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9 Lessons

Pain in the tendon, especially in the Achilles and the patellar tendon, known as tendinopathy, is very common among individuals who play football either competitively or as a hobby. Tendon disorders can also occur in physically inactive individuals. As a result, it appears that physical activity is not always directly associated to histopathology and that physical exercise may be more important for provoking the symptoms than for being the cause of the injury.

The nomenclature used for chronic pain in the tendon is confusing. Until recently, chronic Achilles and patellar pain was thought to involve inflammation and the term “tendinitis” was widely used. Histological studies have since shown that there are no signs of prostaglandin inflammation and, as a result, the term “tendinopathy” is now used to describe a painful tendon. Inflammation of the outer casing of the tendon (the para tendon) can however occur and is called para-tendinitis.

Tendinopathies are not an easy pathology to treat. At present, there are many theories that have sought to explain the origin of the pain. It has been demonstrated that conservational treatment using eccentric exercises (with or without pain) offers very good results in the short and medium term in tendinosis patients. There are also a wide range of other treatment described in the literature

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Learning outcomes

By the end of this module you should:

  • have an awareness of the pathogenesis of tendinopathy;
  • have an understanding of the stages of tendinopathy and how this relates to treatment;
  • be able to take a history, conduct a clinical examination and arrange appropriate investigations in a patient presenting with tendinopathy;
  • have an approach to the management of an athlete with tendinopathy.


  • Read the relevant section in the FIFA Medical Manual and other required reading.
  • Review the suggested reading.
  • View, or listen to, any relevant multimedia content.
  • Complete the course quiz.

Suggested reading

Brukner and Khan’s

Clinical Sports Medicine 4th Ed

Chapters 5 (pages 25-40) and 37 (pages 776-805)


  1. 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):409-416.
  2. Paavola M, Kannus P, Järvinen M. Epidemiology of tendon problems in sport. In: Maffulli N, Renström P, Leadbetter W, eds. Tendon injuries: Basic science and clinical medicine. London: Springer-Verlag London Limited.
  3. Cook JL, Khan KM, Purdam C. Achilles tendinopathy. Man Ther. 2002;7(3):121-130.
  4. Jones BH, Bovee MW, Harris JM 3rd, Cowan DN. Intrinsic risk factors for exercise-related injuries among male and female army trainees. Am J Sports Med. 1993;21(5):705-710.
  5. Hughes H. Imaging of tendon ailments. In: Maffulli N, Renström P, Leadbetter W, eds. Tendon injuries: Basic science and clinical medicine.  London: Springer-Verlag London Limited; 2005.
  6. Alfredson H. The chronic painful achilles and patellar tendon: Research on basic biology and treatment. Scand J Med Sci Sports. 2005;15(4):252-259.
  7. Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic achilles tendinosis. Am J Sports Med. 1998;26(3):360-366.
  8. Visnes H, Bahr R. The evolution of eccentric training as treatment for patellar tendinopathy (jumper’s knee): A critical review of exercise programmes. Br J Sports Med. 2007;41(4):217-223.
  9. Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49(19):1277-1283.
  10. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford). 2006;45(5):508-521.
  11. Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: A randomized controlled trial. JAMA. 2013;309(5):461-469.
  12. Bell KJ, Fulcher ML, Rowlands DS, Kerse N. Impact of autologous blood injections in treatment of mid-portion achilles tendinopathy: Double blind randomised controlled trial. BMJ. 2013;346:f2310.
  13. de Vos RJ, Weir A, van Schie HT, et al. Platelet-rich plasma injection for chronic achilles tendinopathy: A randomized controlled trial. JAMA. 2010;303(2):144-149.
  14. Humphrey J, Chan O, Crisp T, et al. The short-term effects of high volume image guided injections in resistant non-insertional achilles tendinopathy. J Sci Med Sport. 2010;13(3):295-298.
  15. Chan O, O’Dowd D, Padhiar N, et al. High volume image guided injections in chronic achilles tendinopathy. Disabil Rehabil. 2008;30(20-22):1697-1708.
  16. Maffulli N, Spiezia F, Longo UG, Denaro V, Maffulli GD. High volume image guided injections for the management of chronic tendinopathy of the main body of the achilles tendon. Phys Ther Sport. 2013;14(3):163-167.
  17. Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med. 2009;37(9):1855-1867.
  18. Coleman BD, Khan KM, Kiss ZS, Bartlett J, Young DA, Wark JD. Open and arthroscopic patellar tenotomy for chronic patellar tendinopathy. A retrospective outcome study. Victorian institute of sport tendon study group. Am J Sports Med. 2000;28(2):183-190.
  19. Tallon C, Coleman BD, Khan KM, Maffulli N. Outcome of surgery for chronic achilles tendinopathy. A critical review. Am J Sports Med. 2001;29(3):315-320.
  20. Alfredson H. Midportion achilles tendinosis and the plantaris tendon. Br J Sports Med. 2011;45(13):1023-1025.
  21. Brockmeyer M, Diehl N, Schmitt C, Kohn DM, Lorbach O. Results of surgical treatment of chronic patellar tendinosis (jumper’s knee): A systematic review of the literature. Arthroscopy. 2015.
  22. Maffulli N, Longo UG, Spiezia F, Denaro V. Minimally invasive surgery for achilles tendon pathologies. Open Access J Sports Med. 2010;1:95-103.