Tendinopathies: load management over injections — the AU approach

What tendinopathy is

Tendinopathy describes a clinical syndrome of tendon pain and dysfunction arising from failed adaptation to mechanical load. The preferred term replaces “tendinitis” because the histology of chronic tendon pain is not primarily inflammatory — it shows disordered collagen organisation, neovascularisation, mucoid degeneration, and cell death in a pattern of failed healing (Cook BJSM 2009).

The common sites seen in Australian general practice are the lateral epicondyle (extensor carpi radialis brevis — “tennis elbow”), the Achilles tendon (mid-portion 2–6 cm above insertion, or insertional), the patellar tendon at its inferior pole (“jumper’s knee”), and the gluteal tendons at the greater trochanter (often mislabelled “trochanteric bursitis”). Rotator cuff tendinopathy is covered in the shoulder pain article.

Lateral epicondylopathy affects ~1–3% of Australian adults, peaks between ages 35–54, and self-resolves in ~80% of cases within 12 months. Achilles tendinopathy has a lifetime prevalence of ~6% in the general population and ~50% in runners. Gluteal tendinopathy affects 10–25% of women over 40.

A. Core clinical — the AU general-practice framework

History

Tendinopathy classically presents as insidious-onset, anatomically specific pain provoked by tendon loading. The temporal pattern is characteristic: stiffness and pain worse first thing in the morning or after inactivity, improving with initial movement (“warm-up phenomenon”), then worsening again with prolonged or heavy activity.

Ask about:

• Onset pattern — sudden onset suggests rupture or alternative pathology, not tendinopathy
• Load history — sudden increase in training volume, change of surface or footwear, new occupation
• Functional impact — sport, work, activities of daily life
• Contributing factors — diabetes, hypothyroidism, dyslipidaemia, statin use, recent fluoroquinolone antibiotics (ciprofloxacin, levofloxacin — boxed TGA warning for tendon risk)
• Inflammatory features — bilateral or multi-site involvement, dactylitis, psoriasis, family history of inflammatory bowel disease raise the possibility of enthesitis from spondyloarthritis

Examination

Tendinopathy is a clinical diagnosis made by anatomically specific point tenderness at the tendon origin or insertion, provoked by tendon loading tests:

• Lateral epicondylopathy: resisted wrist extension with the elbow extended; resisted middle finger extension (Maudsley’s test)
• Achilles mid-portion: palpation 2–6 cm above the insertion; the Royal London Hospital Test (tenderness in plantarflexion that eases in dorsiflexion); check for Thompson test (squeeze calf — absence of plantarflexion = positive Achilles rupture)
• Patellar tendinopathy: single-leg decline squat reproduces inferior pole patellar pain
• Gluteal tendinopathy: greater trochanter tenderness; pain on single-leg stance ≥30 seconds; resisted hip abduction in side-lying

Look for a palpable gap (rupture), Kanavel’s four signs of septic tenosynovitis in the hand (uniform digit swelling, fixed flexion posture, tender flexor sheath, pain on passive extension), or multi-site enthesitis suggesting inflammatory arthropathy.

Investigations

Imaging is not required for typical tendinopathy at first presentation — it rarely changes management and has a high rate of incidental findings that do not correlate with pain.

Image when there is:

• Diagnostic uncertainty or atypical presentation
• Suspected acute rupture (Thompson test positive, palpable gap)
• Symptoms persisting >3 months despite optimised conservative management
• Pre-surgical planning

MSK ultrasound is first-line for tendon assessment, showing thickening, hypoechoic change, neovascularisation, and partial tears. MRI is reserved for surgical planning, complex presentations, and suspected stress fractures. X-ray for calcific tendinopathy, avulsion fractures, or Haglund deformity.

Bloods: HbA1c, TSH, and lipids are indicated when intrinsic risk factors for tendinopathy are suspected — diabetes, hypothyroidism, and dyslipidaemia all predispose to tendon pathology and should be identified and treated.

B. Evidence: loading exercise over injections

Why progressive loading works

Tendons adapt to load by reorganising collagen and increasing load-bearing capacity. The fundamental error in tendinopathy management is removing all load — this leads to deconditioning and worse long-term function. The correct approach is load management: reduce the aggravating activities to a tolerable level while systematically increasing tendon load through progressive exercise.

The JOSPT 2024 Achilles Tendinopathy CPG and eTG endorse a progressive loading programme as the cornerstone of treatment:

1. Isometric loading for initial pain modulation (wall-sit holds for patellar; single-leg calf-raise holds for Achilles; wrist extension holds for lateral epicondylopathy)
2. Progressive resistance training — concentric and eccentric contractions with increasing load
3. Heavy slow resistance (HSR) training — 3 sets of 6–15 repetitions at high load with slow tempo (3 seconds per phase), three times weekly for 12 weeks — shown to be comparable or superior to eccentric-only protocols (Beyer AJSM 2015)
4. Functional and sport-specific return — the final phase before returning to full activity

The pain-monitoring model is used throughout: pain ≤4/10 during exercise is acceptable; pain should settle within 24 hours of training. Symptoms that persist beyond 24 hours indicate the load was too high.

The corticosteroid injection problem

The TENNIS trial (Coombes JAMA 2013) — the landmark Australian RCT of corticosteroid injection for lateral epicondylopathy — showed that injection produced better short-term pain relief at 4 weeks but significantly worse outcomes at 12 months: higher recurrence rates and slower complete recovery compared with physiotherapy or watchful waiting.

For the Achilles and patellar tendons, corticosteroid injection carries a meaningful risk of tendon rupture and should be avoided. For gluteal tendinopathy, a single image-guided injection provides modest short-term benefit, but should not be repeated more than twice in 12 months and should not substitute for the loading programme.

Short-term analgesia

A short course of NSAIDs (ibuprofen 400 mg three times daily, naproxen 500 mg twice daily for 1–2 weeks) is appropriate for initial pain control per eTG. Prolonged NSAID use may impair tendon healing by inhibiting COX-mediated collagen remodelling. Topical NSAIDs (diclofenac gel) are a useful lower-risk option. Avoid opioids.

C. Site-specific notes

Lateral epicondylopathy (tennis elbow): Reassurance that ~80% self-resolve within 12 months is itself therapeutic. A counterforce brace (epicondyle brace worn 2–3 cm below the lateral epicondyle) provides modest short-term pain relief during activity. The core treatment is progressive wrist extensor loading. Refer to physiotherapy if pain is limiting function beyond 6 weeks.

Achilles tendinopathy: Distinguish mid-portion (2–6 cm above insertion — responds to exercise including eccentric heel drops on a step) from insertional (at the calcaneal insertion — use flat-surface heel raises; avoid stretches that compress the insertion). Both benefit from a structured 12-week calf strengthening programme. High-top footwear and heel lifts reduce insertional compression. GTN (glyceryl trinitrate) patch 0.25 mg applied to the tendon provides modest additional benefit in some patients (off-label use; headache is the main side effect).

Patellar tendinopathy: High-load strength training (decline squat protocol, HSR quadriceps programme) three times weekly. Avoid jumping and plyometrics during the reactive phase. A patellar tendon strap (infrapatellar brace) reduces pain with activity. Return-to-sport is phased: no jumping until single-leg decline squat is pain-free at load.

Gluteal tendinopathy (greater trochanteric pain syndrome): Avoid compressive postures — sleeping on the affected side, sitting with legs crossed, and hip adduction during standing all compress the gluteal tendons. A pillow between the knees in side-lying reduces night pain. Hip abductor and external rotator strengthening is the core exercise prescription.

D. Australian operations

Medicare (MBS): Standard consultations (items 23, 36, 44) for initial assessment. For chronic tendinopathy with functional impairment, a GPCCMP (items 965/967) enables referral to physiotherapist (with tendinopathy expertise), exercise physiologist, or podiatrist — up to five allied-health sessions per year (10 for ATSI patients). MSK ultrasound (items 55844/55848) and image-guided injection (items 55064 range) are rebatable when indicated.

TGA fluoroquinolone warning: Ciprofloxacin, levofloxacin, and other fluoroquinolone antibiotics carry an active TGA boxed warning for tendinopathy and tendon rupture risk, particularly in patients over 60, those on corticosteroids, and renal transplant recipients. The Achilles tendon is the most commonly affected. If a patient taking a fluoroquinolone develops Achilles pain, stop the antibiotic immediately and arrange urgent imaging to exclude rupture.

PBS: Paracetamol and oral/topical NSAIDs are on general schedule. GTN patch (Nitroderm, Transiderm) is general schedule — but is off-label for tendinopathy. Corticosteroid preparations (triamcinolone, methylprednisolone) for image-guided injection are available on general schedule; the injection procedure itself requires a Medicare-rebatable radiologist or sports physician. PRP injection and ESWT are not PBS-subsidised.

Occupational tendinopathy: Repetitive-strain tendinopathies (lateral epicondylopathy in keyboard users, Achilles tendinopathy in postal workers) are compensable under state workers’ compensation schemes. Document the occupation, work tasks, and load history clearly. Allied-health referral via GPCCMP streamlines workers’ rehabilitation.

E. Special populations

Diabetes: Elevated HbA1c predisposes to tendinopathy and impairs healing. Optimising glycaemic control is part of the tendinopathy management plan. Mention this at the next diabetes review.

Perimenopause and postmenopause: Oestrogen influences tendon collagen and stiffness — falling oestrogen levels during the menopausal transition increase tendinopathy risk, particularly gluteal and Achilles. Explain this biological context when counselling perimenopausal women about tendon symptoms.

Older adults: Tendon tissue becomes less elastic with age and recovery takes longer. The loading programme remains appropriate — reduce starting load and extend the timeframe. Falls risk from lower-limb tendinopathy (especially Achilles and patellar) warrants concurrent balance assessment.

Adolescents: Growing athletes are susceptible to apophyseal avulsion injuries — acute versions of tendon-origin overload at sites such as the tibial tubercle (Osgood-Schlatter disease) and calcaneal apophysis (Sever’s disease). These require X-ray to exclude avulsion fracture and temporary activity modification during growth.

When to escalate

Seek urgent assessment (same-day ED or urgent sports physician/orthopaedic referral) when:

• Suspected acute tendon rupture — sudden severe pain, palpable defect, weakness, positive Thompson test (Achilles)
• Suspected septic tenosynovitis — Kanavel’s four cardinal signs in the hand; surgical emergency
• Suspected DVT mimicking Achilles area pain — calf swelling, warmth, Doppler urgency

Arrange same-week specialist referral for:

• Suspected inflammatory enthesitis (spondyloarthritis — multi-site, dactylitis, psoriasis, IBD) → rheumatology
• Suspected stress or avulsion fracture → orthopaedics
• Suspected fluoroquinolone-associated rupture risk — urgent imaging, cease antibiotic

Routine specialist referral for: tendinopathy persisting beyond 6 months despite optimised loading programme and NSAID course — for ESWT, PRP, or surgical assessment.

What this article is and is not

This article summarises current Australian general practice and sports medicine guidance on tendinopathy, drawing on Therapeutic Guidelines (eTG), the RACGP, ACSEP, Sports Medicine Australia, the JOSPT 2024 Achilles CPG, and key trials including the TENNIS trial and Beyer et al. It is general health information and does not substitute for personal medical assessment. Decisions about specific treatments — including any injection procedures — are made with a treating clinician.

For consumer information: HealthDirect — Tendonitis, Better Health Channel — Tendinitis, Sports Medicine Australia.

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Sources cited

1. Therapeutic Guidelines (eTG) — Pain: Tendinopathy
2. RACGP — Tendinopathy resources
3. ACSEP — Australasian College of Sport and Exercise Physicians
4. Sports Medicine Australia
5. Australian Medicines Handbook
6. TGA — Fluoroquinolone tendon safety
7. Choosing Wisely Australia
8. JOSPT 2024 — Achilles Tendinopathy CPG
9. TENNIS trial — Coombes (JAMA 2013)
10. Beyer — HSR vs eccentric (AJSM 2015)
11. Cook — tendon continuum model (BJSM 2009)
12. Liao — ESWT Cochrane 2015
13. HealthDirect — Tendonitis
14. Better Health Channel — Tendinitis