Tendon Problems: Why Loading Is the Therapy — Not Rest

The old picture of "tendon inflammation" is outdated: in chronic complaints there is usually no classic inflammation but an overload reaction with disturbed remodelling — the tendon structure becomes more disorganised and less loadable. The modern continuum model by Cook and Purdam describes it as a staged process: from reactive irritation (after sudden extra load — the new training plan, the house move, the hiking week) to degenerative change after long ignoring. The practical consequence of the model: the load dose steers the direction — too much keeps irritating, too little keeps weakening, the right middle rebuilds.

Typical candidates: Achilles tendon (runners, returners), patellar tendon/"jumper's knee", tennis elbow (outer elbow — mostly not tennis players but mouse and screwdriver hands), golfer's elbow (inner side), shoulder tendons.

The classic of tendon research is Alfredson's eccentric calf protocol: controlled lowering of the heel over a step edge, daily, for twelve weeks — the study that established dosed loading as tendon therapy. Later randomised comparisons showed: heavy slow resistance training (e.g. loaded calf raises, 2–3 times per week) works equivalently — and fits many lives better. The shared logic of both protocols: slow, controlled, heavy stimuli, progressed over months.

Part of it is a pain traffic light that surprises people: mild pain during the exercise (roughly up to 3–4 out of 10) counts as acceptable in the protocols — as long as it is back to baseline after 24 hours. More pain, swelling, or increase over days means: dose too high, one step back. Precisely this fine-tuning is why the treatment belongs under physiotherapy guidance — this dossier explains the principle but explicitly does not replace the individual protocol. Specifically for patellar tendon and patellofemoral complaints, a 2025 Dutch multidisciplinary guideline now offers a real guideline answer instead of just study evidence: exercise therapy is first-line treatment, with a clear 6-to-12-week window of consistent execution before further steps are considered.

• Cortisone injections: the randomised tennis elbow trial is blunt — best short-term relief, but after twelve months a worse outcome and more relapses than physiotherapy or wait-and-see. Guidelines have grown correspondingly cautious; as a first-line therapy for chronic tendon complaints, the quick shot has no place.
• Anti-inflammatory painkillers: can cap acute irritation peaks — but treat nothing causal (chronically there is usually no inflammation present) and, in constant use, mask the most important steering signal: the pain.
• Creams, straps, insoles: sometimes sensible as companions (straps can unload short term), unsuitable as the main therapy — none of them makes the tendon more loadable.
• "Modern" injections (autologous blood/PRP & co.): mixed, overall unconvincing evidence at considerable cost — anyone considering them does so in specialist consultation, not on an Instagram recommendation.

• 1. Identify the trigger: tendon irritations almost always follow a sudden change — more volume, new footwear, a new exercise, harder ground. Reversing the change is step one.
• 2. Reduce, don't eliminate: lower the load to the level that respects the 24-hour rule — not to zero. Use alternatives (cycling instead of running; easy endurance almost always remains possible).
• 3. Start a strength protocol — professionally guided, slowly progressed, thought in months. The fundamental patterns from the squat and hinge are usually part of the solution, not the problem.
• 4. Measure progress in weeks, not days — the yesterday comparison applies here in slow motion.
• 5. Take red flags seriously: a sudden "whip crack" with loss of function (suspected rupture), strong swelling, redness with fever, night pain or complaints without any load connection — that is immediate medical assessment, not load management.

And for everyone with diagnoses like diabetes or elevated blood lipids: tendons often heal more slowly there — one more reason for medical-physiotherapy guidance instead of solo management.