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10 Things to Avoid with Lower Limb Tendon Pain

10 Things to Avoid with Lower Limb Tendon Pain

“Graded loading exercises are important for tendon rehabilitation”

Tendon pain is the main feature of tendinopathy, which refers to degeneration of the tendon usually without inflammation. The most common tendinopathy of the lower limb is Achilles tendinopathy affecting 2.35 per 1,000 adults. There are many treatment options for tendinopathy, but consistent positive outcomes are a difficult thing to achieve. We know that treatment should be active (i.e., patient is involved in their care, e.g., exercises) and consistent engagement in rehabilitation is important. It is also important to tell patients what type of treatments do not help and should avoid. Here we will list 10 points of treatments to avoid as they do not improve lower limb tendinopathy.

1. Don’t rest completely

If you completely rest your tendon it will actually reduce its load tolerance and increase its stiffness within 2 weeks. It can also reduce muscle strength and changes how you use the tendon and joint. Initially, treatment should focus on reducing pain and high tendon load, but introduce graded and beneficial loads (e.g., isometric exercises). Once pain is manageable, graded load can be increased to improve the tendons capacity (e.g., slow-heavy exercises, leading into tendon load absorption and release).

2. Don’t do the wrong exercise

Gradual loading exercises are very important for the correct exercise regime. Tendons are like springs that can absorb and release load and this allows us to jump and propel forward. But, injured a tendons should avoid these types of movements. Instead, slow-heavy exercises are usually prescribed with or without weights to quickly and appropriately load the tendon. Loading the tendon correctly straight after the injury occurred is associated with a better outcome than rest alone. Although, some longer tendons can compress where it attaches to the bone with some exercises. This adds a lot of load and in some cases should be avoided, even slowly, early in your rehabilitation.

3. Don’t rely on passive treatments

Passive treatments are ones that the clinician does for the patient (e.g., massage, heat therapy, mobilisations, manipulations, ultrasound etc.). They may play an important role initially, but they are not helpful in the long-term. This is because they promote dependance on clinicians and do not increase tendon load tolerance.

4. Avoid injection therapies

Injections, like cortisone, into tendons are not any more effective than placebo. Tendons will not return to normal by having injections. There is no reason to get into the semantics of pathological tissue changes. This is because there is evidence that tendons adapt to pathology and has lots of tolerance to high load. Injections may change pain levels in the short-term as they affect nerves, but should only be considered if your tendon has not responded to an appropriate exercise-based programme.

5. Don’t ignore pain

Pain is not necessarily a bad thing, in fact pain usually increases a day after excess tendon loading. But, if pain levels are 2 or more (out of 10) on a daily basis with loading, then you may have to regress to less loaded training. The overload is usually due to excessive spring-like movements like jumping.

6. Don’t stretch it

Besides tendon loading with sport, there are compressive loads where the tendon meets the bone when it is at its longest length. Stretching only adds compressive load that can have a negative effect on the tendon.

7. Don’t use friction massage

A tendon that is painful and irritated (i.e., reactive phase) does not respond to massage or friction. In fact, this will increase pain and not help the pathology. Massage may give some immediate, short-term pain reduction, but it will quickly return with overloading.

8. Don’t get scans just to diagnose or use for outcome measure

Abnormal tendon investigations (i.e., ultrasound and MRI) in isolation do not support a diagnosis of tendon pain, because many people that do not even have tendon pain will have some pathology changes on scans. No aspect of scans (e.g., ‘tears’) give clinicians information to determine outcome.

9. Don’t  worry about rupture

Pain is actually a good thing. Pain is protective as it causes unloading. In fact, most people who have a ruptured tendon do not have pain despite considerable pathology.

10. Don’t rush rehabilitation

Tendons and muscles require a lot of time, as much as 3 months or more, to strengthen and build load capacity. But, your long-term health outcomes will be good if you follow through with correct rehabilitation.


A graded and progressive programme starting with muscle strengthening and leads into spring-like exercises including endurance exercise will load injured tendons correctly and give best long-term results.

Our clinicians at Balmain Chiropractic Centre are highly trained to identify and conservatively manage tendon injuries. If you have an injury, visit our Inner West clinic today.

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Balmain Chiropractic Centre is the chiropractic division of Sydney Spine & Sports Centre.


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Phone (02) 80211172