Massage therapy is used for treating chronic overuse tendon pain. The main tendon pathology is pain from chronic overuse or repetitive loading. Massage therapy is used with much success for treating chronic overuse tendon pain, which is one of the most common soft-tissue disorders.

However, there are also situations in which the treatment seems less effective.

Current research is helping us learn more about tendon structure, function and what is behind painful tendon disorders. A better understanding of these common tendon disorders helps us be more effective in the treatment room.

Tendons are composed of multiple strands of collagen fibers primarily oriented in a parallel direction. This parallel fiber orientation provides the greatest tensile strength in a longitudinal direction.

The primary mechanical load on tendons is the pulling force of muscle, so longitudinal tensile strength is very important.

The main function of tendons is to connect muscle to bone and thereby transmit the pulling force of muscle contraction to the bone. The shape and size of the tendons are dictated by the muscles they are attached to and the force loads those muscles generate.

Some tendons are small and rounded, such as the distal wrist flexor tendons. Others, such as the iliotibial band, are large and sheet-like, so there is much more surface area for muscle attachment.

Tendon Pathologies

Figure 1: Tendon compression at the distal Achilles tendon attachment. Images used with permission by 3D4Medical’s Complete Anatomy application

The main pathology involving tendons is pain from chronic overuse or repetitive loading. Previously this condition was called tendinitis as it was believed to be an inflammatory reaction to excessive loading.

Once research studies established the absence of inflammatory activity in many tendon disorders, these problems were more commonly referred to as tendinosis or tendinopathy simply indicating some type of pathology in the tendon.

The primary clinical symptoms of tendinopathy included localized tendon pain (especially with loading), tenderness to palpation (usually increased when the tendon is loaded) and impaired function.

Tendinopathy can usually be traced back to one or more key factors:

  • Chronic tensile loading (excess pulling from muscles). The chronic tensile load frequently occurs with repetitive motion disorders, such as those present in many occupations or recreational activities.
  • Compressive loading. While tensile loading from repeated muscle pulling is the most common cause of tendon disorder, repeated tendon compression can also cause tendinopathy.

There are numerous locations where tendons are compressed against a nearby bony prominence. An example is the insertion of the Achilles tendon at the calcaneus (Figure 1). The repeated compression of the tendon can lead to degenerative changes in tendon structure.1

  • Friction. Similar to compression pathology excessive friction during repetitive movement plays a part in tendon pathology. Tenosynovitis (inflammatory reaction between the tendon and surrounding synovial sheath under retinacula in the distal extremities) is a good example of friction stress on the tendon.
  • Medications. We have known for some time that corticosteroids (cortisone injections) and a family of antibiotics called fluoroquinolones are associated with tendinopathy.

Medication induced tendinopathy appears to affect large tendons (those attached to powerful muscles and significant tensile loads) the most. However, smaller tendons such as the wrist and hand may be affected as well.2

Despite our understanding of these common causes of tendinopathy, there are still some mysteries of its presentation. It is baffling why tendon pain is so prevalent, persistent and why it comes and goes with little reason in many cases.

Starting in the 1980s high-tech imaging studies caught many clinicians and researchers by surprise when they showed an absence of inflammatory cells in many overuse tendon disorders. Since that time there has been a consistent move away from focusing on an inflammatory component of these problems.

Figure 2: Retinacula in the distal extremities often cause tendon friction.

However, more recent research has suggested that there may actually be inflammatory activity going on in some cases and at certain stages, so the idea of an inflammatory component should not be abandoned.

The model of the tendon pathology continuum described by Cook and Purdam (described later in this article) gives a good explanation for why we may sometimes encounter inflammation and other times not.3

What Makes Tendons Hurt?

Formerly the primary idea behind the pain of tendinopathy was that the pain was a direct result of tissue damage within the tendon.

The presence of localized pain that is persistent with palpation and specific tendon loading reinforce this idea.

However, recent imaging studies have called that idea into question as there are numerous cases of tendon damage evident on imaging with no pain at all. This would suggest other factors may also be involved in chronic tendon pain.

So, what causes a tendon to be painful? It is clear that excess tendon loading is a primary factor in most painful tendon disorders. However, dysfunctional signal processing in the nervous system is now recognized as a likely cause for pain in many of these conditions, and this has important ramifications for treatment.4

Another interesting pattern with tendinopathy is that there seems to be a warm-up effect. Patients frequently report symptoms gradually diminish with activity, but often recur with great intensity after the activity has ceased. It is likely that there is some type of neurological gating or nociception inhibition during activity that is involved in this process.

Current research suggests a role for the central nervous system in ramping up the alarm of the body’s pain system. Essentially this occurs when the central nervous system gets out of calibration and sets off the pain alarm when it shouldn’t.

This is a process called central sensitization and it appears to be linked with many chronic pain conditions. It is likely that long-duration tendon disorders may have some degree of central sensitization as a primary cause of the persistent pain.

One possible suggestion for the cause of tendon pain is a ‘mis-regulation’ of tendon load and the perception of potential damage which then leads to persistent pain. If this type of central neurological processing error is occurring, then local tissue-based interventions aimed directly at the tendon may have limited effectiveness.

A New Model of Tendon Pathology

Cook and Purdam suggest that common overuse tendon disorders may not be just one type of pathology, but instead lie on a continuum. This could be one reason that various symptoms are inconsistent and treatments are inconsistent in their effectiveness. Treatment success is more dependent on what stage of the continuum the condition is at.(3)

Cook and Purdam’s three stages of the continuum(3):

  • Stage 1: Reactive Tendinopathy: non-inflammatory phase with tendon thickening—often from a burst of physical activity. May be either excessive compressive or tensile loading—often seen in younger individuals.
  • Stage 2: Tendon Dysrepair: similar to reactive tendinopathy but with greater matrix breakdown. Hard to identify this stage, but there may be some focal tendon thickening and some more significant changes visible on imaging studies. An older person with less tendon adaptability may move more quickly into this stage of degeneration.
  • Stage 3: Degenerative Tendinopathy: seen more common in elderly people, but also present in younger individuals with chronically loaded tendons that have not been able to adapt. Typical presentation is middle aged athlete (the weekend warrior) with Achilles tendon pain and thickening.

There are often repeated bouts of tendon pain that seem to occur as the person is gradually working toward some degree of adaptation. If extensive, degenerative tendinopathy can lead to rupture. It is much harder to rebound from degenerative tendinopathy once it has reached this stage.

There is a strong suggestion that tendon loading and soft-tissue treatments like massage are beneficial in the healing process, especially at specific stages along this continuum. Some of the benefits may be related to actual mechanical loading of the tendon and in other cases it may be related to regulation of neurological processes that help decrease pain.5

Key Takeaways for Assessment and Treatment

  • Physical examination is still very important to identify potential tendon pathology and evaluate if there is consistency with diagnostic imaging results that may have been performed. Presentation clinical factors are very important, so comprehensive physical assessment is crucial.
  • Consider that the tendon pathology may be at varying stages depending on your client’s age and activity levels, for example.
  • Treatment approaches should focus on methods that are not just tissue oriented (like friction). Those that engage higher-order neurological processes (like active engagement techniques) may have added benefit for tendinopathy.
  • The more frequently treatment, loading and movement strategies are reinforced, the better and more long-lasting those effects are likely to be.

Tendon disorders are very common in clients seeking massage therapy. Keeping up with current research, such as that presented in this article, helps us better understand these conditions, which helps us deliver the most effective treatment strategies for our clients.


  1. Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy? Br J Sports Med. 2012;46(3):163–8.
  2. Berger I, Goodwin I, Buncke GM. Fluoroquinolone-Associated Tendinopathy of the Hand and Wrist: A Systematic Review and Case Report. Hand. 2017;12(5):NP121-NP126.
  3. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409–16.
  4. Rio E, Moseley L, Purdam C, Samiric T, Kidgell D, Pearce AJ, et al. The pain of tendinopathy: Physiological or pathophysiological? Sport Med. 2014;44(1):9–23.
  5. Rio E, Kidgell D, Moseley GL, Gaida J, Docking S, Purdam C, et al. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med [Internet]. 2016 Feb [cited 2016 Feb 8];50(4):209–15. Available here.


Whitney Lowe, LMT, directs the Academy of Clinical Massage. He teaches continuing education in advanced clinical massage through the academy, and offers an online training program in orthopedic massage. He is a regular contributor to MASSAGE Magazine. His articles include “Clinical Reasoning as a Component of Orthopedic Massage.” This article was excerpted from Lowe’s upcoming new edition of Orthopedic Assessment in Massage Therapy, due out in 2019.


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