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TENDINOPATHY MANAGEMENT:
A CLINICAL FRAMEWORK

ASSESSMENT · JUN 07, 2026 · DENNIS SCHWENDER · — MIN READ

Millar et al. (2021) · Nature Reviews Disease Primers

5
loading stages at the core of tendinopathy management.

From isometric exercise to energy storage and release — the evidence-based load progression for tendinopathies across all common anatomical sites.

Tendinopathies describe a range of changes occurring in damaged and diseased tendons that lead to pain and reduced function. They are characterised by abnormalities in the microstructure, composition, and cellularity of tendons. The ability of tendons to withstand considerable forces, store energy, and release it is essential for everyday activities (Millar et al., 2021).

Prevalence by Anatomical Location

Tendinopathies occur across multiple anatomical sites with varying prevalence (Millar et al., 2021):

Shoulder
Rotator Cuff
5.5 %
Hip
Gluteal Tendons
4.2 %
Foot / Ankle
Achilles Tendon
2.4 %
Foot / Ankle
Peroneal / Post. Tibialis
2.4 %
Knee
Patellar Tendon
1.6 %
Elbow
Common Extensor / Flexor Origin
0.7 %

Risk Factors

Risk factors for tendinopathy are classified as intrinsic (patient-related) or extrinsic (load- and environment-related) (Millar et al., 2021):

Intrinsic
Patient-Related
Systemic diseases
Metabolic disorders — diabetes mellitus, hyperlipidaemia
Inflammatory conditions
Family history
Obesity · Age
Restricted or excessive joint mobility
Muscle weakness · Neuromuscular control deficits
Tendinosis and altered tendon structure
Extrinsic
Load & Environment
Overuse
Sudden increase in activity or intensity
Onset of new activities (e.g. overhead work, jumping, running)
Inadequate recovery
Highly repetitive movements
Poor workplace ergonomics
Medications — fluoroquinolones, HRT, statins

Management Framework

Management follows a structured, patient-centred algorithm. Early and accurate diagnosis is the starting point, followed by individualised load management. Reassessment drives all subsequent decisions (Millar et al., 2021).

Step 1
Diagnosis
Consider differential diagnoses · Apply ICON 2019 consensus guidelines
Step 2
Patient Presentation
Education · Review prior treatment attempts · Identify fear-avoidance behaviour
Step 3 · 0–12 Months
Load Management
Individual, tailored loading programme — progressing through the five stages. Reassess regularly.
Step 4 · 12 Months
Reassessment
Review differential diagnosis · Address psychosocial factors · Consider surgical referral if no improvement after 12 months of a personalised loading programme

The 5 Loading Stages

The loading programme is the cornerstone of first-line treatment. It progresses through five stages, beginning with low-demand isometric exercise and advancing to energy storage and release activities relevant to the patient's functional goals (Millar et al., 2021):

01
Isometric
Static muscle contraction without joint movement — effective for pain modulation in early stages
02
Isotonic
Dynamic loading through full range of motion — builds tendon and muscle capacity
03
Eccentric
Lengthening under load — high mechanical demand on the tendon-muscle unit
04
Energy Storage Loading
Loading the tendon's elastic storage capacity — introduces plyometric-type demands
05
Energy Storage + Release Loading
Full stretch-shortening cycle demands — sport- and function-specific loading at maximal velocity

When Progress Stalls

If the patient is not progressing within the loading programme, adjunct therapies can be considered alongside continued load management, education, and a biopsychosocial framework (Millar et al., 2021):

ESWT
Extracorporeal shockwave therapy
NSAIDs
Non-steroidal anti-inflammatory drugs and/or injection
GTN
Glyceryl trinitrate — topical application
Load Revision
Modify the loading programme
Education
Reinforce understanding and expectation management
Biopsychosocial
Address psychological and social contributing factors

Three Core Principles

Across all tendinopathy locations and management stages, three principles underpin best practice (Millar et al., 2021):

Early Diagnosis
A thorough differential diagnosis using the ICON 2019 consensus guidelines is essential. Missed or delayed diagnosis delays the start of appropriate load management.
Patient-Centred, Individualised Approach
No generic programme. The loading plan must be tailored to the individual — accounting for the specific tendon, activity demands, and patient goals. Reassessment within a 3-month cycle determines next steps.
Education & Fear-Avoidance
Education about the clinical course, acknowledgement of previous treatment attempts, and reduction of fear-avoidance behaviour around tendon loading are prerequisites for a successful outcome.

Reference

  1. Millar NL, Silbernagel KG, Thorborg K, Kirwan PD, Galatz LM, Abrams GC, Murrell GAC, McInnes IB, Rodeo SA. Tendinopathy. Nat Rev Dis Primers. 2021;7(1):1. doi:10.1038/s41572-020-00234-1.

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