Patient handout

Tendinopathy (Achilles / lateral elbow / patellar / gluteal / rotator-cuff overlap)

PRODUCTION

1. Your condition

This handout is for tendinopathy (achilles / lateral elbow / patellar / gluteal / rotator-cuff overlap). Your care team identified this based on: load-related localised mid-portion or insertional achilles pain / morning stiffness (jospt achilles 2018 martin; 2024 chimenti).

Other reasons your team may use this plan: lateral elbow pain with gripping / resisted wrist extension (lateral epicondyle / ecrb) (jospt lateral elbow 2022 lucado); anterior knee / inferior-patellar-pole pain with jumping / decline loading (patellar tendinopathy) (kongsgaard 2009); lateral hip pain over the greater trochanter, worse side-lying / single-leg load (gluteal tendinopathy / gtps) (mellor leap 2016).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
education + load management + relative rest (pain-monitoring model)	—	—	—	ICON 2019 Scott PMID 31399426 + Silbernagel 2007 PMID 17307888 — continued loading under a pain-monitoring model is safe and effective; RELATIVE rest, not strict rest; de-emphasise structural labels (structure does not track symptoms — Cook/Rio 2016 PMID 27127294)
progressive/eccentric or heavy-slow-resistance (HSR) tendon-loading programme	—	—	—	First-line at every site: Alfredson 1998 PMID 9617396 — heavy-load eccentric calf, 15/15 returned to running vs 0/15 conventional; Kongsgaard 2009 PMID 19793213 / 2010 PMID 20154324 — HSR and eccentric both durable to ≥6 mo (corticosteroid deteriorated); Malliaras 2013 PMID 23494258 — eccentric-only non-response up to 45%, eccentric-concentric/HSR equivalent or superior (HSR superior collagen-turnover/imaging in patellar) so isolating the eccentric component is not required; definitive LEAP RCT Mellor 2018 PMID 29720374 (n=204, MRI-confirmed gluteal tendinopathy) — education+exercise vs wait-and-see 8-wk global-improvement risk difference 49.1% (95% CI 34.6–63.5), NNT 2.0; education+exercise vs corticosteroid injection 52-wk risk difference 20.4% (95% CI 4.9–35.9), NNT 4.9 — education+exercise > CSI > wait-and-see, durable to 52 wk

Plan: Progressive-loading-first tendinopathy ladder (education + progressive/eccentric/HSR loading first-line at every site; relative rest with pain-monitoring model; analgesic bridge + ESWT/GTN adjunct restraint; corticosteroid de-prioritised — long-term harm; surgery last-line) (JOSPT Achilles 2018/2024; JOSPT Lateral Elbow 2022 Lucado; Kongsgaard 2009; Coombes JAMA 2013)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Improving with loading

If you have:

Pain decreasing and load tolerance improving over weeks
Able to do the progressive loading programme within the pain-monitoring limits
No sudden pop, loss of function, fever or spreading swelling

Do this:

Keep doing the progressive loading programme — tendon recovery is slow (months) (Alfredson 1998 PMID 9617396)
Use the pain-monitoring model — some pain during/after loading is acceptable if it settles; relative rest, not complete rest (Silbernagel 2007 PMID 17307888)
Use topical/oral painkillers only short-term and only if pain limits your exercises, per your prescriber
Continue maintenance loading even once better to prevent recurrence

YELLOW — Not improving / persistent pain

If you have:

No improvement after an adequate loading trial (around 3 months)
Pain limiting daily activities, sleep or work
New tendon pain after starting an antibiotic (fluoroquinolone) or a breast-cancer / cholesterol tablet

Do this:

Continue loading and contact your provider for review and re-assessment (ICON 2019 Scott PMID 31399426)
A steroid injection may give short-term relief but tends to lead to WORSE long-term recovery and recurrence — discuss the trade-off (Coombes JAMA 2013 PMID 23385272)
If a new medicine triggered the pain, tell your prescriber promptly — it may need stopping or review (van der Linden 1999 PMID 10510157)

Call your provider if:

No progress after an adequate loading trial
Tendon pain that started on a fluoroquinolone antibiotic
Pain regularly waking you at night or stiffness in several tendons (possible inflammatory cause)

RED — Cannot-miss / urgent

If you have:

Sudden pop / snap with loss of push-off or a palpable gap in the tendon (possible complete rupture)
Hot, very swollen, exquisitely painful tendon/bursa with feeling unwell or feverish (possible infection)
Severe tendon pain on a fluoroquinolone antibiotic, especially if you have kidney disease or take steroids

Do this:

Seek urgent medical care / go to the emergency department now
For a suspected rupture, do not load the limb and ask specifically about urgent orthopaedic review (JOSPT Achilles 2018 Martin)
If on a fluoroquinolone, stop high-impact activity and contact your prescriber about stopping the antibiotic (Koumou 2021 PMID 34285735)

Call your provider if:

Always seek emergency care for a suspected complete tendon rupture, a hot infected-looking tendon, or severe tendon pain on a fluoroquinolone (JOSPT Achilles 2018 Martin; Sangiorgio 2024 PMID 38949172)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Sudden pop / loss of push-off with positive Simmonds–Thompson calf-squeeze (sens 0.96, spec 0.93, LR+ 13.7, LR− 0.04), positive Matles knee-flexion test (sens 0.88, spec 0.85, LR+ 5.9) and a palpable gap (sens 0.73–0.81, spec 0.89, LR+ 6.6) — Achilles, or equivalent loss of function at another site (Maffulli 1998 PMID 9548122; JOSPT Achilles 2018 Martin)
New tendon pain on a fluoroquinolone (esp. ofloxacin) with risk multipliers — renal failure / chronic haemodialysis, concomitant glucocorticoid, age >60 (van der Linden 1999 PMID 10510157; Sangiorgio 2024 PMID 38949172; Koumou 2021 PMID 34285735)
Hot, exquisitely tender, rapidly swelling tendon/bursa with systemic illness or fever (septic bursitis / tenosynovitis)(life-threatening)

5. Follow-up

Loading maintenance + graded return-to-load / return-to-sport / return-to-work; recurrence and drug-avoidance counselling (avoid future fluoroquinolone where alternatives exist; tendon-pain return precautions on any future fluoroquinolone/aromatase inhibitor); re-evaluate persistent / worsening symptoms for re-phenotyping, delayed imaging or surgical opinion (ICON 2019 Scott; JOSPT Achilles 2018/2024)

6. Sources

Guideline: JOSPT Midportion Achilles Tendinopathy CPG 2018 (Martin) + 2024 revision (Chimenti) + JOSPT Lateral Elbow Tendinopathy CPG 2022 (Lucado) + ICON 2019 Consensus Terminology (Scott) + Cook & Purdam continuum model