Tendinopathy and Enthesitis

Definition

Tendinopathy is a clinical term used to describe persistent tendon pain and reduced function. It often develops when a tendon is repeatedly exposed to more load than it can currently adapt to and recover from. Changes may occur within the tendon, but the amount of structural change does not always match the level of pain or disability. [1,2]

Enthesitis affects the enthesis — the area where a tendon or ligament attaches to bone. This attachment has to transfer force between soft tissue and bone and can be exposed to considerable pulling and compression during movement. [3]

Although tendinopathy and enthesitis can produce similar symptoms, they are not the same condition. Tendinopathy primarily involves the tendon itself, whereas enthesitis is centred around the attachment to bone. The underlying cause and the most appropriate treatment approach may therefore differ.

How tendinopathy and enthesitis work: Anatomy, Physiology and Biomechanics

Tendons are strong bands of connective tissue that attach muscles to bones and transfer force during movements such as walking, running, lifting and gripping. They are made mainly from collagen fibres arranged to tolerate repeated loading and, in some areas, to store and release energy during movement. The enthesis is the specialised area where a tendon, ligament or joint capsule attaches to bone. It helps spread forces between soft tissue and bone and may be exposed to both pulling forces and compression during movement.

Healthy tendons adapt to regular physical load. Problems can develop when the amount or intensity of activity increases faster than the tissue can recover and adapt. This may happen after a sudden increase in exercise, repetitive work, changes in movement or technique, or returning to activity after a period of reduced exercise.

In tendinopathy, changes can develop in the structure and load tolerance of the tendon. At the enthesis, repeated pulling and compression may irritate the attachment area and make it more sensitive.

Importantly, the amount of pain does not always match the amount of structural change seen on imaging. Tendon and enthesis-related pain is therefore best understood as a complex interaction between tissue changes, mechanical loading, recovery and functional capacity rather than a single structural problem. [1,4]

What causes tendinopathy and enthesitis?

Tendinopathy and mechanically related enthesis pain often develop when the tendon or its attachment to bone is repeatedly exposed to more load than it can currently tolerate. Symptoms may result from a combination of mechanical loading, reduced tissue capacity, biomechanics and insufficient recovery rather than one single cause.

Possible contributing factors include:

• Sudden increases in exercise, training volume or intensity
• Repetitive loading through work, sport or everyday activities
• Returning to activity too quickly after injury or a period of reduced activity
• Reduced muscle strength or conditioning around the affected area
• Changes in movement, technique or biomechanics that alter how forces are distributed
• Repeated compression of a tendon or enthesis against nearby bone
• Previous injury or surgery affecting the way the area is loaded
• Age-related changes in tendon structure and recovery capacity
• Certain metabolic or systemic conditions that may affect tendon health
• Some medications, including certain antibiotics and corticosteroids, which may increase tendon injury [5]

Enthesitis can also occur as part of inflammatory conditions such as spondyloarthritis or psoriatic arthritis. In these cases, inflammation affects the sites where tendons and ligaments attach to bone and the problem is not simply caused by mechanical overload. Medical investigation may therefore be required alongside physiotherapy. [3] These factors do not affect everyone in the same way, and different mechanisms may contribute to similar symptoms.

Typical symptoms

Common symptoms of tendinopathy and enthesitis may include:

• Localised pain around a tendon
• Tenderness when pressing over the affected area
• Pain during activities that load the tendon, such as walking, running, jumping, lifting or gripping
• Stiffness, particularly after rest or first thing in the morning
• Pain at the beginning of activity that may ease as the area warms up, then return afterwards
• Reduced strength or difficulty generating force through the affected muscle and tendon
• Reduced tolerance to repeated activity or heavier loading
• Swelling or thickening around the tendon in some cases
• Pain when the tendon or enthesis is compressed in certain positions

Symptoms can vary considerably depending on which tendon or enthesis is affected, how long the problem has been present and whether the main driver is mechanical loading, tissue sensitivity or an underlying inflammatory condition.

Assessment and safety

A detailed assessment helps identify which tendon or enthesis is involved, how sensitive it is to load and what factors may be contributing to the problem. We look at how the symptoms started, which activities aggravate them, how the area responds to movement and resistance, and whether there have been recent changes in training, work or activity levels.

Assessment may include tenderness, swelling, range of movement, muscle strength, tendon-loading tests and relevant biomechanical factors. We also consider previous injuries, recovery between activities and whether the symptoms suggest an inflammatory condition or another health problem affecting the tendon.

The aim is to distinguish a primarily mechanical tendon problem from presentations that may require additional medical investigation.

Treatment options

Treatment for tendinopathy and enthesitis depends on the structure involved, how the tissue responds to load and whether symptoms are mainly mechanical or influenced by an inflammatory condition.

Physiotherapy may combine progressive exercise, load management, manual therapy and selected treatment technologies. The aim is to reduce symptoms, improve strength and movement, and gradually restore the tendon or enthesis to everyday, occupational and sporting demands.

Progressive loading and rehabilitation form the core of treatment in most mechanical tendon presentations. Resistance exercise has an established role in tendinopathy management, although the most appropriate loading programme, intensity and progression depend on the tendon and individual presentation. [4]

INDIBA radiofrequency

INDIBA uses 448 kHz capacitive-resistive monopolar radiofrequency to deliver controlled energy through the treated tissues. Research on 448 kHz radiofrequency has demonstrated thermal and local physiological effects, while a small randomised clinical trial has reported short-term changes in supraspinatus tendon elasticity. [6,7]

In tendinopathy, INDIBA may therefore be used as a supportive treatment to reduce discomfort and tissue sensitivity and improve tolerance to movement, manual treatment and subsequent loading.

At PhysioB, INDIBA is used mainly around active rehabilitation. It can be applied before or alongside manual therapy and exercise to prepare the area for loading, improve treatment tolerance and help the patient progress into strengthening and movement more comfortably.

Focused (fESWT) and radial shockwave therapy (rESWT)

Extracorporeal shockwave therapy (ESWT) delivers mechanical pressure or acoustic waves into the affected tissues. It has been studied in a range of upper- and lower-limb tendinopathies and tendon-attachment disorders, particularly in persistent presentations. [8,9]

Focused shockwave therapy (fESWT) delivers energy to a more precisely defined depth and may be useful when treatment needs to target a specific tendon or enthesis. Radial shockwave therapy (rESWT) distributes energy more broadly through more superficial tissues.

Evidence suggests that shockwave therapy (ESWT) may reduce pain and improve function in some tendinopathies, although treatment response varies according to the tendon, condition and treatment protocol. [8,9]

At PhysioB, shockwave (ESWT) is therefore selected according to the location, depth and clinical presentation and is combined with progressive exercise, manual therapy and load management rather than used as a standalone treatment.

Additional supportive modalities

Additional physical therapies may be incorporated when they are relevant to the patient’s symptoms, tissue sensitivity and rehabilitation goals. Low-level laser therapy may be used as an adjunct to rehabilitation in selected tendon presentations. Systematic-review evidence suggests potential improvements in pain and function in some tendinopathies, particularly when appropriate treatment parameters are used and laser therapy is combined with exercise. [10]

Therapeutic ultrasound can also be considered selectively as an adjunct rather than as a primary treatment for tendinopathy. [11]

Magnetotherapy (pulsed electromagnetic field therapy – PEMF) may be used as a supportive treatment for pain modulation and rehabilitation in selected presentations.

Electrotherapy, including transcutaneous electrical nerve stimulation (TENS), may be considered primarily for pain modulation where reducing discomfort helps progression with movement or exercise.

Where appropriate, these modalities are combined with manual therapy, progressive exercise and load management to improve treatment tolerance and support active rehabilitation.

How we help at PhysioB

At PhysioB, treatment for tendinopathy and enthesitis is based on the findings of the assessment and the way the affected tissue responds to load. Rather than following a fixed protocol, treatment is adapted according to the tendon or enthesis involved, the severity and duration of symptoms, and the demands of everyday activity, work or sport.

Depending on the presentation, treatment may combine progressive therapeutic exercise, load management, manual therapy and selected treatment technologies where clinically appropriate. Each element is used for a specific clinical purpose—for example, reducing pain and tissue sensitivity, preparing the area for hands-on treatment, improving tolerance to loading and then progressing into strengthening and functional rehabilitation.

Treatment is reviewed throughout the course of care. We monitor changes in pain, strength, movement, tolerance to loading and return to normal activity, and adjust the treatment plan as the tendon or enthesis becomes more capable of handling everyday and sporting demands.

Red flags: when to seek further assessment

Most tendon and enthesis problems are related to mechanical loading and are not caused by serious disease. However, some symptoms require prompt medical assessment or further investigation.

Seek further assessment if you experience:

• Sudden severe pain with a snapping or tearing sensation, especially if followed by marked weakness or loss of function
• Inability to bear weight, push off, lift or use the affected limb normally after an acute injury
• Rapid or significant swelling, bruising or visible deformity
• Increasing redness, warmth, swelling or fever that may suggest infection
• Persistent or unexplained night pain, particularly when not clearly related to movement or loading
• New numbness, weakness or other neurological symptoms
• Symptoms affecting several tendon attachment sites, particularly when associated with prolonged morning stiffness, swollen joints, psoriasis, inflammatory bowel disease or recurrent painful or inflamed eyes [3]
• Persistent symptoms that continue to worsen despite appropriate activity modification and rehabilitation

If assessment suggests a tendon rupture, significant acute injury, infection, inflammatory disease or another condition requiring further investigation, appropriate medical, rheumatology or orthopaedic referral should be prioritised.

If tendon pain, stiffness, weakness or pain around a tendon attachment is limiting walking, running, lifting, work, sport or everyday activities, book an assessment at PhysioB in Ealing. We will identify the structures and loading factors contributing to your symptoms and build an individual treatment plan combining hands-on treatment, progressive rehabilitation and appropriate treatment technologies where indicated.