic tendon ruptures in Hong Kong: a 25-year epidemiological study using big data from public hospitals.. Scientific reports. doi:10.1038/s41598-025-33465-x PMID 41526611
4. Simpson M, Rio E, Cook J (2016). At What Age Do Children and Adolescents Develop Lower Limb Tendon Pathology or Tendinopathy? A Systematic Review and Meta-analysis.. Sports Medicine. doi:10.1007/s40279-015-0438-0 PMID 26626072
5. Challoumas D, Crosbie G, O'Neill S, Pedret C, Millar NL (2023). Effectiveness of Exercise Treatments with or without Adjuncts for Common Lower Limb Tendinopathies: A Living Systematic Review and Network Meta-analysis.. Sports medicine - open. doi:10.1186/s40798-023-00616-1 PMID 37553459
6. Miller LE, Parrish WR, Roides B, Bhattacharyya S (2017). Efficacy of platelet-rich plasma injections for symptomatic tendinopathy: systematic review and meta-analysis of randomised injection-controlled trials.. BMJ open sport & exercise medicine. doi:10.1136/bmjsem-2017-000237 PMID 29177072
7. Dai W, Yan W, Leng X, Wang J, Hu X, Cheng J, Ao Y (2021). Efficacy of Platelet-Rich Plasma Versus Placebo in the Treatment of Tendinopathy: A Meta-analysis of Randomized Controlled Trials.. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. doi:10.1097/JSM.0000000000000961 PMID 34342296
8. Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC (2014). Platelet-rich therapies for musculoskeletal soft tissue injuries.. The Cochrane database of systematic reviews. doi:10.1002/14651858.CD010071.pub3 PMID 24782334
9. Millar NL, Silbernagel KG, Thorborg K, Kirwan PD, Galatz LM, Abrams GD, Murrell GAC, McInnes IB, Rodeo SA (2021). Tendinopathy.. Nature Reviews Disease Primers. doi:10.1038/s41572-020-00234-1 PMID 33414454
10. de Vos RJ, van der Vlist AC, Zwerver J, Meuffels DE, Smithuis F, van Ingen R, van der Giesen F, Visser E, Balemans A, Pols M, Veen N, den Ouden M, Weir A (2021). Dutch multidisciplinary guideline on Achilles tendinopathy.. British Journal of Sports Medicine. doi:10.1136/bjsports-2020-103867 PMID 34187784
11. Cook JL, Rio E, Purdam CR, Docking SI (2016). Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?. British journal of sports medicine. doi:10.1136/bjsports-2015-095422 PMID 27127294
12. Cook JL, Purdam CR (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy.. British journal of sports medicine. doi:10.1136/bjsm.2008.051193 PMID 18812414
13. Fu SC, Rolf C, Cheuk YC, Lui PP, Chan KM (2010). Deciphering the pathogenesis of tendinopathy: a three-stages process.. Sports medicine, arthroscopy, rehabilitation, therapy & technology : SMARTT. doi:10.1186/1758-2555-2-30 PMID 21144004
14. Rio E, Moseley L, Purdam C, Samiric T, Kidgell D, Pearce AJ, Jaberzadeh S, Cook J (2014). The pain of tendinopathy: physiological or pathophysiological?. Sports medicine (Auckland, N.Z.). doi:10.1007/s40279-013-0096-z PMID 24027089
15. McAuliffe S, McCreesh K, Culloty F, Purtill H, O'Sullivan K (2016). Can ultrasound imaging predict the development of Achilles and patellar tendinopathy? A systematic review and meta-analysis.. British journal of sports medicine. doi:10.1136/bjsports-2016-096288 PMID 27633025
16. Ladurner A, Fitzpatrick J, O'Donnell JM (2021). Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation.. Orthopaedic Journal of Sports Medicine. doi:10.1177/23259671211016850 PMID 34377713
17. Grimaldi A, Mellor R, Nasser A, Vicenzino B, Hunter DJ (2024). Current and future advances in practice: tendinopathies of the hip.. Rheumatology Advances in Practice. doi:10.1093/rap/rkae022 PMID 38601140
18. Riel H, Lindstrøm CF, Rathleff MS, Jensen MB, Olesen JL (2019). Prevalence and incidence rate of lower-extremity tendinopathies in a Danish general practice: a registry-based study.. BMC musculoskeletal disorders. doi:10.1186/s12891-019-2629-6 PMID 31113484
19. Garzón M, Balasch-Bernat M, Cook C, Ezzatvar Y, Álvarez-Lliso Ó, Dueñas L, Lluch E (2024). How long does tendinopathy last if left untreated? Natural history of the main tendinopathies affecting the upper and lower limb: A systematic review and meta-analysis of randomized controlled trials.. Musculoskeletal science & practice. doi:10.1016/j.msksp.2024.103103 PMID 38879981
20. Cooper K, Alexander L, Brandie D, Brown VT, Greig L, Harrison I, MacLean C, Mitchell L, Morrissey D, Moss RA, Parkinson E, Pavlova AV, Shim J, Swinton PA (2023). Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness.. Health technology assessment (Winchester, England). doi:10.3310/TFWS2748 PMID 37929629
21. Irby A, Gutierrez J, Chamberlin C, Thomas SJ, Rosen AB (2020). Clinical management of tendinopathy: A systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments.. Scandinavian journal of medicine & science in sports. doi:10.1111/sms.13734 PMID 32484976
22. Girgis B, Duarte JA (2020). Physical therapy for tendinopathy: An umbrella review of systematic reviews and meta-analyses.. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. doi:10.1016/j.ptsp.2020.08.002 PMID 32877858
23. Coombes BK, Bisset L, Vicenzino B (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials.. Lancet (London, England). doi:10.1016/S0140-6736(10)61160-9 PMID 20970844
24. Ye Z, Yuan Y, Kuang G, Qiu L, Tan X, Wen Z, Lu M (2025). Platelet-rich plasma and corticosteroid injection for tendinopathy: a systematic review and meta-analysis.. BMC musculoskeletal disorders. doi:10.1186/s12891-025-08566-3 PMID 40200209
25. Guo NY, Wang SQ, Liu W, Mao ZM, Wang JQ, Xu BB (2026). The Effect of Extracorporeal Shockwave Therapy in Tendinopathy: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.. Orthopaedic surgery. doi:10.1111/os.70408 PMID 42733276
26. Challoumas D, Clifford C, Kirwan P, Millar NL (2019). How does surgery compare to sham surgery or physiotherapy as a treatment for tendinopathy? A systematic review of randomised trials.. BMJ open sport & exercise medicine. doi:10.1136/bmjsem-2019-000528 PMID 31191975
27. Habets B, van den Broek AG, Huisstede BMA, Backx FJG, van Cingel REH (2018). Return to Sport in Athletes with Midportion Achilles Tendinopathy: A Qualitative Systematic Review Regarding Definitions and Criteria.. Sports medicine (Auckland, N.Z.). doi:10.1007/s40279-017-0833-9 PMID 29249084
28. Bohm S, Mersmann F, Arampatzis A (2015). Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults.. Sports Medicine - Open. doi:10.1186/s40798-015-0009-9 PMID 27747846
29. Mabrouk A, Lee CYM, Sherman AL (2026). Patellar Tendinopathy (Jumper's Knee).. StatPearls. PMID 30422564
30. Dan M, Phillips A, Johnston RV, Harris IA (2019). Surgery for patellar tendinopathy (jumper's knee).. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD013034.pub2 PMID 31546279
31. Lambers Heerspink FO, Veen EJD, Dorrestijn O, Visser CPJ, Leijs MJC, Van Poppel D, Stroomberg PA, Ottenheijm RPG, Kallewaard JW, De Ruiter TJW, Martens HA, Janssen FM, Geltink T, Ruiter MS, Van Raaij JJAM (2026). Update of guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopedic Association Part 1: preventive measures, diagnostics, and non-surgical treatment of subacromial pain syndrome.. Acta Orthopaedica. doi:10.2340/17453674.2026.45365 PMID 41718640
32. Greenbaum B, Itamura J, Vangsness CT, Tibone J, Atkinson R (1999). Extensor carpi radialis brevis. The Journal of bone and joint surgery. British volume. doi:10.1302/0301-620x.81b5.9566 PMID 10530864
33. Nasser AM, Vicenzino B, Grimaldi A, Anderson J, Semciw AI (2021). Proximal Hamstring Tendinopathy: A Systematic Review of Interventions.. International Journal of Sports Physical Therapy. doi:10.26603/001c.21250 PMID 33842025
34. Sebastiani RS, Herman ZJ, Rothrauff BB, Fowler JR, Lin A (2026). Clinical outcomes following treatment of distal biceps tendon partial tears and tendinopathy: a systematic review.. JSES Reviews, Reports, and Techniques. doi:10.1016/j.xrrt.2026.100770 PMID 42305929
35. Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP (2015). Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy. The American journal of sports medicine. doi:10.1177/0363546515584760 PMID 26018970
36. Mendonça LM, Leite HR, Zwerver J, Henschke N, Branco G, Oliveira VC (2020). How strong is the evidence that conservative treatment reduces pain and improves function in individuals with patellar tendinopathy? A systematic review of randomised controlled trials including GRADE recommendations.. British journal of sports medicine. doi:10.1136/bjsports-2018-099747 PMID 31171514

Every source the library cites

Changes

• October 15, 2026 First published.