Tendinopathy loading programmes: how graded exercise rehabilitation works

A tendon adapts to load. When the load is suddenly raised, or the tendon is under-conditioned for what it is asked to do, it can become painful and thickened. A loading programme reverses that gradually by giving the tendon a measured amount of work, increasing it over weeks, and watching how the tendon responds.

The official UK pages used here do not publish detailed exercise tables, repetitions or weekly progressions, and they differ by tendon. This guide therefore describes principles rather than a prescription. A physiotherapist chooses the exercises, because the right type and speed depend on which tendon is affected and how irritable it currently is.

NHS inform is direct on this for the Achilles: it does not improve with rest, and normal daily activity with modifications is recommended. For soft tissue injuries in general, it says too much rest can slow recovery and that movement should start as soon as possible.

Rest settles pain temporarily but leaves the tendon less able to cope when activity resumes, so symptoms often return. The alternative to rest is relative rest: continuing everyday activity while reducing the specific movements or volumes that clearly provoke the tendon.

NHS inform describes a pain scale that fits tendon rehabilitation well. Activity should sit around 4 to 5 out of 10 for pain, should ease quickly afterwards, and should be no worse the next morning. If pain exceeds 6 out of 10 during activity, reduce intensity, pace or frequency. For the Achilles it says short-term pain that returns to usual within a few hours is acceptable.

This lets a person adjust the programme day to day without needing a clinician at every step. If pain is regularly above the guide, the load is too high. If it is minimal and settles instantly, there may be scope to progress, ideally with advice.

• Pain during exercise in the acceptable range is not in itself harmful.

• Pain that is worse the following morning suggests the previous day was too much.

• Change one thing at a time: weight, repetitions, speed or frequency.

• Keep a simple log so you can see trends over weeks.

For tennis elbow, NHS inform stresses activity modification, adjusting grip or lifting, reducing carried weight, taking breaks and starting an exercise programme. For subacromial pain syndrome, which involves the rotator cuff tendons, it describes targeted stretching and strengthening and says gradual return to work aids recovery. The NHS gives physiotherapy with stretching and strengthening for tennis elbow after unsuccessful home care.

Each of these tendons has its own page in this guide set. The shared idea is that a tendon with pain is not fragile in the way a broken bone is: appropriate load is part of the treatment. The kind of load, such as a slow strengthening movement versus a stretch, is what a physiotherapist selects.

NHS inform says over-the-counter painkillers can make movement more comfortable, which supports exercise. For tennis elbow it describes limited evidence for elbow supports, and says corticosteroid injections may be considered if other measures fail but have limited benefit, with concern about tendon damage. Arthritis UK says steroid injections give short-term relief only for elbow tendon pain and notes platelet-rich plasma injections are described as promising.

Heat or ice can be used for comfort, for no longer than 20 minutes at a time with a barrier to protect the skin, according to NHS inform. They are comfort measures rather than a treatment of the tendon.

NHS inform advises seeking help if Achilles symptoms are not improving within 12 weeks or are getting worse, and for subacromial shoulder pain if symptoms persist beyond 6 weeks or worsen. The NHS suggests seeing a GP for tennis elbow after at least 2 weeks of self-care without improvement, and mentions surgery as an option if symptoms persist after 6 to 12 months.

A sudden sharp pain with a snap, a gap in the tendon, or loss of strength after an injury is a different situation from gradual overuse and needs prompt assessment, because a tendon rupture is treated differently.