Overview
- Pain, swelling and reduced function in a tendon from repetitive overload
- Degenerative, not inflammatory, so tendinitis is inaccurate
- Achilles, patellar, rotator cuff, gluteal and common extensor tendons most affected
- Clinical diagnosis, supported by ultrasound or MRI
- Load management and progressive loading first line
- Corticosteroid near weight bearing tendons risks rupture
Pathology
- Failed healing response with disorganised collagen, increased ground substance, rounded tenocytes and neovascularisation
- Inflammatory cells are scarce, so the term tendinitis is abandoned
Classification
Cook and Purdam continuum
| Stage | Description |
|---|---|
| Reactive | Thickened tendon with intact collagen, reversible with load reduction |
| Disrepair | Matrix breakdown and early neovascularity |
| Degenerative | Cell death and disordered matrix, prone to rupture |
Original publication Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409-16.
- Reactive areas on a degenerative tendon explain acute flares
Aetiology
- Fluoroquinolones raise Achilles rupture risk, worse with age, corticosteroids and renal impairment
Clinical Features
- Midportion Achilles disease lies 2 to 6 cm above the insertion
- Insertional Achilles disease accompanies Haglund deformity and responds less to eccentric loading
- Patellar disease affects deep posterior fibres at the inferior pole, graded by Blazina
- Gluteal tendinopathy drives greater trochanteric pain syndrome, aggravated by adduction
- Lateral elbow disease arises at the ECRB origin, and most settle within two years
Investigations
- Ultrasound shows thickening, hypoechoic areas and Doppler neovascularity
Management
- Isometrics for reactive phase pain
- Alfredson eccentric and heavy slow resistance give similar outcomes, with better adherence to heavy slow resistance
- Shockwave has moderate evidence in gluteal and calcific disease
- Surgery after six months of failed rehabilitation
- Corticosteroid in lateral elbow disease worsens one-year outcome and recurrence
- PRP showed no benefit over placebo in Achilles trials
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.