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Issue 7

Table of Contents

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Biopsychosocial approach to tendinopathy

Dr. Joe Camoratto PT, DPT

Key takeaways:
  • Tendinopathy should not be treated significantly differently than other MSK presentations
  • Psychosocial factors may play a larger role in tendinopathy management than structural changes
  • Patient education should emphasize promoting patient empowerment and self efficacy


As always, we have much to get into. We even have a guest reviewer, Mark Doherty, that will be presenting the second article this month! There has always been a distinct air around tendon involved symptoms that seem to differentiate it from other symptoms. It always seemed more… physically involved. I’m not 100% sure why honestly, but there simply seemed to be an asterisk when considering tendon symptoms that didn’t exist with every other symptom.

I would educate patients on the biopsychosocial aspects of their low back pain or their subacromial pain syndrome or their anterior knee pain. But when I would get to patella tendinopathy, that wouldn’t be as pronounced. I would discuss how it was an overuse injury, how there is likely some degenerative process happening that we would need to strengthen up or insinuate that there was some local process we would need to focus on.

While this still may be true, the article that we are going through in this issue, Biopsychosocial approach to tendinopathy, illuminates much of the darkness that existed around tendinopathy treatment in a BPS world, and I’m ecstatic about it.

Getting down to brass tacks, the term tendonitis is outdated and we should move away from the use of that word entirely. The -itis insinuates an inflammatory process occurring, and that seems to not be the case in most tendon issues. Replacing this word with something like “tendon-involved symptoms” or the umbrella temr of tendinopathy would likely be better suited. That way we aren’t hinting at using rest, ice and NSAIDs as a first line intervention simply with the word we use to describe what’s going on.

Tendinopathy seems to be consistently involved in load related activities, which is hard to understand how else it would be involved considering that tendons transmit load from muscles to bones (except for the patellar tendon). What this consideration brings to mind personally is a quote that I heard in my earlier years of moving away form the church of under-loading patients:

“When load is the problem, load is likely also the solution” – Socrates (not really)

As with any presentation with the confines of my personal bias, exercise and loading programs are the first line intervention. The good part about the paper we are reviewing is that they also recommend this verbatim! Score one for confirmation bias.

“Exercise and loading programs remain the best evidence-based first-line management.” Keep this in the back of your mind as we wade through the rest of this paper.

If you haven’t heard before, tendinopathy can take as long as 12 months to resolve. Now if you don’t have tendinopathy, that might not seem like a really long time, especially if you are in the MSK world and know that it can be a process of patience and waiting for things to do what they will do.

When it’s being received from a patient’s perspective, 12 months is a substantial amount of time for something that they want gone yesterday. The long lasting nature of tendinopathy is one of the main factors of the negative psychological impact it can have. Considering a similar duration of presentation of persistent low back pain, we can partially extrapolate the disability and loss of quality of something like that can be brought to the table.

Mentioning something like persistent low back pain can actually serve as a good segway into tendinopathy, although lets linger on our understanding of something like persistent low back pain for a moment. We know that things like fear, anxiety, depression, a sense of hopelessness can all affect not only the presentation of persistent low back pain, but also the rehabilitation in and of itself.

The golem effect comes to mind, more readily known as a self fulfilling prophecy. Not only can these things exacerbate symptom presentation, but it can lead to suboptimal patient outcomes, decreased perception of ability to succeed, and low self efficacy. All this occurs without even getting into what is going on physically with the low back, if anything.

The only thing we need to do now is replace persistent low back pain with tendinopathy, and all of the same attributes apply. The paper does a fine job of pulling at the self-efficacy thread, which they define as the perception of their (the patient) ability to succeed in a particular situation. They spend almost an entire paragraph speaking on perceptions of success:

“In addition to self-efficacy, fear-avoidance beliefs have been shown to influence rehabilitation outcomes. The fear-avoidance model describes the interpretation of pain via maladaptive or adaptive pathways. It is commonly used to explain how psychological factors can influence the perception and development of chronic pain. Negative perceptions of pain can lead to a catastrophizing response within the maladaptive pathway. The resulting hypervigilance and disuse can develop into kinesiophobia, beginning a harmful cycle of chronicity, which has recently been highlighted in Achilles tendinopathy. In addition, hypervigilance and avoidance of physical activity can cause deconditioning of the MSK system, predisposing to further injury.”



While I could have reworded that, it seemed pretty great as it was. I do want to spend a little more time on the last sentence though. “Avoidance of physical activity can cause deconditioning of the MSK system, predisposing to further injury.” The reason being that this is a prevailing principle in almost all of the conversations I have around time spent in the clinic. How does deconditioning of the MSK system predispose someone to further injury?

Well stress swings in two different directions. The application of stress on someone can drive adaptation, influencing tissue tolerances and capacity. The other side of that coin is that the removal of stress can influence adaptation, but in a direction that decreases tissue tolerance and capacity. So as we spend time that is not physical activity, or we recommend doing less, for whatever reason, we are opening the patient up to increased risk of injury.

I have no problem sounding like an extremist in the sense of using physical activity as a first and foremost intervention for each and every MSK presentation one can think of due to this very context. Is the passive modality that you are giving to the patient that has terrible science to support it an ok way to utilize finite time with the patient who is not yet meeting the minimum requirements for physical activity? The requirements that we know decrease morbidity and mortality as well as non communicable chronic disease? Just because it makes them feel good in the short term? Or just because you’ve seen it work? OK, enough lingering there.

So why move away from a structural approach to tendon pain? Well, it seems that just like osteoarthritis, structural low back changes and acromial shape (to name a few), there is a poor connection between structural changes seen on imaging and how the patient presents.

“The structural changes seen on imaging of tendinopathic tendons often do not explain the response to exercise-led interventions, suggesting that physical factors are not the only influential component of rehabilitation. In fact, psychological factors may exert more influence over clinical outcomes than visible structural damage.”

So to poke a hole in some clinical reasoning here, why would we opt to utilize a structural narrative on a patient (get imaging, treat the donut not the hole, use heavy slow resistance to increase tendon strength) when it doesn’t seem to matter as much what the tendon structure is doing? Not only that, but the psychosocial factors might matter more. This is not to say that we should shy away from things like heavy slow resistance, but shifting the view as to the utility behind loading programs can help. There are two very different things communicated non verbally when load programs look like A) 3×10 sets of supine glute squeezes and B) 3×10 sets of 75% 1RM box squats. Not to mention the different health benefits accrued from them.

So if we want to minimize things like fear, anxiety, kinesiophobia and misconceptions about symptom etiology, patient education is going to be quite important. Let’s itemize a few things that should be on your list of things to educate about:

  • Pain is not exactly representative of tissue structure
  • Reframing misconceptions about what could be contributing to symptoms
  • It is ok to feel pain while performing a loading program
  • Loading programs are the gold standard
  • Loading programs must be followed consistently for success


The thing to remember about patient education is that it needs to come from a trusted source. No one takes advice from someone they don’t like or trust, and program consistency is a large issue, considering that only 50% of patients follow them. Building a relationship while simultaneously implementing things like what this paper mentions is key.

“A close working alliance is required to elicit patient understanding, identify barriers to implementation and understand the patient’s acceptable pain response.”

The end goal being patient empowerment and increased feeling of self efficacy. Patient empowerment is defined by the article as a scenario in which “the patient has the ability to largely self-manage their condition.” It is insinuated that this should be worked into patient education, setting expectations that the role of the provider in rehab is not one of an operator, but an interactor.



This does not mean however that the patient is left to their own devices, as most will choose rest over a more active management style. What this does mean is helping design a program that fits the context and avoiding things that are done to the patient, like most passive modalities. Luckily these are not first line recommendations for care anyway.

“With a wide range of treatments existing claiming to treat tendinopathy with varying efficacy, it is equally important to guide patients to ensure they do not become over-reliant on passive treatments while neglecting active loading plans.”

I know it seems like tendinopathy is floating around in its own little world, I hope that this review and paper can help to reign it back into the world of the BPS model of treatment. It’s easy to forget that there is an entire conscious human sitting in front of us and focus more so on their knee and its local dealings.

Consider that taking a step back, building rapport, designing a training program specifically for them and taking the time to educate them in a way to empower them and make them feel robust is a substantially better way to go about patient care. I know it doesn’t sound like a tall order, but you would be surprised by what is out there when you step outside of the bubble you are in. The same one that landed you in this research review.


  1. Edgar N, Clifford C, O’Neill S, et al. Biopsychosocial approach to tendinopathy. BMJ Open Sport & Exercise Medicine 2022;8:e001326. doi:10.1136/ bmjsem-2022-001326


Appropriate Reporting of Exercise Variables in Resistance Training Protocols: Much more than Load and Number of Repetitions

Mark Doherty

Key takeaways:
  • Resistance training is widely used to induce neural and structural adaptations such as muscle strength and muscle size
  • Resistance training adaptations generally follow a dose-response relationship where the dose (or stimulus) affects the response


Knowledge of resistance training program development is fundamental for coaches and clinicians. There are many variables that shape a resistance training program. Understanding how to manipulate these variables is important in maximizing outcomes. In this PDF, we will discuss the basics of programming principles and the manipulation of training variables to help you guide the training process.

Which factors should we consider?

Resistance Training Adaptations

Resistance training is widely used to induce neural and structural adaptations such as muscle strength and muscle size, respectively.

  • Neural, muscle strength: motor unit recruitment, synchronization and firing rate, decreased neuromuscular inhibition.
  • Structural, muscle size: muscle volume, cross sectional area, muscle architecture (e.g. fascicle elongation and/or fascicle angle widening), and reinforcement of the muscle–tendon complex.


These adaptations are dependent upon a number of variables that together formulate the training volume. Understanding these variables is a key factor for individual scaling of each resistance training exercise.

Within-Exercise Variables Affecting Resistance Training Volume

  • Load
  • Total Number of Repetitions
  • Repetitions to failure/Not to failure
  • Displacement/ROM
  • Time Under Tension
  • Concentric vs Eccentric vs Concentric-Eccentric phases
  • Internal vs External focus
  • Inter-set rest


Quantifying the volume of each exercise requires the specification of within-exercise variables further than the load and the number of repetitions. Using this comprehensive approach practitioners may quantify the volume of each exercise more effectively, and adjust variables to increase, equalize or decrease the stimulus induced by a single exercise.

Dose Response-Relationship

Resistance training adaptations generally follow a dose-response relationship where the dose (or stimulus) affects the response. Dosing too high may generate a negative response (fatigue). If the dose is too low there may be no response at all. But if the dose is *just right* it should generate a positive response. (Goldilox reference?)

What’s the most effective dose?

Dosing varies on an individual basis depending on a myriad of factors. We suggest a “start low, go slow” approach where exposure to greater doses of training are graded over time while monitoring response and adjusting training variables as needed.


  1. Coratella, G. Appropriate Reporting of Exercise Variables in Resistance Training Protocols: Much more than Load and Number of Repetitions. Sports Med – Open 8, 99 (2022). https://doi.org/10.1186/s40798-022-00492-1