Tendinopathy Is Not Just a Tendon Problem

Tendinopathy is usually managed as a mechanical loading problem, but this review shows that psychological factors also matter. Across 21 studies involving 2,176 participants, people with tendinopathy were compared with people without tendon pain. The review examined depression, anxiety, pain catastrophising, kinesiophobia, self-efficacy, mental health, personality, sleep, stress, and related factors.

The clearest finding was that people with tendinopathy tended to report more pain catastrophising, poorer mental health, and, particularly in lower-limb tendinopathy, higher depression and anxiety. This was especially relevant for Achilles, gluteal, plantar fascia, proximal hamstring, and other lower-limb conditions, where pain may interfere with basic daily activities such as walking, standing, or running. In contrast, upper-limb tendinopathies showed less consistent psychological differences, perhaps because people can more easily avoid painful arm use.

Importantly, kinesiophobia—fear of movement—was not clearly higher in people with tendinopathy. This challenges the assumption that tendon pain follows the same fear-avoidance pathway often described in chronic low back pain. A patient may have negative thoughts, frustration, worry, or low mood without necessarily being afraid to move.

For therapists, this means assessment should go beyond pain location, load tolerance, and strength. Asking about mood, confidence, sleep, stress, beliefs about the condition, and how tendon pain affects daily life may reveal barriers to recovery. However, the review cautions against overinterpreting the evidence: study quality was generally low, and certainty of evidence was very low across all meta-analyses.

The practical message is not that every tendinopathy patient needs psychological treatment. Rather, therapists should avoid treating tendinopathy as purely structural. Some patients may need reassurance, education, graded exposure to activity, help reframing unhelpful beliefs, or referral for additional psychological support.

A patient-centred approach remains essential. For tendinopathy, the key psychological issue may not be fear of movement, but the broader burden of persistent pain: worry, frustration, low mood, reduced activity, and the sense that recovery is uncertain.