Tendon pain is one of the most common — and most misunderstood — problems in sport and everyday life. Treating it well means finding why the tendon became painful, not just treating the symptom. This guide, from a tendonitis specialist doctor, explains what tendonitis is, how it’s diagnosed, and which treatments genuinely work.
What is tendonitis?
Tendons are rope-like bundles of collagen protein that transmit force from muscle to bone, producing movement. In tendonitis, those collagen proteins break down. Overloading the tendon — gradually, or through sudden stress — is the usual cause. Ageing, and conditions such as obesity and diabetes, also contribute. A key part of a tendon specialist’s job is finding the factors that led to the tendonitis in the first place.
Is tendonitis due to inflammation?
We used to think active inflammation was central — hence the older term “tendinitis”. We now know that tendons swell with water and then undergo a slow breakdown of collagen. This shift in understanding — from inflammation to collagen breakdown — has changed how we treat it, and it’s why anti-inflammatories are no longer the mainstay.
What features are common in tendonitis?
People with tendonitis typically report pain arising from the tendon itself. The pain usually comes on with an activity that stresses that tendon — running for the Achilles or knee tendons, or tennis and golf for the elbow tendons. Classically, the pain “warms up” with activity, then worsens once you cool down.
Most tendonitis is diagnosed from the pain history, but examination matters — to rule out other sources such as muscle, ligament, or joint pain. Knee pain in a runner, for instance, can come from a cartilage injury rather than patellar tendonitis. The job of a tendon specialist is to get the right diagnosis first time.
Finding why the tendon became painful is just as important. Often, training has increased too quickly — the sudden addition of interval or hill work. Sometimes conditions such as menopause, obesity, or diabetes raise the risk.
Does a tendonitis specialist doctor always scan the tendon?
Not always. Scans such as ultrasound or MRI help in complex cases, or when the problem doesn’t respond to simple treatment. A normal tendon scan is useful in itself — it suggests the pain isn’t coming from the tendon.
Ultrasound shows tendon swelling, collagen breakdown, and increased blood flow. It’s inexpensive and can be done in the same appointment as your consultation, saving time and money. For some tendons — such as the hamstring or hip tendons — we prefer MRI, because it also shows the surrounding structures, including the hip and sacroiliac joints.
What are the most effective treatments for tendonitis?
We used to advise anti-inflammatory tablets such as ibuprofen, back when inflammation was thought to be central. Recent evidence suggests ibuprofen may actually slow healing — though a short course still helps acute tendon pain.
Far more effective is exercise therapy, supervised by an experienced physiotherapist.
How does exercise therapy work?
We don’t know exactly. It probably works by stimulating collagen in the tendon and increasing muscle strength — and the benefit occurs regardless of the type of exercise. In Achilles pain, for example, concentric loading (the muscle shortening as it contracts) works about as well as eccentric loading (the muscle lengthening).
One key principle: for lower-limb tendons such as the Achilles and patellar tendons, the load should be heavier but less frequent; for upper-limb tendons such as the elbow and shoulder tendons, lighter but more frequent. Exercise also provides graded exposure, so the tendon gradually adapts to heavier loads.
An example: strengthening the calf
- Reduce the aggravating load first. If you’re a runner, cut running frequency, intensity, and duration until the pain is stable — as a rule, reduce running by about 50%, then reassess.
- Strengthen progressively. Seated and standing calf raises on a step, every third day. Use a single leg, since weakness also occurs on the pain-free side. Aim for three sets of 8–10 repetitions.
- Add load weekly (for example, 2.5 kg) to keep building strength. Strength goals: standing calf raise, an extra ½ × body weight; seated calf raise, an extra 1–1.5 × body weight.
We focus on concentric-eccentric (isotonic) work and sometimes add eccentric-only exercises to load the tendon more heavily.
Can you exercise through tendon pain?
Generally, yes — as long as the pain is stable. Stable pain is low-level (say, under 3/10), comes on after exercise, and settles within a day. Unstable pain is higher (over 3/10), lasts more than 24 hours, and needs medication — a sign you’re doing too much for the tendon to handle.
What other treatments does a tendonitis specialist doctor use?
Exercise is the most effective treatment, but several others improve the results:
- GTN patches — a non-invasive option applied over the swollen tendon during the day (removed at night), typically for 1–2 months.
- Shockwave therapy — sound waves that stimulate healing and calm pain-generating nerves; evidence supports its use for hamstring, gluteal, and Achilles tendinopathy.
- Injections — used to support tendon healing. A review of tendon injections co-authored by tendon specialist Dr Masci found no clear favourite. Cortisone can cause harm to certain tendons, such as those affected by tennis elbow, so we use it cautiously; PRP is increasingly popular, though evidence remains limited for most tendons. Other options include needle tenotomy and sclerosants.
- Tendon scraping — a minimally invasive alternative to surgery, with good results for some tendons.
Surgery is a last resort, for cases that fail everything else — and a recent review found its outcomes are no better than physiotherapy, despite the risks.
Tendon neuroplastic training
There’s preliminary evidence that chronic tendon pain leads to brain-driven muscle inhibition. Using a metronome during strength training appears to improve muscle drive by reducing inhibition — a technique known as tendon neuroplastic training. Improving strength and muscle control this way may speed up tendon rehabilitation, for both upper- and lower-limb tendons. A tendon specialist may incorporate metronome training into your rehab.
Frequently asked questions for a tendonitis specialist doctor
Which diseases cause tendonitis?
Most tendonitis results from exercise or sport that exceeds what the tendon can handle. But several medical conditions raise the risk — diabetes, obesity, high cholesterol, gout, and inflammatory arthritis such as psoriatic arthritis. A large plantaris tendon next to the Achilles is another Achilles-specific cause. Sorting out these contributors is one of the advantages of seeing a tendon specialist.
Can I run with Achilles tendonitis?
Yes, but correct the calf weakness first, and return to running slowly and progressively over weeks. Run on non-strengthening days, and only increase your running while the pain stays stable.
Can yoga cause tendonitis?
It can, mainly through direct stretching of a sore tendon. But yoga can be modified to reduce the load on the tendon rather than aggravate it — a “yoga butt” (proximal hamstring) injury is a good example of where modification helps.
What are the best shoes for Achilles tendonitis?
A stable shoe if you have flat feet, a cushioned one if you have high arches — and avoid tight shoes that press on the tendon, since direct pressure worsens the pain. A heel raise can also reduce Achilles load, which is especially useful for insertional Achilles tendonitis.
Is there a psychological component to tendon pain?
Yes. As with other chronic pain, people with anxiety or depression find tendon pain harder to manage. Addressing the worry around the pain is an important part of treatment.
How long does tendonitis take to get better?
There’s rarely a quick fix — recovery is usually measured in months, not weeks. Most cases improve with a progressive exercise programme, with other treatments added where needed. Unrealistic expectations of a quick cure are among the most common reasons people give up too soon.
Final word from Sport Doctor London: seeing a tendonitis specialist doctor
Tendonitis is complex, and rarely fixed quickly — most people who expect a “quick fix” are disappointed. Exercise is effective in the great majority of cases, with shockwave and GTN patches helping in some cases, and injections or surgery reserved for when everything else fails. The value of a tendonitis specialist doctor lies in getting the diagnosis right first time, finding the underlying cause, and guiding rehabilitation.
If you have persistent tendon pain, Dr Masci can assess you in London, including ultrasound in clinic. Contact the team here or call +44 (0) 203 488 0350.
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