Tendinopathy

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 11 Jun 2025

Last updated: 09 Mar 2023

Tendinopathy is a general term that describes tendon degeneration characterised by a combination of pain, swelling, and impaired performance.

Common sites include the rotator cuff (supraspinatus tendon), wrist extensors (lateral epicondyle) and pronators (medial epicondyle), patellar and quadriceps tendons, and Achilles' tendon.

The exact aetiology is unclear. Studies suggest it is an over-use condition leading to inadequate tendon repair that predisposes the tendon to micro-tears and degeneration.

Treatment consists of activity modification, relative rest, ice, stretching, and strengthening. Stretching and strengthening are best guided by a physiotherapist.

Extracorporeal shockwave therapy or ultrasound-guided injection of platelet-rich plasma may be considered in recalcitrant tendinopathy, but their use remains controversial.

Those who do not improve with conservative therapy should seek surgical evaluation.

Definition

There are over 600 muscle-tendon units in the human body. Theoretically, tendinopathy can occur in any one of them. This topic will focus on the common sites including: the rotator cuff (supraspinatus tendon) in the shoulder, wrist extensors (lateral epicondyle) and pronators (medial epicondylitis) in the elbow, patellar and quadriceps tendon in the knee, and Achilles' tendon in the heel.

In athletes, common locations for tendinopathy include the Achilles' and patellar tendons.

In the general population, the Achilles' and lateral epicondyle are the most commonly affected.

There are many terms used to characterise chronic tendon disorders. Tendonitis refers to a painful tendon with histological signs of inflammation within the tendon. Tendinosis is a localised intrinsic degeneration of unknown aetiology, characterised by localised swollen tendon nodes. Several studies have shown that tendon biopsies taken at surgery lack inflammatory cells.[1][2][3] In clinical settings, tendinopathy describes impaired tendon healing characterised by pain, swelling, and impaired performance.[4][5][6]

History and exam

Key diagnostic factors

presence of risk factors
insidious onset
well-localised tenderness

Full details

Other diagnostic factors

pain during activity
tendon thickening
tendon nodularity
crepitus

Full details

Risk factors

athletic training
unsuitable equipment
hard and high-friction playing surface
increasing age
fluoroquinolone treatment

Full details

Diagnostic investigations

1st investigations to order

clinical diagnosis

Full details

Investigations to consider

ultrasound
MRI
x-ray

Full details

Treatment algorithm

ACUTE

shoulder with rotator cuff tendinopathy

shoulder with biceps tendinopathy

elbow with lateral epicondylitis

elbow with medial epicondylitis

knee with patellar tendinopathy

knee with quadriceps, iliotibial band, or popliteus tendinopathy

ankle with Achilles' tendinopathy

Contributors

Authors

James H-C. Wang, PhD

Professor and Director

MechanoBiology Laboratory

Department of Orthopaedic Surgery

University of Pittsburgh School of Medicine

Pittsburgh

Disclosures

JHW declares that he has no competing interests.

Benjamin B. Rothrauff, MD, PhD

Research Fellow

UPMC Center for Sports Medicine

University of Pittsburgh

Pittsburgh

Disclosures

BBR declares that he has no competing interests.

Kevin J. Byrne, MD

Research Fellow

UPMC Center for Sports Medicine

University of Pittsburgh

Pittsburgh

Disclosures

KJB declares that he has no competing interests.

Acknowledgements

Dr James H-C. Wang, Dr Benjamin B. Rothrauff, and Dr. Kevin J. Byrne would like to gratefully acknowledge Dr Kivanc Atesok, Dr Chad Griffith, Dr Garth N. Walker, Dr Chealon Miller, Dr Paulo H. Araujo, Dr Margaret S. Lo, Dr Márcio Albers, and Dr Freddie H. Fu, previous contributors to this topic. Unfortunately, we have since been made aware that Dr Freddie H. Fu is deceased.

Disclosures

KA, CG, GNW, CM, PHA, MSL, and MA declare that they have no competing interests. FHF declared that he had no competing interests.

Peer reviewers

Per Renström, MD

Professor Emeritus

Karolinska Institute

Stockholm

Sweden

Disclosures

PR declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Almekinders LC, Temple JD. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc. 1998 Aug;30(8):1183-90. Abstract

Beaudreuil J, Dhénain M, Coudane H, et al. Clinical practice guidelines for the surgical management of rotator cuff tears in adults. Orthop Traumatol Surg Res. 2010 Apr;96(2):175-9.Full text Abstract

Schepsis AA, Jones H, Haas AL. Achilles tendon disorders in athletes. Am J Sports Med. 2002 Mar-Apr;30(2):287-305. Abstract

Kukkonen J, Joukainen A, Lehtinen J, et al. Treatment of nontraumatic rotator cuff tears: a randomized controlled trial with two years of clinical and imaging follow-up. J Bone Joint Surg Am. 2015 Nov 4;97(21):1729-37. Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Rotator cuff tear
- Osgood-Schlatter's disease
- Sinding-Larsen-Johansson disease
More Differentials
Guidelines
- ACR appropriateness criteria: chronic shoulder pain
- ACR appropriateness criteria: chronic elbow pain
More Guidelines
Patient information
Rotator cuff injury
More Patient information
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Tendinopathy

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

shoulder with rotator cuff tendinopathy

shoulder with biceps tendinopathy

elbow with lateral epicondylitis

elbow with medial epicondylitis

knee with patellar tendinopathy

knee with quadriceps, iliotibial band, or popliteus tendinopathy

ankle with Achilles' tendinopathy

Contributors

Authors

James H-C. Wang, PhD

Disclosures

Benjamin B. Rothrauff, MD, PhD

Disclosures

Kevin J. Byrne, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Per Renström, MD

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice