The continuum

It is clear that not all athletes presenting with tendon pain are the same. For example, it does not seem likely that an athlete at FC Barcelona who has a four-day history of a painful Achilles tendon has the same problem as a 50-year-old recreational football player who has had pain for six months. As you will see later in the module, this elite athlete might be treated with a short period of rest while the older athlete might need an aggressive strengthening programme. To reflect the differences between these patients, and to attempt to understand them better, a “continuum” model has been proposed.1

Click on the following tabs to learn more about each of the phases of the “continuum” of tendinopathy.

Reactive tendinopathy
The elite athlete described above is likely to have “reactive tendinopathy”. This term refers to an acute overload of the tendon causing thickening and pain in the tendon. It is more common in the young athlete and is produced through increases in training load or commencement in training if previously sedentary. Imaging studies at this time show mild fusiform swelling. The proposed treatment is a period of relative rest and analgesia.
Tendon disrepair
This involves a worsening of the tendon pathology with breakdown of the tendon matrix. The symptoms are likely to have been present for longer. It may be possible to see some hypoechoic areas or neovascularity within the tendon on ultrasound.
Degenerative tendinopathy
This stage generally occurs after the symptoms have been present for a prolonged period. It is more common in older athletes, like the recreational athlete described above. Tendon changes, including neovascularity and hypoechoic regions, are common during this stage. These patients are likely best treated with aggressive eccentric strengthening.
While the continuum model of tendinopathy has not been scientifically validated, it can help the clinician decide how to treat an athlete presenting with these conditions.

Dr Ricard Pruna

Sport and Exercise Medicine

Click on the following link to read Dr Jill Cook’s paper outlining the continuum model of tendinopathy.

If you are unable to access this article consider listening to this BJSM podcast. Dr Jill Cook talks about the continuum of tendinopathy.