











































MANUSCRIPT TYPE


POINT-OF-CARE (PRACTICE CHARACTERISTICS) RESEARCH 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020 
 

Point-of-Care Research: Retrospective Analysis of the Evaluation and 
Classification of Tendon Pathology in Athletic Training 
Ashley J. Reeves, DAT, AT*; Russell T. Baker, PhD, DAT, AT, CMP, PRT-c*; Scott W. Cheatham, PhD, DPT, PT, 
OCS, AT, CSCS†; and Alan Nasypany, EdD, AT* 
*University of Idaho, Moocow, ID †California State University Dominguez Hills, Carson, CA  
 

 
ABSTRACT 

Tendon pathology has been studied across healthcare 
professions but remains poorly understood. Imaging and 
clinical findings have been used to diagnose tendon 
pathology, but these findings are discrepant. It is vital that 
clinicians use sound clinical judgment to determine the most 
accurate clinical diagnosis and treatment options given 
documented clinical findings. The purposes of this study were 
to assess athletic trainers’: 1) documented clinical findings for 
patients presenting with tendon pain, 2) use of documented 
findings to inform clinical diagnosis of tendon pathology, and 
3) change in tendon pathology classification when presented 
with a novel diagnostic term. A total of 430 patients (20.70 
± 7.35y) from a multisite research database were included 
in the study. Pain at the site of injury was documented in 
95.8% of cases (n = 412). Pain during exercise that changed 
activity (n = 274, 63.7%), and an identified tender point (n 
= 259, 60.2%) were also present in almost two-thirds of 
cases. Of the patients diagnosed with tendinitis, 35.0% had 
pain as the only documented inflammatory sign. Of the initial 
set of clinical diagnosis options, tendinopathy was the most 
commonly (n = 290, 67.4%) selected. There was a 46.0% 
and 15.0% decrease in the number of tendinopathy and 
tendinitis diagnoses, respectively, when ‘tendinalgia’ was an 
option as a diagnostic classification term. There does not 
appear to be adequate clinical evidence to label tendon 
pathology as either inflammatory or degenerative. 
Furthermore, clinicians either appear to be: 1) relying on few 
symptoms to identify a diagnosis or 2) not at first fully 
considering all clinical findings when diagnosing a patient. 
According to these findings, tendinalgia seems to be the most 
appropriate term to describe tendon pain, to help clinicians 
understand tendon pathology as a pain condition rather than 
as inflammatory or degenerative. 
 
Key Phrases 
Diagnostic testing, upper extremity, tendinopathy, clinical 
reasoning 
 
Correspondence 
Dr. Ashley Reeves, University of Idaho, 875 Perimeter Drive 
MS 2401 
Moscow, ID 83844. 
E-mail: reevesa@uidaho.edu  
 
 
 

Full Citation 
Reeves AJ, Baker RT, Cheatham SW, Naypany A. Point-of-
care research: Retrospective analysis of the evaluation and 
classification of tendon pathology in athletic training. Clin 
Pract Athl Train. 2020;3(2):33-44. 
https://doi.org/1031622/2020/0002.5.   
Submitted: August 1, 2019 Accepted: March 2, 2020 
 

INTRODUCTION 

Tendon pathology is a common problem among 

physically active individuals, but is poorly 
understood by researchers and clinicians alike.1-3 
Previously, pain at a tendon has been termed 
tendinitis or tendinosis, describing either an 
inflammatory or degenerative condition, 
respectively.3-6 Tendinitis involves signs and 
symptoms of inflammation, which include heat, 
redness, pain, swelling, and decreased function.3-

9 Clinicians grade tendinitis from first to third 
degree based on the severity and consistency of 
the patient’s symptoms.10 Generally, symptoms 
become progressively more persistent as the 
condition worsens, advancing from pain noted 
only after activity to more consistent pain and 
decreased performance.10 Even though tendon 
pain is often referred to as tendinitis, tendinosis 
may be a more correct description, as evidenced 
by the lack of inflammatory markers in histological 
studies.3,6,11 In contrast to tendinitis, which 
describes a primarily inflammatory condition, 
tendinosis describes changes in tissue integrity 
(i.e., degeneration) without signs of active 
inflammation.3-6,12,13 Tendinosis is categorized 
according to the assumed severity of the condition, 
with Stage I correlating to transient pathology 
and Stage II correlating with more lasting changes 
to less than half of the tissue structure.14 

Imaging studies (e.g., magnetic resonance imaging 
[MRI] and diagnostic ultrasound) provide further 

https://doi.org/1031622/2020/0002.5


Point-of-Care Research: Retrospective Analysis of the Evaluation and Classification of Tendon Pathology in Athletic Training 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

evidence of the potential inaccuracy of a tendinitis 
diagnosis, in which imaging findings are often 
uncorrelated to patient symptoms.3,15-23 For 
example, in a sample of 253 healthy, 
asymptomatic individuals ages 13-89 years old, 
65% of individuals had tissue abnormalities of the 
proximal hamstring tendon on MRI (13% 
unilateral, 52% bilateral).23 Of note, none of the 
participants had a history of hamstring 
pathology.23 In a second study, which involved 
ultrasound examination of 51 asymptomatic 
males, 96% had some form of pathological 
change to the rotator cuff.20 Of those individuals 
with positive findings, 75% had rotator cuff 
pathology, with the most commonly affected 
structure being the supraspinatus tendon (65% of 
total; 5 full thickness tears, 12 partial-thickness 
tears).20 These findings indicate that pathological 
changes to the tissue may not be the actual cause 
of a patient’s symptoms, if asymptomatic 
individuals have the same tissue abnormalities on 
imaging studies that would typically only be 
expected in symptomatic patients.3,15-23 

Due to these discrepancies, imaging has not been 
advocated as the most accurate form of 
assessment, nor does it increase the limited 
understanding of tendon pathology.3,15-23 Most 
often, tendon pathology is diagnosed clinically 
based on the patient’s pain narrative, previous 
history, and outcomes of pain provocation 
tests.3,10,24,25 Palpation may also identify pain, 
increased tendon thickness, and/or crepitus.3,25-29 
Pain upon palpation has been found to be 
reliable across multiple studies when identifying 
tendon pathology, especially when moderate to 
high levels of pain upon palpation are 
present.26,27,29 However, when moderate to high 
pain levels upon palpation and patient-reported 
symptoms were considered together, these 
findings were not an adequate predictor of 
positive imaging findings (p > 0.05).26 These 
findings again reinforce the idea that symptoms 
and tissue pathology are not always 
congruent.3,15-23,26 

As the uncertainty surrounding tendon pathology 
continues to increase across healthcare despite 
extensive research, alternate diagnostic 

classification terms, such as tendinopathy and 
tendinalgia, have been introduced.3,30,31 
Tendinopathy is an generic term to describe 
tendon pathology that presents with tendon pain 
and increased tendon thickness.3 Tendinopathy, as 
opposed to the previously used tendinitis or 
tendinosis, implies some type of tissue-based 
tendon pathology, without specifying a particular 
cause, reflecting the inconsistencies between 
imaging, histological, and clinical findings.3,11,15-23 
The newest term, tendinalgia, is an expansion of 
the term lateral epicondylalgia, originally coined 
by Waugh to describe pain at the anatomical 
location (i.e., lateral epicondyle) without 
indicating that abnormal changes in the tissue are 
the cause of the symptom presentation.30,31  

Patient outcomes further support the notion that 
actual tissue changes may not be the underlying 
cause of a patient’s symptoms. With respect to 
tendon pain, eccentric loading, which aims to 
create changes in tissue structure, is often 
incorporated into rehabilitation.3 However, 
according to a recent literature review, the use of 
eccentric exercise, though helpful for patient 
symptoms, did not result in a concomitant 
improvement in tendon thickness on imaging 
studies.32 If tendon pathology was primarily due 
to a tissue abnormality, eccentric exercise should 
have resulted in both a change in patient 
symptoms and tissue structure. These discrepancies 
give reason to question the traditional 
classifications of tendon pathology, many of which 
imply tissue-related causes of pain (e.g., tendinitis, 
tendinosis). Although treatments such as eccentric 
exercise may be effective for reducing patient 
symptoms, it does not appear that these 
treatments are having the hypothesized effect 
(i.e., change in tissue structure).3,32 This may 
indicate that tendon pain is actually due to a pain 
processing dysfunction rather than actual tissue 
pathology.3,33 Using a more general term like 
tendinalgia would free the clinician to treat the 
source of pain as a processing dysfunction rather 
than a tissue pathology.  

Due to the lack of consensus among imaging 
studies and patient outcomes, clinical assessment 
remains the primary strategy for evaluation and 



Point-of-Care Research: Retrospective Analysis of the Evaluation and Classification of Tendon Pathology in Athletic Training 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

diagnosis.3,15-24 However, limited data exists on 
healthcare providers’ evaluation findings. Most 
studies regarding tendon pathology have 
involved physical therapists and orthopedic 
surgeons, but the evaluation has often been 
standardized as part of a controlled study.26,27,29 

Moreover, there is little literature regarding the 
evaluation practices and reported findings of 
athletic trainers with respect to tendon pathology, 
even though tendon conditions are common in 
physically active individuals.1,2 Despite evidence 
negating the validity of imaging, and therefore 
the emphasis on clinical evaluation, it is unknown 
what athletic trainers are reporting from their 
clinical evaluations of patients with tendon pain. 
By extension, it is also unknown if athletic trainers 
are matching their clinical diagnoses to their 
reported clinical findings based on the current 
evidence and recommendations for tendon 
pathology. In order to maximize the likelihood of 
positive treatment outcomes for patients 
presenting with tendon pain, it is important to gain 
a better understanding of the current practices of 
athletic trainers to identify practices that facilitate 
optimal treatment choices and areas needing 
improvement. Therefore, the purposes of this study 
were to assess athletic trainers’: 1) documented 
clinical findings for patients presenting with 
tendon pain, 2) use of documented findings to 
inform clinical diagnosis of tendon pathology, and 
3) change in tendon pathology classification when 
presented with a novel diagnostic term. 
 
METHODS 
 
This study was a retrospective descriptive analysis 
of a research database created and stored in 
Qualtrics (Provo, UT, 2002). Athletic trainers 
currently pursuing their doctorate in athletic 
training contributed to the database for this 
multisite research study. Clinicians were practicing 
in a wide range of clinical settings and working 
with patient populations of various physical 
activity levels. Participating clinicians were asked 
to input de-identified patient data into the 
database for later analysis. Before entering data, 
patients signed an informed consent form to allow 
for the inclusion of de-identified information in the 

research database. The study protocol was 
approved by the University of Idaho Institutional 
Review Board.  
 
Procedures 
 
The database contained open-ended, multiple 
choice, and multiple select items pertaining to 
each portion of a standard clinical evaluation. To 
be included in the present study for retrospective 
analysis, patients had to present to the intake 
clinician with: 1) involvement of a specific muscle 
or tendon, 2) localized tendon pain, and 3) point 
tenderness over the involved tendon, as pain is 
one of the primary clinical symptoms that serve as 
a focus of treatment10,14,25 Due to the nature of the 
study, evaluations were not standardized. 
Clinicians were encouraged to perform their 
typical evaluation, which allowed for an authentic 
picture of typical athletic training practices in the 
evaluation of suspected tendon pathology.  
Clinicians were asked to enter data regarding 
patient history, which included, but was not limited 
to: 1) age, 2) patient sport or occupation, and 3) 
pain scores rated on the 0-10 Numeric Pain Rating 
Scale (NRS; i.e., current pain, pain at best within 
the past 24 hours, pain at worst within the past 24 
hours, pain at onset, and pain at rest). Clinicians 
also described pain characteristics based on the 
classifications set forth by Nirschl and Ashman 
regarding tendinosis and any objective findings 
(e.g., swelling, changes in tissue appearance, 
palpation findings, special tests performed, etc.) 
from the evaluation.14 It should be noted that 
although the classifications defined by Nirschl and 
Ashman are meant to describe the severity of 
pathology, and are therefore ordinal in nature, 
clinicians were allowed to choose more than one 
category based on patient presentation.14 
At the completion of the evaluation, clinicians 
identified a working clinical diagnosis based on 
their documented findings under two separate 
conditions. First, they chose from a list of 
traditionally recognized tendon pathologies (i.e., 
first-, second-, or third-degree tendinitis; first or 
second stage tendinosis; or tendinopathy). A 



Point-of-Care Research: Retrospective Analysis of the Evaluation and Classification of Tendon Pathology in Athletic Training 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

second question then asked them to classify the 
same tendon pain with tendinalgia, a more 
general term, added as a classification option to 
the previous list.  The definition of all diagnostic 
terms, including tendinalgia, had been previously 
operationally defined and provided to the 
clinicians involved in the study.    
 
Data Analysis  
 
Data were analyzed in Statistical Package for 
Social Sciences (Version 25.0, IBM, Armonk, NY) 
and Microsoft Excel (Version 16.16.10, Microsoft, 
Redmond, WA). Patient cases with missing clinical 
diagnoses were excluded from analysis to keep 
sample sizes equal across analyses and to 
facilitate comparisons across the data. If the text 
entry from an open-ended response was unclear, 
the data was classified as “unknown”. Means and 
standard deviations were calculated for patient 
age and pain scores. Frequencies and 
percentages were calculated for all other data to 
derive comparisons across documented clinical 
findings.  
  

RESULTS  

Patient Demographics  

A total of 430 patient cases involving a primary 
complaint of tendon pain were extracted from the 
database. On average, patients were 20.7 ± 7.3 
years old (range: 14-62 years old) and 
participated in over 20 different sports and/or 
activities. The five most common sports or activities 
included basketball (n = 75, 17.4%), track and 
field (n = 48, 11.2%), soccer (n = 45, 10.5%), 
football (n = 44, 10.2%), and baseball (n = 42, 
9.8%).  

Reported Clinical Findings  

Documented clinical findings are presented in 
Tables 1a-c. Pain at the site of injury was the most 
commonly documented clinical finding during 
evaluation (n = 412, 95.8%), followed by pain 

that changes activity (n = 274, 63.7%). The most 
commonly documented tissue changes included the 
presence of a tender point (n = 259, 60.2%), 
changes in tissue tension (n = 60, 14.0%), and 
changes in tissue thickness (n = 53, 12.3%), as 
determined from the clinician’s evaluation. 
Overall, 87.2% of patients (n = 375) had two or 
fewer documented signs of inflammation (i.e., 
pain, loss of function, local swelling, redness, 
and/or heat).7-9 A total of 103 individuals were 
diagnosed with some degree (i.e., first, second, or 
third) of tendinitis. Of these 103 individuals, 
35.0% (n = 36) had pain at the site of injury as 
their only documented sign of inflammation. 
Furthermore, pain and loss of function were the 
only documented signs of inflammation in 10.7% 
(n = 11) of these 103 cases. Finally, clinicians 
reported using at least one orthopedic special test 
(e.g., tests for structural integrity of the ligaments, 
joint capsule, musculotendinous unit, etc.), 76.7% 
(n = 330) of the time.  

 

 

Table 1a. Prevalence of Reported Inflammatory Signs 
Sign/Symptom Frequency (n) Percent (%) 
Pain 412 95.8 
Heat 45 10.5 
Redness 23 5.3 
Swelling 98 22.8 
Loss of Function 101 23.5 
   

Table 1b. Prevalence of Reported Tissue Changes 

Sign/Symptom Frequency 
(n) 

Percent 
(%) 

Spasm 34 7.9 
Trigger Point 44 10.2 
Tender Point 259 60.2 
Change in Tissue Tension 60 14.0 
Change in Tissue Texture 40 9.3 
Change in Tissue Tone 25 5.8 
Change in Tissue Thickness 53 12.3 
Change in Sensation 17 4.0 



Point-of-Care Research: Retrospective Analysis of the Evaluation and Classification of Tendon Pathology in Athletic Training 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

 
Pain Descriptions 

Using the pain characteristics defined by Nirschl 
and Ashman, clinicians documented that 63.7% (n 
= 274) of patients experienced pain that 
changed their activity, and patients reported 
that their pain after activity resolved within 24 
hours in 34.4% (n = 148) of cases.14 Pain scores 
were also recorded for each patient. The ‘worst’ 
pain ranged from 2/10 to 10/10 for all 
patients, with the average worst pain being 6.7 
± 1.7 points. Current pain across the entire 
sample averaged 3.2 ± 2.2 points, and overall 
average pain (i.e., averaged current, best, and 
worst scores) ranged from 0.7 to 9.0, with a 
sample average of 4.0 ± 1.5 on the NRS. 
Descriptive statistics for NRS scores are provided 
in Table 2. 

Classification of Tendon Pathology 

Clinician classifications of tendon pathology 
based on reported clinical findings are 
presented in Table 3 and Figure 1. Without 
tendinalgia as a classification option, the most 

common clinical diagnosis was tendinopathy (n = 
290, 67.4%), with the second most common 
being some degree (i.e., first, second or third) of 
tendinitis (n = 103, 23.9%). When tendinalgia 
was added as a classification option, there was 
a 46.0% decrease in the number of cases 
classified as tendinopathy, and tendinalgia 
instead became the most common diagnosis (n = 
272, 63.3%). Of the 103 patients originally 
diagnosed with some degree of tendinitis, 51.5% 
(n = 53) of those diagnoses were switched to 
tendinalgia when this was an option. 
Furthermore, of the 290 (67.4%) cases originally 
diagnosed with tendinopathy, 125 individuals 
(43.1%) were given a final diagnosis of 
tendinalgia. 

 

 

  

Table 1c. Prevalence of Reported Pain Patterns 

Sign/Symptom 
Frequency 

(n) 
Percent 

(%) 
Pain Post-Exercise - 
Resolves in <24 Hours 

148 34.4 

Pain Post-Exercise - 
Resolves in >24 Hours 

83 19.3 

Pain Post-Exercise - 
Resolves with Warm-Up 

31 7.2 

Pain During Exercise - 
Does Not Alter Activity 

101 23.5 

Pain During Exercise - 
Does Alter Activity 

274 63.7 

Pain with Heavy ADLs 126 29.3 
Pain with Light ADLs but 
Intermittent at Rest 

116 27.0 

Constant Pain at Rest 
that Disturbs Sleep 

38 8.8 

Categories adapted from Nirschl and 
Aschman15 Table 2. Pain Scores 

Pain Score Mean ±SD Minimum Maximum 
Onset 4.8 2.1 0.0 10.0 
Rest 1.8 1.8 0.0 8.0 
Current 3.2 2.2 0.0 10.0 
Best 2.0 1.9 0.0 8.0 
Worst 6.7 1.7 2.0 10.0 
Averagea 4.0 1.5 0.7 9.0 
aAverage = Avg(Current,Best,Worst) 

Table 3. Classification of Tendon Pathology with and 
without Tendinalgia as an Option 
 Without With 

Classification Frequency (n) Frequency (n) 
Tendinitis 103 38 
     First Degree 78 27 
     Second Degree 23 9 
     Third Degree 2 2 
Tendinosis 37 28 
     Stage I 28 17 
     Stage II 9 11 
Tendinopathy 290 92 
Tendinalgia N/A 272 



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CLINICAL APPLICATION 

Through the analysis of patient data included in a 
broader patient outcomes database, the 
frequency of various documented clinical findings 
in patients presenting with tendon pathology in 
athletic training clinics was assessed. This study 
also aimed to evaluate the clinical diagnoses 
chosen by athletic trainers based on these 
findings. Finally, changes in clinical diagnosis were 
evaluated with the introduction of the term 
tendinalgia, which has been proposed as an 
alternate term to account for the discrepancies 
currently surrounding tendon pathology.3,11,15-

23,30,31 

In the present study, the three most frequently 
documented clinical signs and symptoms were all 
related to pain (i.e., pain at site, 95.8%; pain that 
changes activity, 63.7%; tender point, 60.2%). 
Theoretically, because localized pain over the 
involved tendon was part of the inclusion criteria 
for the present study, pain at the site of injury 
should have been reported for all patients, rather 

than only 95.8%. These inconsistencies could be 
due to: 1) different interpretations of the 
definitions between inclusion criteria and clinical 
findings, 2) failure to evaluate for the presence of 
pain at the site of injury, or 3) clinician error in 
reporting findings. Regardless of the reason, a 
primary finding of pain is consistent with the 
tendency for individuals to continue activity 
despite pain, only seeking treatment as the 
condition worsens to the point that they can no 
longer participate in physical activity at their 
desired level.3,6,24 The average reported pain 
scores from the present study (current pain: 3.2 ± 
2.2; worst pain: 6.7 ± 1.7) also support this 
pattern. Pain scores at initial evaluation (i.e., 
current) were high enough to allow for a decrease 
of at least one minimal clinically important 
difference on the NRS (i.e., 2 points), meaning 
patients would be able to identify a difference in 
pain after treatment, thereby giving them reason 
to seek care.34 

Point tenderness and the general pain 
characteristics found in the present study were 

0.0

67.4

2.1

6.5

0.5

5.3

18.1

63.3

21.4

2.6

4.0

0.5

2.1

6.3

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0

Tendinalgia

Tendinopathy

Tendinosis - Stage II

Tendinosis - Stage I

Tendinitis - Third Degree

Tendinitis - Second Degree

Tendinitis - First Degree

Percent (%)

With Tendinalgia Without Tendinalgia

Figure 1. Classification of Tendon Pathology from Reported Clinical Findings 



Point-of-Care Research: Retrospective Analysis of the Evaluation and Classification of Tendon Pathology in Athletic Training 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
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representative of clinical presentations outlined in 
the literature, but clinical diagnoses did not 
always align with documented signs and 
symptoms.3,6,10,13,14,28 For example, tendinitis was 
the second most common diagnosis when 
tendinalgia was not given as an option, and over 
one-third of patients had pain as the only 
documented inflammatory sign of the five cardinal 
signs of inflammation. However, pain by itself 
does not indicate a primarily inflammatory 
condition. Patients with tendon pathology often 
present with pain, but histological and imaging 
studies do not always support the presence of 
inflammation within the tissues.3,6,10,11,14,24-27 
Therefore, pain – without other key signs or 
symptoms of inflammation – cannot conclusively 
indicate an inflammatory condition. 

Loss of function was the second most documented 
sign of inflammation. However, because pain can 
affect movement, loss of function may be a 
notable finding regardless of the nature of the 
pathology (e.g., inflammatory, degenerative, 
etc.).35 Just over 10% of individuals diagnosed 
with tendinitis had pain and loss of function as 
their only signs of inflammation. Therefore, the 
accuracy of many of the tendinitis diagnoses in the 
present sample is questionable, though it could be 
argued that clinicians were aware of this 
possibility. Two-thirds of patients originally 
diagnosed with tendinitis were eventually 
diagnosed with tendinalgia when this was an 
option. It seems clinicians may not be using their 
documented findings to inform their clinical 
diagnoses when using a common, generic term like 
tendinitis or tendinopathy. This disconnect is a 
potential problem because if clinicians label a 
condition as inflammatory, they should also be 
choosing treatments that directly affect the 
inflammatory process, but the patient may not 
optimally benefit from treatment if the tendon 
pain is not truly inflammatory in nature.3,11,24,25 

It is also important to ask why clinicians, who 
originally diagnosed their patients with tendinitis 
but then changed their diagnosis to tendinalgia, 

did not originally choose tendinopathy, as 
tendinopathy is at least a more general term.3 In 
identifying tendinalgia as their final diagnosis, it 
could be argued that clinicians demonstrated their 
understanding of the obscurities of tendon 
pathology described in the literature.3,11,15-23,30 
Under this premise, tendinopathy would have 
been a more representative term given the first 
group of diagnostic options (i.e., without 
tendinalgia).3 These discrepancies could be due 
to: 1) clinician error in data entry, 2) failure to 
report clinical findings that were actually present, 
and/or 3) failure to consider the implications of 
all reported clinical findings. If clinicians are not 
considering the interrelatedness of all documented 
findings, diagnoses could be misled, again 
increasing the risk for ineffective treatment.24,25 

Similar arguments could be made for the 
observed number of tendinosis diagnoses in 
relation to reported signs and symptoms. 
Increased tissue thickness was documented 12.3% 
of the time, but Stage I and Stage II tendinosis 
were only diagnosed in 8.6% of cases. Because 
the presence of tissue thickening was less than the 
number of tendinosis diagnoses, clinicians may, in 
this case, have considered this one sign in 
conjunction with the rest of their clinical findings, 
rather than considering it in isolation. In contrast, 
Nirschl and Ashman have also identified that 
lateral elbow tendinosis is most common in 
individuals in their thirties to fifties, but the 
majority of the patients included in the present 
study were younger.14 Therefore, the likelihood of 
true tendinosis in the present study is less 
probable, given the average age was just over 
20 years old. Considering the average age of 
individuals in this study, along with the fact that 
imaging studies were not performed, ultimately 
bring into question the accuracy of the tendinosis 
diagnoses, and instead reinforce the use of terms 
tendinopathy or tendinalgia.  

Despite the patterns noted previously in clinicians’ 
classifications of tendon pathology, with 67.4% of 
patients being diagnosed with tendinopathy, 



Point-of-Care Research: Retrospective Analysis of the Evaluation and Classification of Tendon Pathology in Athletic Training 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

diagnoses generally seemed to reflect the lack of 
understanding of tendon pathology described in 
the literature.3,11,15-23,30 Moreover, when the term 
tendinalgia was added, there was a 46.0% 
decrease in the number of tendinopathy 
diagnoses, and a 15.0% decrease in tendinitis 
diagnoses. Specifically, 178 total classifications 
were switched from tendinitis or tendinopathy to 
tendinalgia. The large shifts in clinical 
classification to tendinalgia may reflect the lack 
of accurate understanding of tendon pathology. 
Or, it may indicate that clinicians are not 
effectively using their clinical findings to inform 
their initial working diagnosis. Under the 
assumption of the former, this could imply that 
tendinopathy may even be misleading in both 
describing the nature of tendon pathology and 
determining treatment choices. Of note, 125 of 
the 290 original tendinopathy cases were 
changed to tendinalgia when this term was 
included as a possible diagnosis. Perhaps the use 
of the term tendinalgia more accurately describes 
the current level of knowledge and primary 
findings regarding tendon pathology. 
Specifically, these findings suggest that tendon 
pain is the only consistent finding, and clinicians 
must perform more through examinations to 
determine the root cause of the tendon pain.  

This exploratory study has several implications for 
clinical practice. There is a need for 
comprehensive evaluation of tendon pathology if 
clinicians are to more fully understand how these 
types of conditions manifest clinically and what 
causes, other than local tissue inflammation or 
degeneration, may be the cause of the patient’s 
root dysfunction. According to numerous imaging 
studies, tissue changes can often occur without 
symptoms.3,15-23 For patients presenting with pain, 
this indicates that degenerative or inflammatory 
changes noted with imaging may not actually be 
the cause of a patient’s symptoms. Moreover, if 
observable changes in tissue structure that appear 
on imaging studies do not match a patient’s 
symptoms – or lack of symptoms – then clinical 
findings, which indirectly indicate the nature of 

pathology through observation of inflammatory 
signs and pain provocation, may not give clinicians 
much further information about a patient’s 
pain.3,15-25 This idea was supported in the present 
study, with many clinicians ultimately diagnosing 
their patients with tendinalgia, simply indicating 
pain at the tendon.30,31 These findings reinforce 
the need for detailed evaluation to determine 
local and regionally interdependent causes of 
pain and dysfunction that may result in localized 
tendon pain instead of treating local tissue 
pathology alone.24,25,35,36 Thus, more general 
terms, such as tendinalgia, may be more 
appropriate when classifying and labeling tendon 
pain.  

The lack of understanding of the nature of 
pathology, and the possibility that clinical 
diagnoses do not accurately represent these 
pathologies, is not uncommon. There is evidence 
that the same is true for lateral ankle sprains, 
range of motion limitations, and meniscal lesions, 
in which tissue is the supposed cause of the 
dysfunction.36-38 The tissue model hypothesis has 
not been supported across any of these 
pathologies because the time to discharge, 
change in function, and/or resolution of pain was 
faster than the time that would be necessary for 
true tissue healing and/or changes to have 
occurred.36-39 While the present study did not 
include a treatment component, similar questions 
could be raised about the actual cause of tendon 
pain. In a case study performed by Baker et al., 
a patient presenting with reactive tendinopathy of 
the proximal biceps tendon was pain-free and 
discharged after three days of manual therapy 
treatment, with no return of symptoms after 
resuming physical activity.30 If the patient had 
reactive tendinopathy, which implies pathological 
tissue changes, it should have taken longer for 
symptoms to be eliminated, and would have most 
likely required intermittent rest during training to 
avoid the return of symptoms.25,39 Therefore, at 
this point in time, it does not seem appropriate for 
clinicians to confidently label tendon pathology 
based on the tissue model hypothesis. Instead, it 



Point-of-Care Research: Retrospective Analysis of the Evaluation and Classification of Tendon Pathology in Athletic Training 
 

 

41 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

seems most acceptable to describe suspected 
tendon pathology as pain manifesting near a 
tendon, which is best captured with the term 
tendinalgia. At the very least, clinicians should 
acknowledge the limitations in the clinical 
understanding of tendon pathology, and 
subsequently treat patients accordingly. Terms 
such as tendinalgia may help remind clinicians to 
treat the patient’s pain as it presents, rather than 
treating under the assumption of an inflammatory 
or degenerative condition without evidence to 
support these notions.  

Limitations 

While the limited understanding of tendon 
pathology that exists across healthcare has been 
reinforced, the present study does have 
limitations. Several possible patterns were not 
assessed, including how patients may differ in 
clinical presentation based on sport or occupation, 
age, or sex, nor how clinicians may differ in their 
clinical diagnoses based on years of experience 
or other factors. Additionally, data analyzed 
within the database did not allow for assessment 
of whether or not the sign or symptom was 
assessed. It is possible that a sign or symptom was 
assessed but was not reported because it either 
was not present or was not documented by the 
clinician inputting the examination. Therefore, 
limitations and inaccuracies may exist within the 
data due to clinician error. However, the goal of 
the present study was to assess everyday clinical 
practice. Thus, completely accurate results with 
solely clinician judgment will be difficult to obtain 
no matter the nature of the study, so long as 
researchers and clinicians are only analyzing 
daily clinical practice without confirmation from 
imaging or other histological studies. In the future, 
it would be beneficial to assess: 1) patient 
presentation stratified by various demographic 
factors, 2) factors that affect clinician choice in 
diagnosis, and 3) the relationship between clinical 
diagnosis and treatment. Gaining a better 
understanding of the clinical presentation of 
tendon pain and clinical reasoning may 

subsequently lead to improved treatment 
decisions and patient outcomes.  

CONCLUSION  

According to the present study, the most frequent 
symptom of tendon pathology appears to be the 
presence of pain (e.g., at the site of injury, during 
activity, etc.). Given the discrepancies in tendon 
pathology diagnosis and imaging results, clinicians 
must critically analyze patient presentation to 
identify an appropriate clinical diagnosis and 
subsequent treatment plan. Understanding of the 
term tendinalgia, like the previously introduced 
term of lateral epicondylalgia, may be more 
relevant to clinicians to improve the documentation 
of clinical findings, diagnostic classification, and 
the matching of treatments to address causes of 
pain. Specifically, patient outcomes may be 
improved if clinicians operate under the premise 
that tendon pathology is a pain-related condition, 
rather than treating from the perspective that 
there are inflammatory or degenerative changes 
within the tissue.  

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All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

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