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msk.tendinopathy.core.v1

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

rheumatologysubacutechronicadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Tendinopathy is a load-related continuum doctrine, not a single diagnosis; phenotype = site + continuum stage (reactive → disrepair → degenerative); pain/structure/function are dissociated and imaging structure does NOT track symptoms; use ICON 2019 terminology "tendinopathy", not "tendinitis" (Cook & Purdam 2009 PMID 18812414; Cook/Rio 2016 PMID 27127294; Scott ICON 2019 PMID 31399426)

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Scope framed: load-related continuum, site + stage, ICON terminology adopted

Patient inputs (13)

Site (Achilles mid-portion vs insertional, lateral elbow, patellar, gluteal, hamstring) sets the pre-test prior, the site-specific provocative-test battery and the loading protocol (JOSPT Achilles 2018/2024; JOSPT Lateral Elbow 2022)

Training-load spike / occupational repetitive gripping / jumping exposure is the dominant driver and the pre-test prior; also sets the load-management plan (Cook & Purdam 2009; Silbernagel 2007)

Continuum stage skews degenerative with age; fluoroquinolone rupture risk rises sharply >60 y; gluteal tendinopathy peaks peri/post-menopause 40–60 y (Sangiorgio 2024; Mellor LEAP 2016)

Fluoroquinolone- and aromatase-inhibitor/statin-associated tendinopathy/rupture — deprescribe the offending agent; molecule-stratified risk (van der Linden 1999; Sangiorgio 2024)

eGFR / peptic-ulcer / cardiovascular status gates NSAID use and dose (calc.ckd_epi_2021 on the renal branch); renal failure also multiplies fluoroquinolone rupture risk (Koumou 2021)

Concomitant glucocorticoid multiplies fluoroquinolone rupture risk; diabetes / metabolic syndrome are tendinopathy risk modifiers and steroid-glycaemia caution (Koumou 2021; Cook & Purdam 2009)

Reactive vs disrepair vs degenerative banding sets recovery trajectory expectation, loading protocol and the imaging/surgery T_test (Cook & Purdam 2009; Cook/Rio 2016)

Site-specific provocative-test battery (calf-squeeze, Maudsley/Cozen/Mill, single-leg decline squat, FABER + trochanter palpation) scored with LR± is the diagnostic spine (JOSPT CPGs)

Sudden audible pop + loss of push-off / palpable gap = tendon RUPTURE screen (Simmonds–Thompson calf-squeeze for Achilles) — the time-critical mimic (JOSPT Achilles 2018 Martin)

Inflammatory rhythm (night pain, prolonged morning stiffness), multi-site enthesopathy, psoriasis/IBD/uveitis → enthesitis of spondyloarthritis (route to rheum engine) (ICON 2019 Scott)

US/MRI ONLY when the result changes management (suspected rupture, atypical/refractory course, surgical planning) — structure does not track symptoms (T_test) (Cook/Rio 2016)

Gluteal/greater-trochanteric tendinopathy is markedly female-predominant peri/post-menopause; informs the pre-test prior (Mellor LEAP 2016)

CRP/ESR/HLA-context ONLY to screen for inflammatory enthesitis of spondyloarthritis — not routine in mechanical tendinopathy (ICON 2019 Scott)

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Severity triggers (9)

9 need judgement
  • informationallife_threateningseptic_tendon_or_bursa
    Hot, exquisitely tender, rapidly swelling tendon/bursa with systemic illness or fever (septic bursitis / tenosynovitis)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresuspected_complete_tendon_rupture
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefluoroquinolone_associated_tendinopathy_rupture_risk
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenegative_provocative_cluster_pretest_pivot
    Fully negative site-specific provocative cluster (negative calf-squeeze with intact continuity LR− 0.04; negative Maudsley/Cozen/Mill with painless resisted extension; negative single-leg decline squat; negative trochanter palpation + single-leg-stance + FABER) with non-load-reproducible pain — post-test probability of tendinopathy falls (Maffulli 1998 PMID 9548122; Grimaldi & Fearon 2015 PMID 26381486)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateinflammatory_enthesitis_spondyloarthritis
    Inflammatory rhythm (night pain, prolonged morning stiffness), multi-site enthesopathy, with psoriasis / IBD / uveitis or raised inflammatory markers (ICON 2019 Scott PMID 31399426)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatearomatase_inhibitor_or_statin_associated_tendinopathy
    Tendinopathy/musculoskeletal symptoms temporally associated with an aromatase inhibitor (adjuvant breast-cancer endocrine therapy) or a statin (van der Linden 1999 PMID 10510157)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatereferred_radicular_or_radial_tunnel_lookalike
    Lumbar-radicular pain mimicking gluteal/hamstring tendinopathy, or radial-tunnel / cervical referral mimicking lateral-elbow tendinopathy — negative site-specific provocative tests (JOSPT Lateral Elbow 2022 Lucado)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecorticosteroid_long_term_harm_decision
    Patient or clinician requesting a peritendinous corticosteroid injection for short-term relief (Coombes JAMA 2013 PMID 23385272)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatensaid_comorbidity_risk
    Reduced eGFR (CKD-EPI 2021), active peptic-ulcer disease, significant CVD, third-trimester pregnancy, or frail elderly (STOPP) for whom an NSAID analgesic bridge is considered (JOSPT Lateral Elbow 2022 Lucado)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

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)
axis: progressive_loading_first_tendinopathy_ladderstep 1 - Step 1 — Education + progressive/eccentric/HSR tendon loading + load management (FIRST-LINE)
Selected step "Step 1 — Education + progressive/eccentric/HSR tendon loading + load management (FIRST-LINE)" — Any site-specific tendinopathy along the continuum without a complete-rupture / inflammatory-enthesitis / infection red flag
  • education + load management + relative rest (pain-monitoring model)
    first line
    patient_education
    triggers: any_tendinopathy_site, any_continuum_stage
    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
    therapeutic_exercise
    triggers: achilles_midportion, patellar, lateral_elbow, gluteal, hamstring
    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

outpatient playbook — drug actions (4)

  1. 1. education + progressive/eccentric/HSR tendon loading + relative rest
    structured site-specific loading programme, progressive • physiotherapy • ongoing, reviewed q6–12 wk; expect ≥3 mo
    trigger: Any site-specific tendinopathy without a complete-rupture / enthesitis / infection red flag
    First-line at every site (Alfredson 1998 PMID 9617396; Kongsgaard 2009 PMID 19793213; LEAP Mellor 2016 PMID 27139495)
  2. 2. topical NSAID (rxcui omitted) or naproxen / ibuprofen / acetaminophen
    topical per label / naproxen 250–500 mg BID / ibuprofen 400 mg TID / paracetamol ≤3–4 g/day • topical / PO • short course, BID–QID PRN
    trigger: Pain limiting loading participation; gate eGFR/GI/CVD/pregnancy
    Short analgesic bridge only — never a substitute for loading (JOSPT Lateral Elbow 2022 Lucado)
  3. 3. ESWT / GTN patch (restrained adjunct)
    ESWT course / low-dose GTN patch (rxcui omitted) • physical modality / transdermal • per protocol, alongside continued loading
    trigger: Refractory after an adequate loading trial
    Modest/uncertain adjunct only — Gatz 2021 PMID 33586526 (no significant ESWT benefit vs placebo over loading)
  4. 4. deprescribe offending fluoroquinolone / review aromatase inhibitor or statin
    stop/substitute per offending agent • medication change • as indicated
    trigger: Drug-induced tendinopathy identified
    Stop fluoroquinolone (switch antibiotic); review AI/statin with prescriber; restrict high-load activity + rupture surveillance (van der Linden 1999 PMID 10510157; Koumou 2021 PMID 34285735)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Load-related localised mid-portion or insertional Achilles pain / morning stiffness (JOSPT Achilles 2018 Martin; 2024 Chimenti); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Tendinopathy (Achilles / lateral elbow / patellar / gluteal / rotator-cuff overlap)** (msk.tendinopathy.core.v1).
Phenotype framing: MECE: site-specific tendinopathy (continuum stage) vs full/partial RUPTURE (tendon-continuity pivot) vs ENTHESITIS of spondyloarthritis (inflammatory pivot) vs REFERRED (lumbar radicular for gluteal/hamstring; radial-tunnel/cervical for lateral elbow) vs DRUG-INDUCED (orthogonal modifier — fluoroquinolone/aromatase-inhibitor/statin raises rupture probability irrespective of site). CONDITIONAL DEPENDENCIES modelled as data (§5.5.2): (1) the calf-squeeze rupture LR is conditional on tendon continuity — a positive squeeze with a palpable gap and lost resting tone is near-pathognomonic (Maffulli 1998 PMID 9548122 composite LR+ ≥20) but a positive squeeze with INTACT continuity on US/MRI collapses to a low post-test probability; (2) calf-squeeze, Matles and gap-palpation are NOT conditionally independent (shared loss-of-continuity mechanism) so the cluster LR is sub-multiplicative; (3) the site-test cluster (Maudsley/Cozen/Mill; single-leg decline squat; trochanter palpation + single-leg-stance + FABER) is internally correlated — a single positive provocation adds little once the cluster is positive, and the cluster’s post-test value is conditional on the pre-test prior (activity/age/sex/load-spike); (4) the drug-induced rupture LR is conditional on exposure — it only multiplies rupture probability when fluoroquinolone/aromatase-inhibitor/statin exposure is present, and is itself co-multiplied by renal failure + glucocorticoid + age >60 (Sangiorgio 2024 PMID 38949172; Koumou 2021 PMID 34285735). Co-existence handled: degenerative tendinopathy can co-exist with a superimposed acute partial tear; widespread-pain amplification can co-exist (route msk.fibromyalgia.core.v1); adjacent joint OA can co-drive load intolerance (route msk.osteoarthritis.core.v1 / msk.knee-pain.core.v1 for patellar–PFJ overlap); drug-induced changes overlay pre-existing degeneration (Cook & Purdam 2009; ICON 2019 Scott)
Scope: Tendinopathy is a load-related continuum doctrine, not a single diagnosis; phenotype = site + continuum stage (reactive → disrepair → degenerative); pain/structure/function are dissociated and imaging structure does NOT track symptoms; use ICON 2019 terminology "tendinopathy", not "tendinitis" (Cook & Purdam 2009 PMID 18812414; Cook/Rio 2016 PMID 27127294; Scott ICON 2019 PMID 31399426)

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)** — step "Step 1 — Education + progressive/eccentric/HSR tendon loading + load management (FIRST-LINE)".
1. education + load management + relative rest (pain-monitoring model) (patient_education, first line) — 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)
2. progressive/eccentric or heavy-slow-resistance (HSR) tendon-loading programme (therapeutic_exercise, first line) — 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

Setting playbook (outpatient) — Frame the continuum, phenotype by site + stage, screen the cannot-miss mimics (rupture / enthesitis / infection / drug-induced), deliver education + progressive loading as first-line, gate analgesic/adjunct restraint by comorbidity, deprescribe the offending drug, and defer surgery to last-line (JOSPT Achilles 2018/2024; JOSPT Lateral Elbow 2022 Lucado; ICON 2019 Scott)
3. education + progressive/eccentric/HSR tendon loading + relative rest structured site-specific loading programme, progressive physiotherapy ongoing, reviewed q6–12 wk; expect ≥3 mo — Any site-specific tendinopathy without a complete-rupture / enthesitis / infection red flag (First-line at every site (Alfredson 1998 PMID 9617396; Kongsgaard 2009 PMID 19793213; LEAP Mellor 2016 PMID 27139495))
4. topical NSAID (rxcui omitted) or naproxen / ibuprofen / acetaminophen topical per label / naproxen 250–500 mg BID / ibuprofen 400 mg TID / paracetamol ≤3–4 g/day topical / PO short course, BID–QID PRN — Pain limiting loading participation; gate eGFR/GI/CVD/pregnancy (Short analgesic bridge only — never a substitute for loading (JOSPT Lateral Elbow 2022 Lucado))
5. ESWT / GTN patch (restrained adjunct) ESWT course / low-dose GTN patch (rxcui omitted) physical modality / transdermal per protocol, alongside continued loading — Refractory after an adequate loading trial (Modest/uncertain adjunct only — Gatz 2021 PMID 33586526 (no significant ESWT benefit vs placebo over loading))
6. deprescribe offending fluoroquinolone / review aromatase inhibitor or statin stop/substitute per offending agent medication change as indicated — Drug-induced tendinopathy identified (Stop fluoroquinolone (switch antibiotic); review AI/statin with prescriber; restrict high-load activity + rupture surveillance (van der Linden 1999 PMID 10510157; Koumou 2021 PMID 34285735))

Non-pharmacologic actions:
- Reassurance + de-emphasise structural labels (structure does not track symptoms — Cook/Rio 2016 PMID 27127294)
- Load-management + graded return-to-load/sport/work plan developed early (Silbernagel 2007 PMID 17307888)
- AVOID routine peritendinous corticosteroid — worse long-term recurrence (Coombes JAMA 2013 PMID 23385272)
- Urgent orthopaedic referral for suspected complete tendon rupture (positive calf-squeeze) (JOSPT Achilles 2018 Martin)
- Route inflammatory enthesitis to rheum.axial-spondyloarthritis.core.v1; rotator-cuff overlap to msk.shoulder-pain.core.v1
- Surgical opinion only after a long adequate progressive-loading trial (JOSPT CPGs)

AVOID / contraindication checks:
- Special pop:RENAL — NSAID block if eGFR<30 (race neutral CKD EPI 2021, calc.ckd_epi_2021 gate); dose reduce 30–59; reduced eGFR also multiplies fluoroquinolone rupture risk (JOSPT Lateral Elbow 2022 Lucado; Koumou 2021 PMID 34285735)
- Special pop:HEPATIC — acetaminophen ≤3 g/day if Child Pugh ≥B or chronic liver disease/alcohol; avoid NSAID in decompensated cirrhosis (variceal/renal risk)
- Special pop:PREGNANCY/LACTATION — avoid NSAID 3rd trimester (ductal closure) and from ~20 wk (oligohydramnios); acetaminophen + loading preferred; topical NSAID minimal but avoid late pregnancy; loading programme is the pregnancy/lactation safe first line
- Special pop:GERIATRIC — STOPP: avoid systemic NSAID with eGFR<50 / HF / anticoagulant / age ≥75 without gastroprotection; prefer topical NSAID or acetaminophen + loading; START — ensure an active tendon loading programme is offered (not under treated)
- Special pop:PEDIATRIC/ADOLESCENT — engine is adult scoped; in skeletally immature patients apophyseal traction injury (e.g. Osgood Schlatter / Sever) and avulsion mimic tendinopathy — exclude and manage on a paediatric pathway, not the adult loading/NSAID ladder
- Special pop:DDI — fluoroquinolone + glucocorticoid (and statin) multiplies tendon rupture risk; NSAID + anticoagulant/ACEi ARB/diuretic (triple whammy AKI) and NSAID + low dose aspirin (GI) gate oral NSAID; deprescribe the offending drug pair
- Special pop:DEPRESCRIBING TRIGGER — new tendon pain on fluoroquinolone/aromatase inhibitor/statin triggers the deprescribing axis (stop/substitute or prescriber review) BEFORE escalating tendon treatment
- Avoid routine peritendinous corticosteroid worse long term recurrence (Coombes JAMA 2013 PMID 23385272; Kongsgaard 2009 PMID 19793213)
- Never intra tendinous corticosteroid injection (rupture risk)
- Do not default to surgery before an adequate loading trial (Cook/Rio 2016 PMID 27127294)

Monitoring

Regimen monitoring:
- site outcome VISA-A VISA-P PRTEE VISA-G and load tolerance q6-12wk (ICON 2019 Scott PMID 31399426)
- pain-monitoring model during continued loading (Silbernagel 2007 PMID 17307888)
- NSAID renal GI CVD safety review each visit (calc.ckd epi 2021)
- corticosteroid injection count tracked against ceiling if ever used (Coombes JAMA 2013 PMID 23385272)
- re-phenotype or image if no progress after adequate loading trial (Cook/Rio 2016 PMID 27127294)

Setting (outpatient) monitoring:
- Site outcome (VISA-A/VISA-P/PRTEE/VISA-G) + load tolerance reassessed q6–12 wk; expect slow recovery (ICON 2019 Scott PMID 31399426)
- Pain-monitoring model during continued loading (Silbernagel 2007 PMID 17307888)
- NSAID renal/GI/CVD safety review each visit (calc.ckd_epi_2021) (JOSPT Lateral Elbow 2022 Lucado)
- Delayed-rupture surveillance after fluoroquinolone; medication-safety flag persisted (Sangiorgio 2024 PMID 38949172)

Follow-up plan: 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)
- Close-out criterion: Long-term loading self-management + return plan + drug-avoidance counselling in place

Monitoring phase: Track validated site outcomes (VISA-A Achilles, VISA-P patellar, PRTEE lateral elbow, VISA-G gluteal) and load tolerance using the pain-monitoring model (Silbernagel 2007 PMID 17307888); expect SLOW recovery (≥3 months loading at most sites); NSAID renal/GI/CVD safety review (calc.ckd_epi_2021); enforce any corticosteroid-injection ceiling; confirm offending-drug deprescription and screen for delayed rupture after fluoroquinolone (van der Linden 1999; Sangiorgio 2024)

Disposition

Current setting: outpatient — Frame the continuum, phenotype by site + stage, screen the cannot-miss mimics (rupture / enthesitis / infection / drug-induced), deliver education + progressive loading as first-line, gate analgesic/adjunct restraint by comorbidity, deprescribe the offending drug, and defer surgery to last-line (JOSPT Achilles 2018/2024; JOSPT Lateral Elbow 2022 Lucado; ICON 2019 Scott)

Disposition criteria:
- Continue outpatient progressive-loading-first management with scheduled review (ICON 2019 Scott)
- Urgent orthopaedic referral for suspected complete tendon rupture (JOSPT Achilles 2018 Martin)
- Route to rheum.axial-spondyloarthritis.core.v1 for inflammatory enthesitis; msk.shoulder-pain.core.v1 for cuff overlap

Escalation triggers (move to higher acuity):
- Sudden pop + loss of push-off / palpable gap / positive calf-squeeze → urgent orthopaedic referral (complete rupture) (JOSPT Achilles 2018 Martin)
- Inflammatory rhythm + multi-site enthesopathy + psoriasis/IBD/uveitis → route rheum.axial-spondyloarthritis.core.v1 (ICON 2019 Scott)
- Hot, systemically unwell tendon/bursa → ED for infection (septic bursitis/tenosynovitis)
- Tendon pain on a fluoroquinolone (esp. ofloxacin) with renal failure / glucocorticoid / age >60 → stop drug + restrict loading + rupture surveillance (Sangiorgio 2024 PMID 38949172)
- No progress after a long adequate loading trial → surgical opinion (last-line) (Cook/Rio 2016 PMID 27127294)

Patient Action Plan

**Tendinopathy self-management + progressive-loading plan**
Personalised values: tendon_site, loading_programme, comorbid_CKD_GI_CVD, offending_drug_flag.

**Improving with loading** (green):
Triggers:
- 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
Actions:
- 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

**Not improving / persistent pain** (yellow):
Triggers:
- 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
Actions:
- 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)
Contact provider when:
- 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)

**Cannot-miss / urgent** (red):
Triggers:
- 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
Actions:
- 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)
Contact provider when:
- 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)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Hot, exquisitely tender, rapidly swelling tendon/bursa with systemic illness or fever (septic bursitis / tenosynovitis)
- [SEVERE] 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)
- [SEVERE] 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)

Citations

- 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 [PMID:18812414](https://pubmed.ncbi.nlm.nih.gov/18812414/)
- Cited evidence (PMID 27127294) [PMID:27127294](https://pubmed.ncbi.nlm.nih.gov/27127294/)
- Cited evidence (PMID 31399426) [PMID:31399426](https://pubmed.ncbi.nlm.nih.gov/31399426/)
- Cited evidence (PMID 29712543) [PMID:29712543](https://pubmed.ncbi.nlm.nih.gov/29712543/)
- Cited evidence (PMID 29712549) [PMID:29712549](https://pubmed.ncbi.nlm.nih.gov/29712549/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 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 — PMID:18812414
  • Cited evidence (PMID 27127294) — PMID:27127294
  • Cited evidence (PMID 31399426) — PMID:31399426
  • Cited evidence (PMID 29712543) — PMID:29712543
  • Cited evidence (PMID 29712549) — PMID:29712549