Background
When a Tendon Stops Healing
Chronic tendinopathy is a tendon that has not fully remodeled after repeated strain. It shows up in the Achilles, the patellar tendon, the elbow, and elsewhere. At Novo Soft Tissue in the Denver Tech Center, we find which tendon is involved and how deep the problem sits.
Why Tendon Pain Persists
Most people have tried rest, ice, anti-inflammatories, loading exercises, braces, and sometimes an injection, and many improve. Tendon adapts slowly. When pain persists, the tendon's structure and load tolerance are usually part of the picture, not just inflammation.
Examination
What We Examine
Persistent tendinopathy can involve collagen disorganization, matrix change, altered mechanical properties and impaired load tolerance. Some tendons, such as the Achilles, also have a surrounding paratenon that can be irritated. Tenderness cannot reveal tendon histology, so we look at how the tendon responds to load. We also note depth, since a deep insertion behaves differently from a broad origin near the surface.
- Which tendon is painful, and exactly where along it
- How the tendon responds to loading, such as calf raises, hopping, squatting or resisted testing
- Stiffness after rest, and how symptoms change through the day and with activity
- Strength and endurance of the muscle that loads the tendon
- Neighboring joints, bursae and nerves that can produce pain in the same area
- Signs of a tear, previous imaging, and how you responded to earlier exercise, injections or shockwave
Differential diagnosis
Not All Persistent Tendon Pain Is Tendinopathy
Pain near a tendon is not always coming from the tendon. These need to be considered before tendinopathy is treated.
- Partial or complete tear A sudden onset, marked weakness or a palpable gap in the tendon. Imaging and orthopedic input may be needed.
- Bursitis Irritation of a bursa beside the tendon, which can coexist with tendinopathy, for example at the back of the heel or the outside of the hip.
- Calcific tendinopathy Calcium deposits within the tendon, most often at the shoulder, which can behave differently from non-calcific tendon pain.
- Joint-related pain Arthritis or joint irritation close to a tendon can produce pain in a similar location.
- Nerve-related or referred pain Burning, numbness, tingling or pain that follows a nerve pattern calls for a broader assessment.
- Inflammatory conditions Several painful tendons or joints at once, or marked swelling and morning stiffness, may point to a condition that needs medical evaluation.
Treatment selection
How Treatment Is Selected
Progressive tendon loading remains the foundation of care for most tendinopathy. Shockwave may be considered alongside it when the exam supports it.
Depth and location guide the choice. Focused ESWT reaches deep, discrete insertions and calcific deposits. Radial ESWT suits broader, shallower origins, such as the common extensor tendon at the elbow. For elbow pain specifically, see tennis and golfer’s elbow. For gluteal tendinopathy on the outside of the hip, see lateral hip pain and gluteal tendinopathy. For Achilles tendinopathy, radial, focused, or combined treatment may be considered depending on the presentation. We examine first, and the plan follows the findings.
Imaging & referral
When Imaging or Referral Comes First
Most tendinopathy is diagnosed from the history and examination. Imaging or referral may come first when:
- a sudden pop, marked weakness or a palpable defect suggests a tear or rupture
- several tendons or joints are painful or swollen at the same time
- tendon pain began after starting a fluoroquinolone antibiotic
- night pain, fever or unexplained weight loss accompany the tendon pain
- symptoms are not progressing with appropriate care and the diagnosis remains unclear
Evidence
Focused or Radial Shockwave for Tendinopathy?
A 2026 systematic review and meta-analysis pooled 9 randomized trials and 530 patients with upper and lower limb tendinopathy. Neither focused nor radial ESWT clearly won for pain. Focused ESWT had a statistical edge only as a standalone treatment, and the authors rated the certainty of evidence as low.
In Achilles tendinopathy that had not responded to exercise therapy, a retrospective cohort found that more patients receiving combined radial and focused treatment reached a clinically meaningful VISA-A improvement than with radial treatment alone (89.7% vs. 63.8%), but the study was not randomized and did not establish why the groups differed. More detail is in the Achilles shockwave evidence review.
Sources: Stania et al., Scientific Reports, 2026 · Robinson, Tan & Tenforde, Journal of Foot and Ankle Surgery, 2022
More reading: Radial vs. Focused Shockwave: What the Research Shows and the four tools we use. Golfers with swing-related pain: see our TPI golf performance page.