Why does chronic tendinopathy have fluctuating symptoms?

Chronic tendinopathy’s fluctuating symptoms—periods of worsening and improvement—arise from the complex interplay between tendon overuse, degenerative changes, and partial healing cycles.

Why Symptoms Fluctuate

• Overuse and Healing Cycles: Tendons endure repeated stress and microtrauma with activity, leading to small tears in their fibres. When rest or modification of activity occurs, some healing takes place, decreasing symptoms. When the tendon is stressed again, symptoms flare up.

• Reduced Tendon Tolerance: After injury, a tendon’s ability to tolerate load is lower. If activities exceed this reduced capacity before the tendon heals and strengthens, pain returns. Conversely, appropriate exercise and rest can temporarily raise this threshold, making symptoms subside.

• Degenerative Nature: Chronic tendinopathy—unlike acute inflammation—mainly involves collagen breakdown and degeneration (tendinosis). This makes tendons structurally fragile and slow to recover, leading to “good days and bad days” depending on recent load and healing status.

• Intrinsic Factors: Age, metabolic health (e.g., diabetes), and biomechanical factors can all slow healing and make symptom patterns more variable.

• Activity Changes: Sudden increases, changes, or decreases in physical activity, footwear, or technique can tip the balance between tendon load and capacity, causing symptoms to emerge or recede.

Fluctuating symptoms reflect the slow, incomplete healing of chronic tendinopathy. Periods of activity can cause overload and pain, while rest and rehabilitation allow partial tissue recovery—producing the characteristic cycles of better and worse days.