For years, chronic tendinopathy has been treated as a tendon problem — load it, strengthen it, remodel it. But what if, for some runners, the tendon itself isn’t 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 — not degeneration of the tendon tissue itself — 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 — especially runners stuck in repeated rehab cycles despite “doing everything right.”
This is early, evolving science. But it’s a fascinating glimpse into where chronic tendon treatment may be heading next.
What You’ll 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 “neural modification” treatments aim to do — and why they’re 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 tendon–paratenon 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:
👉 Modifying the neural (nerve-driven) pain environment around the tendon, rather than “fixing” tendon structure itself.
This doesn’t replace exercise-based rehab — 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.
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MEDICAL & EDUCATIONAL DISCLAIMER
The information provided in the Overcoming Proximal Hamstring Tendinopathy (PHT) Podcast, YouTube channel, associated websites, social media, and other educational content produced by Brodie Sharpe is provided for general educational and informational purposes only. It is not intended to constitute, and should not be relied upon as, individual medical, physiotherapy, diagnostic or treatment advice.
Although Brodie Sharpe is a qualified physiotherapist, consuming this content does not establish a physiotherapist-patient or other healthcare professional-patient relationship. Any discussion of symptoms, diagnoses, rehabilitation strategies, exercises, loading programs, running modification, medications, supplements, injections, medical procedures or other treatment options is general in nature and may not be appropriate for your individual circumstances.
Musculoskeletal pain can have multiple causes, and symptoms that appear consistent with proximal hamstring tendinopathy or another tendon disorder may arise from other conditions. Appropriate assessment, diagnosis and treatment depend upon an individual's medical history, symptoms, examination findings, medications, health conditions, training history and other factors that cannot be adequately assessed through general online content.
Do not use this content as a substitute for assessment, diagnosis or treatment from an appropriately qualified healthcare professional.
Before starting, stopping or substantially modifying an exercise or rehabilitation program, medication, supplement, injection, procedure or other treatment discussed in this content, seek advice from an appropriately qualified healthcare professional who can consider your individual circumstances.
Exercise, rehabilitation and medical treatments carry inherent risks. These may include increased pain, symptom flare-ups, aggravation of an existing condition, new injury, adverse reactions or other complications. Individual responses vary and no particular outcome, improvement, recovery timeframe or return to sport can be guaranteed. If an activity or intervention causes significant, unusual or worsening symptoms, stop and seek appropriate professional advice.
References to research, clinical studies, treatment approaches, products or opinions of guests are provided for educational purposes. Scientific evidence evolves over time, may be incomplete or conflicting, and findings from research populations may not apply to every individual. Discussion of a treatment or product does not necessarily constitute an endorsement or recommendation for its use. Views expressed by podcast guests or other contributors are their own and do not necessarily represent the views of Brodie Sharpe.
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If you believe you may have a serious injury or medical condition, or you develop severe, rapidly worsening or otherwise concerning symptoms, seek prompt assessment from an appropriately qualified healthcare professional. In an emergency, contact your local emergency service.