Tendonitis Treatment: Exercises and When to See a PT

Tendonitis vs. tendinopathy: what is the difference?

The term "tendonitis" implies active inflammation, but most chronic tendon pain is not primarily inflammatory — it involves structural changes within the tendon itself. The more accurate term is tendinopathy, which describes a continuum from reactive tendon pain through degenerative change.

This distinction matters for treatment: anti-inflammatory approaches (ice, NSAIDs) may help in the acute phase but do not address the underlying tendon degeneration that causes persistent pain. Loading exercises do.

Common sites include: - Achilles tendinopathy — back of the heel/ankle - Patellar tendinopathy (jumper's knee) — front of the knee, below the kneecap - Lateral epicondylitis (tennis elbow) — outer elbow - Rotator cuff tendinopathy — shoulder - Gluteal tendinopathy — outer hip - Peroneal or tibialis posterior tendinopathy — around the ankle

Why exercise is the foundation of tendon treatment

Tendons respond to mechanical load. Without adequate loading, they become disorganized and weaker. The research on tendinopathy consistently shows that progressive loading exercises — particularly eccentric and heavy slow resistance (HSR) protocols — are among the most effective interventions 1Ref 1Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M, Magnusson SP (2009).Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy.Heavy slow resistance and eccentric training are effective and well-tolerated loading protocols for patellar tendinopathy; corticosteroids not recommended as primary treatment2Ref 2Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR (2018).Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018.APTA clinical practice guideline for Achilles tendinopathy supporting progressive loading and cautioning against over-reliance on corticosteroids.

Eccentric exercises lengthen the muscle while it is under tension. For Achilles tendinopathy, the classic eccentric calf raise involves slowly lowering the heel off a step while using both legs to return to the starting position, isolating the eccentric phase on the affected side.

Heavy slow resistance exercises move the tendon through its full range — both shortening and lengthening phases — with heavy load and slow tempo. Research in patellar tendinopathy has shown HSR to be at least as effective as eccentric-only protocols and better tolerated by many patients 1Ref 1Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M, Magnusson SP (2009).Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy.Heavy slow resistance and eccentric training are effective and well-tolerated loading protocols for patellar tendinopathy; corticosteroids not recommended as primary treatment.

Both approaches stimulate the tendon to remodel and strengthen when done consistently over several weeks to months.

A simple starting exercise protocol for tendon pain

This general framework applies across common tendon sites. Adapt the exercise to the specific tendon:

Phase 1 — Isometric loading (pain reduction phase): Hold a static contraction of the muscle for 30 to 45 seconds, 3 to 5 times. Isometrics are often used early because they load the tendon without the movement that provokes pain. For the Achilles, this might be a standing calf raise held at the top. For the patellar tendon, a wall sit with the knee at the angle that reproduces mild tendon discomfort.

Phase 2 — Isotonic loading (tendon strengthening): Once isometrics are tolerable, progress to slow, controlled movements through range. Aim for a 3-second up, 3-second down tempo. Start with bodyweight and add load progressively over weeks.

Phase 3 — Functional and sport-specific loading: Return to the activities that caused the problem, gradually and with attention to load management.

A score of 0–4 out of 10 pain during and after exercise is generally acceptable. Pain above 5, or pain that persists more than 24 hours after a session, signals too much load too soon.

What else helps with tendon pain?

Load management is critical. Most tendinopathies are caused or worsened by a spike in activity — suddenly increasing training volume or intensity. Reducing the provoking activity while maintaining other movement is the starting point.

NSAIDs (ibuprofen, naproxen) may help with pain in the short term but should not be used long-term as a crutch — they do not fix the tendon and may interfere with the adaptive response to loading in some contexts. Use them as needed for pain control during the early phase, not indefinitely.

Ice after loading sessions can reduce discomfort but does not accelerate healing.

Corticosteroid injections provide short-term pain relief for some tendinopathies but are associated with worsening long-term tendon integrity with repeated use, and are generally not recommended as a primary treatment 2Ref 2Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR (2018).Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018.APTA clinical practice guideline for Achilles tendinopathy supporting progressive loading and cautioning against over-reliance on corticosteroids.

For an overview of exercise for chronic pain conditions including tendinopathy, the evidence consistently supports structured loading programs over passive rest 3Ref 3Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH (2017).Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews.Structured exercise programs are more effective than passive approaches for chronic pain including tendinopathy.

When does tendinopathy need physical therapy?

Consider seeing a physical therapist if: - Pain has persisted for more than 4 to 6 weeks despite self-management - You are unsure of your diagnosis — some conditions that feel like tendinopathy are actually something else (a partial tear, bursitis, nerve entrapment) - You have tried loading exercises but are not progressing - You are a runner or athlete trying to return to training safely

A physical therapist can confirm the diagnosis, set the right loading dosage for your situation, and rule out other contributing factors like gait mechanics or footwear. Gale can help you connect with a PT who works with tendon conditions.