Modern Tendinopathy Treatment: Beyond Rest and Injections

Tendinopathy is a degenerative condition of tendon tissue that impairs function and often resists standard treatment. Tendinopathy can be broadly divided into two categories: tendinitis which is the early onset of tendon injury, and tendinosis which is a chronic, painful, degenerative state. Traditionally, management involved rest, NSAIDs, corticosteroid injections, or even surgical debridement. But modern research has shown that these strategies often miss the underlying problem: tendinopathy is not primarily an inflammatory condition, but a failed healing response driven by mechanical and molecular dysregulation.

At the Performance Medicine Institute, we approach tendinopathy as a biologically active process—one that can be reversed through targeted loading, cellular signaling, and regenerative support.

What Really Happens in Tendinopathy

Healthy tendons adapt to mechanical stress by remodeling their extracellular matrix and stimulating tenocytes to produce aligned collagen. In tendinopathy, this adaptive process breaks down. Collagen becomes disorganized, the matrix thickens, and the tendon develops areas of neovascularization and non-functional tissue.

Key contributing factors include:

• Excessive or unbalanced loading
• Poor neuromuscular coordination
• Altered expression of growth factors like PDGF and IGF-1
• Dysregulated matrix metalloproteinase activity
• Incomplete recovery between training bouts or injuries

Why Corticosteroids and Rest Often Fail

Corticosteroid injections provide short-term relief by suppressing pain-related pathways, but they also inhibit collagen synthesis and increase the risk of tendon rupture. Passive rest can temporarily reduce symptoms, but leads to decreased tendon stiffness and greater susceptibility to re-injury.

These treatments often fail because they do not address the underlying deficit in matrix remodeling and tissue turnover.

Evidence-Based Strategies That Work

Modern tendinopathy treatment is based on restoring the tendon’s ability to respond to mechanical stress. The most effective interventions include:

• Eccentric loading programs: Shown to stimulate tendon remodeling and increase collagen alignment
• Progressive resistance training: Including isometrics and heavy slow resistance
• Neuromuscular re-education: Using tools like Neubie or digital motion analysis to correct loading patterns
• Shockwave therapy: To stimulate angiogenesis and local cellular activity
• Regenerative therapies: PRP or BMAC for chronic or refractory cases, especially when neovascularization is present
• Nutritional and metabolic support: Addressing vitamin D, iron, omega-3s, and metabolic inflammation

These approaches target both the mechanical and cellular aspects of tendon repair.

Our Approach

At the Performance Medicine Institute, each patient with tendinopathy undergoes a biomechanical assessment, functional ultrasound, and metabolic review. We evaluate loading patterns, tendon thickness, and regional blood flow. Based on the findings, we build an individualized plan that may include:

• A structured exercise protocol using heavy eccentric and isometric loading
• Manual therapy or instrument-assisted techniques to address myofascial restrictions
• Regenerative medicine if the tendon is not responding to loading
• Hormonal and nutritional assessment if systemic healing capacity is impaired

Conclusion

Tendinopathy is not just tendon “inflammation” but a complex failure of tissue remodeling. Successful treatment requires restoring the tendon’s biological responsiveness, not just masking symptoms. If you’ve been struggling with chronic tendon pain that hasn’t responded to traditional care, we offer a science-based approach to help you recover. Contact Us today to get started.

References

Sugg, K. B., Korn, M. A., Sarver, D. C., Markworth, J. F., & Mendias, C. L. (2017). Inhibition of platelet-derived growth factor signaling prevents muscle fiber growth during skeletal muscle hypertrophy. FEBS Letters, 591(5), 801–809.

Disser, N. P., Sugg, K. B., Talarek, J. R., Sarver, D. C., Rourke, B. J., & Mendias, C. L. (2019). Insulin-like growth factor 1 signaling in tenocytes is required for adult tendon growth. FASEB Journal, 33(11), 12680–12695.

Mead, M. P., Gumucio, J. P., Awan, T. M., Mendias, C. L., & Sugg, K. B. (2018). Pathogenesis and management of tendinopathies in sports medicine. Translational Sports Medicine, 1(1), 5–13.