Achilles pain. Patellar tendon pain under the kneecap. Rotator cuff tendon pain in the shoulder. Tendinopathy is one of the most common — and most commonly mismanaged — problems we see in the clinic, and a lot of that mismanagement comes from well-intentioned treatments that the research simply doesn't support.
In 2018, Professor Jill Cook — one of the world's leading tendon researchers, based at La Trobe University in Melbourne — published a short, sharp editorial in the British Journal of Sports Medicine titled "Ten treatments to avoid in patients with lower limb tendon pain."1 It remains one of the clearest, most useful summaries of tendon rehab mistakes in the physiotherapy literature.
What follows is my own expansion on Cook's ten points — what they mean in practice, and why each one keeps showing up in the clinic despite the evidence against it.
1. Don't rest completely
The instinct to fully offload a painful tendon is understandable, but it works against recovery. Complete rest measurably reduces tendon stiffness within as little as two weeks, and it also reduces the strength and power of the muscle attached to that tendon.2
The right move in the early, painful stage isn't rest — it's reducing the specific loads that are aggravating the tendon while introducing loads it can tolerate, such as isometric holds.3 Once pain settles and stays consistent day to day, load can be built back up in a structured way.
2. Don't prescribe the wrong exercise
Not all loading is equal, and getting this wrong is one of the most common mistakes I see. A tendon is loaded heavily when it's used like a spring — jumping, changing direction, sprinting. Slow, controlled exercise, even against real resistance, doesn't load the tendon the same way and is genuinely appropriate early in rehab.
What catches people out is length. Exercising a tendon at a longer muscle-tendon length can compress it at its insertion point, adding meaningful load even when the movement itself is slow and controlled. Early in rehab, that compressive position is usually one to avoid, regardless of how light the exercise otherwise feels.
3. Don't rely on passive treatments
Electrotherapy, ultrasound, and ice can genuinely take the edge off pain in the moment. What they don't do is increase the tendon's tolerance to load — which is the actual problem being treated. The relief tends to be temporary, and the pain returns as soon as the tendon is loaded again in daily life.
This isn't an argument against ever using them for short-term comfort. It's an argument against building a treatment plan around them instead of active, load-based rehabilitation.
4. Avoid injection therapies as a first move
Injections — corticosteroid, PRP, or otherwise — have consistently failed to outperform placebo in well-run clinical trials.6 The tendon doesn't need the pathology itself corrected; the tissue adapts around it and generally retains plenty of capacity to tolerate high load once it's rehabilitated properly.
Injections aren't ruled out entirely — they occasionally have a role once a genuine, well-run exercise program hasn't produced the expected response. But reaching for one before that point skips the treatment that actually works.
5. Don't ignore what the tendon is telling you
Tendon pain has a delayed response — a session that overloads the tendon typically doesn't hurt more until the next day. That 24-hour lag is exactly why tracking pain daily matters more than judging a session by how it felt at the time.
As a practical rule with my own patients: if a specific loading test is 2 or more points worse (out of 10) the next day, that's the signal to dial back whatever's driving it — usually the spring-like, high-load movements like running, jumping, or sharp changes of direction — not to stop altogether.
6. Don't stretch the tendon
Stretching feels like it should help a tight, painful tendon. For tendons prone to compression at their insertion — the Achilles at the heel, the patellar tendon at the kneecap — stretching does the opposite of what it feels like it's doing. It adds compressive load at exactly the point that's already irritated.4
This is a common source of frustration for patients who've been stretching a painful Achilles for weeks and can't work out why it's not improving. In many cases, the stretching is quietly working against them.
7. Don't use friction massage
A painful tendon is, by definition, already irritated and overloaded. Aggressively massaging or frictioning it tends to increase irritation rather than resolve it, and any pain relief that does occur is usually a short-lived local nerve effect — it returns as soon as the tendon is loaded again.7
I understand the appeal — it feels like something is actively being done. But the evidence points toward load management doing the real work here, not manual pressure on the tendon itself.
8. Don't diagnose, predict, or track progress from imaging alone
This is one patients find hardest to accept, because a scan feels objective in a way symptoms don't. But abnormal findings on ultrasound or MRI are common in tendons that have never caused a day of pain, so an abnormal scan on its own doesn't confirm that's the source of someone's symptoms.8
Just as importantly, tendon pathology on imaging tends to stay remarkably stable even as pain and function improve substantially with the right rehab.9 If we used repeat scans as the measure of success, most genuinely successful rehabs would look like failures. We track recovery through load tolerance and function, not follow-up imaging.
9. Don't let fear of rupture drive treatment
This one surprises people: most tendon ruptures happen in tendons that were never painful. Pain is actually protective — it causes people to naturally reduce load on a struggling tendon before it fails.10 A tendon that hurts is a tendon that's usually being protected, not one on the verge of rupturing.
That doesn't mean pain should be ignored — it's the primary signal guiding how we load the tendon throughout rehab. It just means the fear of catastrophic failure, on its own, isn't a reason to under-load a painful but well-managed tendon.
10. Don't rush it
Tendon adapts more slowly than muscle. Building genuine, durable capacity in the tendon, the muscle attached to it, and the surrounding kinetic chain reasonably takes three months or more12 — often longer for tendons that have been symptomatic for a long time before treatment starts.
This is the point I find hardest to sell in a first consult, because everyone wants a faster answer. But the research is consistent: rehab that respects this timeline gets people back to full function reliably. Rehab that skips stages to chase a faster return tends to produce exactly the setback it was trying to avoid.
What all ten actually point toward
Every one of Cook's ten points is really the same message from a different angle: tendon pain responds to active, progressive, correctly-dosed loading — not rest, not passive treatment, not injections, and not imaging chasing. The treatments that don't work are, almost without exception, the ones that skip the actual loading process or interrupt it.
A well-run tendon rehab program usually starts with isometrics to settle pain, progresses through heavier, slower resistance work to build tendon stiffness and capacity, and only later introduces the fast, spring-like loading — jumping, sprinting, changing direction — that most tendon injuries actually happened during. It takes months, not weeks. But it works.
Masters of Physiotherapy, University of South Australia. Founded Move Physiotherapy in 2018. Provides match day services to sporting clubs across Perth, with a focus on evidence-based rehabilitation and objective return-to-sport testing.
References
- Cook JL. Ten treatments to avoid in patients with lower limb tendon pain. Br J Sports Med. 2018;52(14):882.
- Kubo K, Akima H, Ushiyama J, et al. Effects of 20 days of bed rest on the viscoelastic properties of tendon structures in lower limb muscles. Br J Sports Med. 2004;38:324–330.
- Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49:1277–1283.
- Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy? Br J Sports Med. 2012;46:163–168.
- Docking S, Samiric T, Scase E, et al. Relationship between compressive loading and ECM changes in tendons. Muscles Ligaments Tendons J. 2013;3:7–11.
- Moraes VY, Lenza M, Tamaoki MJ, et al. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2014:CD010071.
- Stasinopoulos D, Stasinopoulos I. Comparison of effects of exercise programme, pulsed ultrasound and transverse friction in the treatment of chronic patellar tendinopathy. Clin Rehabil. 2004;18:347–352.
- Khan KM, Forster BB, Robinson J, et al. Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. Br J Sports Med. 2003;37:149–153.
- Cook JL, Khan KM, Kiss ZS, et al. Asymptomatic hypoechoic regions on patellar tendon ultrasound: A 4-year clinical and ultrasound follow-up of 46 tendons. Scand J Med Sci Sports. 2001;11:321–327.
- Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am. 1991;73:1507–1525.
- Silbernagel KG, Thomeé R, Eriksson BI, et al. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35:897–906.
- Cook JL, Docking SI. ‘Rehabilitation will increase the “capacity” of your… insert musculoskeletal tissue here…’ Defining ‘tissue capacity’: a core concept for clinicians. Br J Sports Med. 2015;49:1484–1485.