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For years, chronic tendinopathy has been treated as a
tendon problem โ load it, strengthen it, remodel it. But what if, for some runners, the tendon itself isnโt the main driver of pain anymore?
In this episode, Brodie breaks down a new 2026 systematic review that may reshape how we think about stubborn, long-standing tendon pain. The paper explores whether nerve ingrowth and abnormal blood vessels around tendons โ not degeneration of the tendon tissue itself โ may be the real pain source in chronic cases.
We unpack the emerging research, explain each intervention in plain language, and discuss who this may (and may not) apply to โ especially runners stuck in repeated rehab cycles despite โdoing everything right.โ
This is early, evolving science. But itโs a fascinating glimpse into where chronic tendon treatment may be heading next.
What Youโll Learn in This Episode
- Why some chronic tendon pain may be neuropathic (nerve-driven) rather than structural
- How abnormal blood vessels and nerves grow into painful tendons over time
- Why traditional loading programs sometimes stop working in very chronic cases
- What โneural modificationโ treatments aim to do โ and why theyโre gaining interest
- The six intervention categories reviewed in the paper (explained simply)
- How strong (or limited) the current evidence actually is
- Where this research fits alongside exercise-based rehab, not against it
Interventions Reviewed (Plain-English Overview)
1. High-Volume Injections (HVIGI / HVDI)
Large volumes of fluid are injected around the tendon (not into it) under ultrasound guidance to mechanically disrupt abnormal blood vessels and pain-sensitive nerves.
Key takeaway:
Consistent short- to medium-term pain and function improvements, especially in people who had failed exercise-based rehab.
2. Sclerosing Polidocanol Injections
A chemical agent is injected directly into abnormal blood vessels to deliberately close them down, cutting off blood supply to pain-producing nerves.
Key takeaway:
Moderate to strong pain reductions in very chronic cases, with outcomes comparable to surgery in some studies.
3. Radiofrequency Microtenotomy
A minimally invasive procedure using controlled heat to disrupt nerve ingrowth and abnormal vessels at the tendonโparatenon interface.
Key takeaway:
Very strong results in a small cohort, but higher risk and limited evidence so far.
4. Minimally Invasive Paratenon Release
Scar-like adhesions between the tendon and surrounding tissue are mechanically released to restore tendon movement and reduce nerve irritation.
Key takeaway:
Large pain reductions and high rates of pain-free outcomes in non-insertional Achilles tendinopathy.
5. Electrocoagulation Therapy
Electrical energy is used to seal off abnormal blood vessels surrounding the tendon under ultrasound guidance.
Key takeaway:
Promising early results, but evidence limited to one small study.
6. Surgical Interventions (Open & Endoscopic)
Surgery physically separates the tendon from irritated surrounding tissue and removes abnormal vessels and nerves.
Key takeaway:
Effective for some, but invasive, with longer recovery and higher risk.
The Big Picture Takeaway
Across very different procedures, outcomes were surprisingly similar.
That points to a common mechanism:
๐ Modifying the neural (nerve-driven) pain environment around the tendon, rather than โfixingโ tendon structure itself.
This doesnโt replace exercise-based rehab โ but it may explain why a subset of runners with long-standing, highly sensitive tendinopathy stop responding to load alone.
This research is best viewed as a future direction, not a replacement for good rehab principles.