Achilles, patella, Hamstring & gluteal Tendinopathy are common injuries our physiotherapists treat.

Tendinopathy in the lower limb (i.e. below the spine) can be difficult to treat.

Professor Jill Cook at La Trobe University created her “10 things not to do if you have lower limb tendon pain” and we often link patients to her video here.

There is a detailed explanation of each point below, and whilst each one might not be relevant to you specifically, it is helpful to understand these details. Treatment for tendonitis or tendon pain is usually multi-faceted, your physiotherapist will guide you through the rehab process.

At the bottom of this page, you will also find a helpful infographic which summarises this information.

10 things not to do with lower limb tendon pain

1. Rest completely

Tendon pain usually starts because a tendon is not coping with a given “input” or “load”. Load can be seen as a culmination of frequency, intensity and type of exercise. Rest will only decrease the tendon’s capacity to tolerate said load. Rather than completely resting, patients should continue to load the tendon at a level that is comfortable. The aim is to then slowly and progressively increase it over time.

2. Have passive treatments

Passive treatment such as massage, dry needling, ice, heat, TENS, ultrasound and interferential do not improve the tendon’s capacity to tolerate load. They may be helpful in the short term but will usually not provide long lasting benefits. It is understood that these treatments aren’t curative, you should find a therapist that works towards active treatment of your tendon.

3. Have injection therapies

Injections directly into tendon tissues have not been shown to be effective in clinical trials. In some cases, injections can actually have a detrimental effect to the tendon’s health. You should always exhaust your conservative treatments first (i.e. not invasive). Injections may be considered if the tendon has not responded to a well designed and implemented exercise-based program.

4. Ignore your pain

Once you have tendinopathy, it is normal to expect some pain when you place stress on the tendon. Just as you shouldn’t rest completely, you also shouldn’t push through excessive pain. General rule of thumb is that pain more than 3-4/10 pain means the tendon isn’t coping well with the given load. If pain is sits below a 4/10 during and after exercise and the pain settles within 24-48 hours, the tendon will likely adapt, get stronger and tolerate more activity with less pain over time.

5. Stretch your tendon

Unfortunately stretching your tendon places it under high compressive load. We now know that compressive load can be harmful to a painful tendon and may slow down its recovery. There is also no published evidence to support stretching as a useful intervention in tendon pain. If you really feel the need to stretch, work on other areas of the legs away from the painful tendon, or try “trigger point” releasing of the muscles.

6. Massage your tendon

An overloaded and irritated tendon is often further aggravated by the compression of massage. Friction massage, or massage over the tendon, like other passive therapies is not helpful in the long term, though may provide short term pain relief. Again, try working around the area, or in the muscle rather than directly on the tendon if you need short term relief.

7. Be worried about the images of your tendon

Imaging such as ultrasound or MRI and medical terms such as ‘degeneration’ and ‘tear’ can create fear around the tendon. Patients can fear loading the tendon after seeing these changes with concerns that loading may make the tear worse. There is good evidence demonstrating that problematic tendons can eventually tolerate significant load without pain, especially when load is incrementally increased. Interestingly, the amount of changes identified on imaging is poorly associated with the load capacity in a tendon.

8. Be worried about rupture

Pain is a protective mechanism that makes you unload a tendon – therefore you are actually less likely to rupture a tendon which is painful. Most people who rupture a tendon have never had pain in the area prior, despite having substantial pathology when subjected to imaging (see point 7 – imaging is not a reliable indicator of a tendons ability!)

9.  Take short cuts with rehabilitation

Time is required to develop strength and increase a tendon’s ability to dead with load. Although this time can seem long (often > 3-6 months), the long-term outcomes are good if rehabilitation is completed. Things that are often promised as quick fixes may provide short term pain improvements with no positive effect on long term tendon capacity and function. Building strong muscles and therefore a resilient tendon takes many months.

10. Not understanding which tasks require high tendon loads

Tendons generate spring like forces. As a general rule, painful tendons hate being compressed and contracted forcefully from a stretched position. For the achilles and patella tendon, this involves tasks such as jumping, sprinting and changing direction. Early tendon rehab involves slow resistance exercises with gradual increases in load. As your tendon adapts to rehab, you should progress towards faster, spring like actions to prepare you for the functional demands of the muscle-tendon unit.

Our Physios work alongside our sports doctors and orthopaedic surgeons in Barangaroo to ensure you receive the best care possible.