By Katie E. Golden, MD

Social distancing and quarantining have translated to considerable lifestyle changes for most of us, and along with all the other challenges presented by the pandemic, we have seen an increase in patients presenting with muscle and joint pain. More specifically, I have noticed an increase in patients who are experiencing pain from tendon irritation, a condition called ‘tendinopathy’. Tendinopathies are painful, nagging, and can occur in multiple different areas: shoulders, elbows, wrists, hips, knees, ankles. So let’s review what it is, why it happens, and what you can do to help keep your tendons healthy during your daily routine of endless zoom calls, at-home yoga, second grade math tutorials, or re-organizing your pantry for the 7th time this year.

What is tendinopathy?

A tendon is a thick piece of fibrous tissue that connects muscles to bone. The achilles tendon, for example, attaches the calf muscle (gastrocnemius) to the heel (calcaneus). They are made of connective tissue that is both flexible and strong. They contain nerves but significantly less blood vessels than muscle . . . this means when they are injured, they hurt like a strained muscle, but also take much longer to heal.

Tendinopathy used to be referred to as ‘tendonitis’, given they were presumed to be from inflammation in the tendon. This is different from a tear or rupture of a tendon, which suggests a disruption of the tissue, and often results from trauma. More recent analyses of painful tendons (from surgical biopsies) were more consistent with an abnormal healing response and scar tissue than inflammation, thus ‘tendonitis’ fell out of favor and ‘tendinopathy’ became the new hip term. (Hip! get it? who said anatomy wasn’t fun . . . )

Before we get too far into the weeds of a science lesson, tendinopathy can be simply defined as a persistent pain in a specific tendon that typically arrives from overuse or abnormal strain on the tendon.

Why does it develop?

A tendinopathy is typically an overuse injury, and results from repetitive use and ‘microtrauma’ to the tendon. Several factors can contribute to abnormal stress being placed on a tendon:

  • Recreational sports or repetitive exercise routines, particularly in patients over 35 (no one is calling your tendons old, however, they become less flexible as they age)
  • Changes in the body’s mechanics (weight gain or loss, injuries that place increased stress or mechanical load on nearby or opposing joints, normal variations in posture and body types such as hip width or high foot arch)
  • Hormonal changes (drops in estrogen levels, seen after a woman gives birth or during menopause, seem to pose a risk for tendon pain and abnormalities)
  • Chronic medical conditions (diabetes, high cholesterol, and kidney failure are all associated with increased risk of tendinopathy)
  • Medications (fluoroquinolone antibiotics, steroids, statins, and aromatase inhibitors are all guilty of increasing the risk for tendinopathy)

With your newly gained knowledge about tendons, you can make some guesses as to why COVID has led to increased cases of tendinopathy (by my own, unofficial, and anecdotal assessment). I suspect it may be due to a combination of increased time spent in less than ideal ergonomic positions (translation – sitting at desks, bodies bent over phones and zoom calls, non-stop Netflix marathons on the couch), repetitive movements in new home exercise routines (I’m looking at you, Peloton enthusiast), and last but not least, the undeniable contribution of psychosocial stress to musculoskeletal pain. And maybe too much time to think about new sources of pain or health threats.

What are the symptoms?

Tendinopathy tends to cause a persistent and nagging pain. It is often much more painful than a pulled muscle, and is particularly painful anytime the tendon is stretched or flexed. It is not an easy pain to ignore or ‘push through’. Additionally, it often starts spontaneously without any identifiable factor or cause. Patients often initially experience the pain only when the tendon is being used, and it can even subside once the body is ‘warmed up.’ In other words, you experience knee pain at the beginning of your run that tends to improve after 30 minutes or so (I know, who runs for more than 30 minutes?!). A common finding in tendinopathies, however, is that the pain returns several hours or the following day after the exercise. And with higher severity.

Tendinopathy can develop at any tendon, but is particularly prevalent in the following tendons:

  • Rotator cuff tendon (shoulder)
  • Extensor Carpi Ulnaris and Flexor Carpi Radialis (the top and bottom of the wrist)
  • Patellar tendon (knee)
  • Achilles tendon (the back of the ankle)


How is it diagnosed?

This condition is easily diagnosed based on symptoms and physical exam. In some cases, additional testing is obtained to rule out other causes of the pain. If so, abnormalities in the tendon can occasionally be seen on ultrasound or MRI. These tests, however, are often not obtained or necessary to make the diagnosis.

What is the treatment?

There is a lot of debate among experts on the best way to treat this condition. So here, I will present the treatments that all doctors can agree on:

  • Activity modification – strain on the affected tendon should be limited as much as possible.
  • Stretching – gentle stretching exercises that target the affected tendon are recommended. These should be done when the tendon is warmed (from a heating pad, shower, or exercise), and attention should be paid to avoid forceful stretching or overstretching.
  • Ice or Heat? – This is a common question from patients, and the truth is that neither seem to help (or hurt). That being said, don’t stretch the tendon after you have applied ice, and warming the tendon before stretching is advised.
  • Pain medication – Non-steroidal anti-inflammatory drugs (NSAIDs) often provide helpful pain relief (think ibuprofen or naproxen). Start with a topical cream rather than a pill, as this is often effective in these conditions, and avoids the side effects that can occur with the pills.
  • Physical therapy – targeted and progressive increase in resistance loading of the tendon has shown good results in alleviation of pain and return to activity, though this should be done with the instruction and guidance from a physical therapist.

It is important to note that, because of the limited blood flow to tendon tissue, healing and recovery can take several weeks to even months of treatment. So be patient with your body and give it time to heal. It’s good advice for all of us these days. And let’s be honest, we got time.