Tendon Healing: Why Rest Isn't Always the Answer

by osteopath Carien Boshoff

Experiencing tendon pain when running, lifting weights, playing sport or completing everyday activities?

Whether it's your Achilles tendon, knee, shoulder or elbow, tendon pain can be frustrating. You might find yourself avoiding activities you enjoy, reducing your training or wondering whether you should rest completely until the pain settles.

While rest and activity modification can play an important role in the early stages of an injury, prolonged rest isn't always the best approach to tendon rehabilitation.

Tendons connect muscles to bones and help transfer the forces needed for movement. They respond to the demands placed on them, which means finding the right balance between activity, recovery and progressive strengthening is an important part of managing many tendon conditions.

Let's explore how tendons respond to injury, why appropriate movement matters and how an osteopath can help guide you through the rehabilitation process.

What happens when a tendon is injured?

Following an acute tendon injury, the body begins a repair process commonly described in three overlapping stages.

1. Inflammatory phase

The inflammatory phase typically occurs during the first few days following an injury. During this stage, the body initiates an inflammatory response to clear damaged tissue and begin the repair process.

Common symptoms may include:

• Swelling around the injured area

• Increased sensitivity to movement

• Temporary reductions in strength or function

2. Proliferative phase

The proliferative phase begins within the first several days and may continue for several weeks. During this stage, the body produces new collagen to repair the injured tissue. Initially, these collagen fibres are relatively disorganised, meaning the developing tissue has a reduced capacity to tolerate high loads.

3. Remodelling phase

The remodelling phase can continue for several months or longer. During this stage, collagen fibres gradually reorganise, and the tendon continues adapting to the mechanical demands placed on it.

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These stages overlap, and the timeframes can vary depending on the type and severity of the injury.

It's also important to understand that not all tendon pain follows this traditional healing process. Tendinopathy, for example, is a common condition involving changes in the tendon and its ability to tolerate loading.

Why isn't rest alone enough?

Rest can be useful when a tendon is particularly irritated or following an acute injury. However, prolonged complete rest can lead to reduced muscle strength, conditioning and the capacity of the tendon and surrounding structures to tolerate physical demands.

Tendons respond to mechanical loading. Appropriate, progressive exercise can help improve muscle strength and the ability to tolerate everyday activities, exercise and sport.

For example, someone experiencing Achilles tendon pain when running may need to temporarily reduce their running distance, speed or frequency. However, depending on their symptoms and clinical presentation, they may still be able to perform modified strengthening exercises.

The aim isn't to push through significant pain or avoid movement altogether. It's about finding an appropriate level of activity that allows the tendon to be progressively challenged without repeatedly aggravating symptoms.

This is where understanding your individual injury, activity levels and current loading capacity becomes important.

How does progressive loading help?

Progressive loading involves gradually increasing the demands placed on a tendon as its capacity improves.

Rehabilitation may include:

1. Isometric exercises: Static muscle contractions that may provide a tolerable starting point for strengthening.

2. Isotonic strengthening: Controlled exercises such as calf raises, squats or resistance training to improve strength and loading tolerance.

3. Progressive resistance training: Gradually increasing resistance to improve muscle strength and functional capacity.

4. Activity specific exercises: Introducing activities such as running, hopping or jumping when appropriate.

Importantly, these stages aren't a fixed program that everyone needs to follow in the same order. Exercise selection and progression should be based on individual assessment and response to loading.

Does tendon pain always mean damage?

Not necessarily. Tendon pain does not always reflect the amount of structural damage present.

For example, tendinopathy is a common tendon-related condition associated with pain and reduced tolerance to loading. Unlike an acute tendon tear, chronic tendinopathy does not necessarily follow the traditional three-stage healing process.

Pain may be influenced by changes in activity, tendon capacity, strength and individual factors. This is why assessment should consider both symptoms and functional ability rather than imaging findings alone.

Where does osteopathy fit into tendon rehabilitation?

If tendon pain is affecting your ability to exercise, work or participate in everyday activities, an osteopath can assess your presentation and help you understand the factors that may be contributing to your symptoms.

Rather than focusing only on the painful area, an assessment may consider:

• Your injury history and when symptoms first developed

• The activities or movements that aggravate your symptoms

• Your current exercise routine and training load

• Strength, mobility and functional movement

• How your symptoms respond to activity and recovery

• Your personal goals, whether that's returning to running, lifting weights or simply walking comfortably

Based on the findings, management may involve several approaches.

Activity modification and education

Understanding which activities may need to be temporarily modified, and which can be continued, can help you maintain movement while managing tendon symptoms.

Individualised exercise rehabilitation

Your osteopath can help identify suitable strengthening exercises and guide you through gradual progression. This may include adjusting resistance, repetitions, frequency and exercise selection as your capacity changes.

Hands-on treatment

Depending on your presentation, hands-on osteopathic techniques may be used to address associated musculoskeletal discomfort or movement restrictions. These techniques may form part of a broader management plan alongside exercise and activity modification. They should not be considered a replacement for appropriate tendon loading and rehabilitation.

Return-to-activity planning

Returning to running, sport, gym training or physically demanding work requires more than simply waiting for pain to disappear. Your osteopath can help you consider strength, function, training demands and symptom response when planning a gradual return to activity.

Further assessment or referral

Not all tendon injuries can be managed through exercise and hands-on treatment alone. If your symptoms suggest a more significant injury, or further investigation is indicated, your osteopath can discuss appropriate referral options or recommend assessment by another healthcare professional.

The aim is to help you understand your injury, make informed decisions about your activity and develop a management approach suited to your individual needs and goals.

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Take home message

Tendon healing involves three overlapping stages: inflammation, proliferation and remodelling. While rest may help manage symptoms initially, tendon recovery isn't just about resting.

For many tendon conditions, appropriate progressive loading is an important part of improving strength, function and tolerance to activity. It's not about doing nothing or pushing through pain. It's about finding the right amount of movement and load at the right time.

An osteopath can assess your symptoms, help identify appropriate management options and guide you through exercise progression and a gradual return to the activities that matter to you.

If tendon pain is stopping you from running, exercising or doing the things you enjoy, book an appointment with our osteopaths to discuss your concerns and explore appropriate management options.

References

Darrieutort-Laffite, C., Blanchard, F., Soslowsky, L. J., & Le Goff, B. (2024). Biology and physiology of tendon healing. Joint Bone Spine, 91(5), 105696. https://doi.org/10.1016/j.jbspin.2024.105696

Martin, R. L., Chimenti, R., Cuddeford, T., et al. (2024). Achilles pain, stiffness, and muscle power deficits: Midportion Achilles tendinopathy revision 2024. Journal of Orthopaedic & Sports Physical Therapy, 54(12), CPG1–CPG32. https://doi.org/10.2519/jospt.2024.0302