Seven Myths Regarding Tendon Pain


Seven Myths Regarding Tendon Pain

Plantar fasciitis? Achilles tendinitis? Jumper’s knee? Rotator cuff problem? Golfer’s elbow? Tennis elbow? Any of these sound familiar to you? If so, you might want to read this article.  How are all of these conditions similar? They are all different types of tendinopathies, which basically translates to “something is messed up with the tendon.”

A tendon is the tissue that connects your muscle to a bone.  So for plantar fasciitis, it’s an issue with the tendon connecting the foot muscles to your heel.  With rotator cuff issues, it’s the tendon between one or more of the rotator cuff muscles and where they attach to your upper arm.  Basically, every muscle has a tendon where it attaches to the bone, so theoretically you could develop a tendinopathy of any muscle.  Since there are so many muscles to develop a tendinopathy, many active people do develop an issue somewhere.  As a result, this leads to all kinds of BS regarding how to treat them.  So let’s get rid of some common myths regarding tendinopathies.

Seven Myths Regarding Tendon Pain

Achilles tendinopathy
(photo courtesy of

1 – It’s an inflammatory issue

We used to call these issues tendinitis, as “itis” means an inflammatory state.  The reason was that they typically presented like acute inflammatory issues.  There is often pain and swelling with use and decreased symptoms with rest and/or ice.  Then, a research group lead by tendon superstar Jill Cooks actually looked at tissue from a tendinopathy under a microscope and found that markers of acute inflammation were not present.[i]  Basically, it’s an issue of chronic degenerative changes.  For that reason, they suggested using the term tendinopathy.  Unfortunately, that was in 1999 and people are still using tendinitis and using inflammation as the cause of the pain.

2 – Tendinopathy improves with rest

Nope. We just showed how this isn’t an inflammatory condition so rest isn’t going to provide any long-term help. I treat a lot of endurance athletes and they are often amazed that even months of rest did not change their Achilles or knee issue one bit.  This is due to the SAID principle, or Specific Adaptation to Imposed Demand, which is a key principle relating to anything from bodybuilding to cardiovascular training to even tendon remodeling.  Basically, if a demand is not placed on the tendon, it’s not going to adapt and won’t ever be able to tolerate more loading.

3 – All I need is an injection

I’m sounding like a broken record here but again, most tendon issues aren’t inflammatory. So would an anti-inflammatory medication provide any long-term benefit? No. And the research confirms this.[ii]  They do provide short-term relief, but no changes in long-term outcomes.  However, multiple injections can often have negative effects on the tendon, as corticosteroids break down tendon tissue. [iii] In case you’re wondering, tissue breakdown is not a good thing.

4 – The muscle is too tight, so stretching/foam-rolling/etc. is the cure

Rarely is there a difference in muscle length between the muscle with the tendon issue compared to the non-painful side.  Often, patients can’t even produce the pain with any kind of stretch.   If you can produce the pain with a stretch, go ahead and stretch it.  However, it’s not the key to treatment.  We’ll get to that later.

5 – Imaging findings correlate to pain

This is a big one.  All sorts of studies have shown that imaging findings have very poor correlation to pain, and this is true for tendinopathies as well.  One study found that 50% of PAIN-FREE individuals have structural changes in a tendon[iv].  In patients with pain, effective rehab usually resolves the issue within 12 weeks. However, these improvements don’t correlate with changes in imaging[v]. Hell, even two-thirds of rotator cuff TEARS produce no symptoms at all.[vi]  Bottom line; don’t let imaging findings alone dictate your treatment or activity levels.

6 – Avoid load to help tendon heal

This ties in with the myth about rest, but it’s important enough to make it a separate item. Loading the tendon is actually the key to recovery. However, it needs to be an appropriate and individualized load.  Too little load? Not enough stimulus to force an adaptive change in the tendon.  Too much load? Overuse of tendon which causes further degenerative changes.  The solution? A “Goldilocks” approach where the load is not-too-little and also not-too-much.

7 – The “bad tendon” will always be weaker

Our bodies are amazing at adapting.  Most noteworthy, a 2016 study (by the same Jill Cooks mentioned previously) found that in both Achilles and Patellar tendinopathies, the “bad” tendon actually has a greater amount of healthy tissue than the “normal” tendon. [vii] Consequently, this is huge for rehabilitation, as it allows for considerable adaptations in tissue strength.  So, stop resting and start loading up that tissue to get back to being healthy again.

Jeff Remsburg DC MS DACRB Cert MDT

Common loading for Achilles tendon issues


[i] Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med. 1999;27:393–408.

[ii] Wilson JJ, Best, TM. Common Overuse Tendon Problems: A Review and Recommendations for Treatment. Am Fam Physician. 2005 Sep 1;72(5):811-818.

[iii] Dean BJFD, Franklin SL, Murphy RJ, et al. Glucocorticoids induce specific ion-channel-mediated toxicity in human rotator cuff tendon: a mechanism underpinning the ultimately deleterious effect of steroid injection in tendinopathy. British Journal of Sports Medicine 2014; 48 (22) 1583-1583

[iv] Leadbetter WB. Cell-matrix response in tendon injury. Clin Sports Med. 1992;11:533-578.

[v] Drew BT, Smith TO et al. Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review. Br J Sports Med 2012;0:1–8

[vi] Minagawa H, Yamamoto N, Abe H et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village.J Orthop. 201;10(1):8-12.

[vii] Docking SI, Cook J. Pathological tendons maintain sufficient aligned fibrillar structure on ultrasound tissue characterization (UTC). Scand J Med Sci Sports. 2016 Jun;26(6):675-83.