It's Not Just the Tendon: The Surprising Psychological Profile of Persistent Tendinopathy
Key findings: 60-second read
- People with tendinopathy have higher pain catastrophizing - an exaggerated negative mental state in response to pain, which was elevated compared to those without tendinopathy.
- Depression and anxiety were higher in lower-limb tendinopathy - but not in upper-limb tendinopathy, possibly because lower-limb pain is harder to avoid during daily activities like walking.
- No difference in kinesiophobia (fear of movement) - contrary to the fear avoidance model, people with tendinopathy did not show elevated fear of movement compared to controls.
- No differences in general self-efficacy or personality traits - extraversion and neuroticism were similar between those with and without tendinopathy.
- The fear avoidance model may not apply to tendinopathy - the psychological profile of tendinopathy appears different from chronic low back pain, suggesting the need for different treatment approaches.
If you have ever dealt with persistent tendinopathy - whether it is in your Achilles, patellar tendon, rotator cuff, or elbow - it may evolve beyond a physical problem. It can affect your mood, your sleep, your confidence, and your ability to do the things you love.
A new systematic review and meta-analysis published in the Journal of Orthopaedic & Sports Physical Therapy (Mc Auliffe et al., 2025) has looked into this. The researchers analysed 21 studies involving 2,176 participants to compare psychological factors between people with persistent tendinopathy and those without.
The findings challenge some long-held assumptions about how psychological factors interact with tendon pain and have important implications for how we treat tendinopathy.
"People with tendinopathy had different psychological profiles than people without tendinopathy. Pain catastrophizing was elevated, and depression and anxiety were higher in those with lower-limb tendinopathy."
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Pain catastrophizing: higher in tendinopathy
Pain catastrophizing is defined as "an exaggerated negative mental state" in response to pain - essentially, the tendency to magnify the threat of pain, feel helpless about it, and dwell on it.
The meta-analysis found that people with tendinopathy had higher pain catastrophizing than those without tendinopathy. This effect was greater in lower-limb tendinopathy.
However, the authors caution that the difference was small - falling below minimal clinically important change scores - and may be due to the presence of pain rather than representing a truly maladaptive cognitive response.
What is pain catastrophizing?
Pain catastrophizing is not just "thinking negatively." It is a specific pattern of thinking characterised by magnification (exaggerating the threat of pain), rumination (being unable to stop thinking about pain), and helplessness (feeling unable to cope). It is a well-established predictor of poor outcomes in many pain conditions.
Depression and anxiety: lower-limb only
One of the most interesting findings was the site-specific nature of depression and anxiety.
For lower-limb tendinopathy (Achilles, patellar, gluteal, plantar fasciopathy, etc.), there was a small but significant difference in both depression and anxiety compared to controls.
For upper-limb tendinopathy (rotator cuff, lateral elbow), there were no significant differences in either depression or anxiety.
Why the difference? The authors suggest that lower-limb tendinopathies affect activities that are harder to avoid - like walking and standing. When pain is unavoidable during daily activities, the psychological burden may be greater. Conversely, upper-limb tendinopathies may be easier to "work around" by avoiding using the affected limb.
"Depression and anxiety were part of the psychological profile of those with lower-limb, but not upper-limb, tendinopathy. Pain with propulsive activities such as walking and running may make it difficult for those with lower-limb tendinopathy to avoid pain."
Kinesiophobia: no difference found
Kinesiophobia is an irrational fear of movement stemming from the belief that one is fragile or susceptible to injury. It's a central feature of the fear avoidance model in chronic low back pain.
Despite this, the meta-analysis found no difference in kinesiophobia between people with and without tendinopathy.
This is a significant finding. It suggests that the fear avoidance model - which proposes a sequential progression from pain catastrophizing to fear of movement to avoidance and disability - may not apply to tendinopathy in the same way it does to chronic low back pain.
Key takeaway
"While people with tendinopathy appeared to have higher levels of pain catastrophizing than those without tendinopathy, people with tendinopathy do not necessarily go on to develop fear of movement. Kinesiophobia may not be the most important psychological factor to address in people with tendinopathy."
What this means for the fear avoidance model
The fear avoidance model has been hugely influential in chronic pain management. It suggests that pain catastrophizing leads to fear of movement, which leads to avoidance, which leads to disability and depression.
This study suggests that tendinopathy does not fit this model neatly. People with tendinopathy do catastrophise more - but they do not necessarily develop a fear for movement. This means that treatments developed for chronic low back pain based on the fear avoidance model may not translate directly to tendinopathy.
The authors suggest that a "fear network" with more complex interplays between pain and psychological variables might be a more appropriate model for tendinopathy - one where pain interference and depression interact differently than in low back pain.
Cause or consequence? What the study actually tells us
The big question I had when reading this research was as follows:
Was the psychological distress there before the tendinopathy, or did the tendinopathy cause the psychological distress?
Furthermore, would being a "catastrophiser" predispose someone to developing and tendinopathy?
The short answer is that this study does't really explore this. It was designed to compare psychological profiles between people who already have tendinopathy and those who do not - not to assess their mental state prior and see who went on to develop a tendinopathy.
However, the available evidence strongly suggests that the psychological differences observed are a consequence of living with persistent pain, rather than a predisposing factor that causes tendinopathy to develop.
Either way, I'm incredibly interested in whether this might be the case.
Key evidence for the "byproduct" interpretation:
- Site-specific findings: Depression and anxiety were elevated in lower-limb tendinopathy but not upper-limb tendinopathy. If psychological distress were a pre-existing cause, it is unclear why it would be specific to the location of the pain, rather than present in all groups with tendinopathy.
- Absence of fear: The fear avoidance model predicts that pain catastrophizing leads to fear of movement. Yet people with tendinopathy did not show elevated kinesiophobia. This suggests the psychological distress seen is a direct response to ongoing pain and functional limitations, not part of a pre-existing vulnerability.
The authors are careful to state that people with tendinopathy "had different psychological profiles," not that these profiles caused the condition. The most likely interpretation is that living with persistent tendon pain - especially when it interferes with unavoidable activities like walking - can take a psychological toll.
"The differences in psychological factors between those with and without tendinopathy may be due to factors other than tendinopathy diagnosis. However, the site-specific nature of depression and anxiety suggests that the burden of living with unavoidable pain is a key driver."
Implications for people with tendinopathy
This study has several important implications:
1. Take note of psychological factors with tendinopathies. Pain catastrophizing, depression, and anxiety may be present even in the absence of fear of movement. Keep an eye out for these factors, particularly in lower-limb tendinopathy.
2. Do not assume the fear avoidance model applies. Treatments that focus primarily on reducing fear of movement may be less relevant for tendinopathy than for chronic low back pain. Addressing pain catastrophizing directly may be more appropriate.
3. Consider the site-specific nature of psychological burden. Lower-limb tendinopathies may carry a greater psychological burden because pain is harder to avoid during daily activities. This should factor into your recovery strategy.
4. Normalise the psychological response. People need to hear that feeling frustrated, helpless, or anxious about their tendon pain is a normal response - not a sign of weakness or a "psychological problem." This validation can reduce secondary distress.
5. Patient-centred care remains essential. The authors note that their findings "support clinicians' patient-centred approach when managing people with tendinopathy." Each patient's psychological profile will be unique. If you are seeking treatment from someone, make sure they treat you as a whole, not just a tendon.
Study limitations
Several limitations should be considered:
- Very low certainty of evidence - all meta-analyses were downgraded for risk of bias, inconsistency, and indirectness
- Clinical heterogeneity - different tendinopathy sites have different clinical profiles, which may affect psychological factors
- Underrepresentation of upper-limb tendinopathy - fewer upper-limb studies were available, so findings may not generalise equally
- Confounding factors - differences in psychological factors may be due to factors other than tendinopathy diagnosis (e.g., age, comorbidities)
- Cross-sectional design - most studies were cross-sectional, so causation cannot be determined
From my clinical experience
As a physiotherapist, I see the psychological impact of tendinopathy every day. Patients come in frustrated, demoralised, and often convinced that they are "doing something wrong" or that their body is "broken." They have tried everything - rest, ice, strengthening, stretching, injections - and nothing feels like it works.
This study also validates what I see clinically - that pain catastrophizing can be real and needs our respect. Associated depression and anxiety is also real, however, this doesn't mean people are actively avoided movement and activity.
This distinction matters. It means that simply telling a patient "movement is safe" is not enough. Most already feel that movement is safe. What they need is a way to move that does not flare up their symptoms. They need respectful and successful strategies, not just reassurance.
It also means that addressing the psychological factors requires a different approach. Cognitive-behavioural techniques that work for fear-avoidance may be less relevant. Instead, helping patients understand that tendon pain is not a sign of damage, that it fluctuates, and that they can gradually increase their capacity may be more helpful.
"Kinesiophobia did not differ between those with and without tendinopathy, suggesting that the fear avoidance model is insufficient to explain the complex clinical presentation. People with tendinopathy may be prone to negative thoughts regarding their condition, which clinicians need to consider, even in the absence of pain-related fear or fear of movement."
Conclusions
This systematic review and meta-analysis provides important insights into the psychological profile of people with persistent tendinopathy. Pain catastrophizing is elevated, and depression and anxiety are higher in lower-limb tendinopathy. However, kinesiophobia is not elevated, challenging the applicability of the fear avoidance model to tendinopathy.
The authors conclude: "People with tendinopathy had higher pain catastrophizing. Depression and anxiety were part of the psychological profile of those with lower-limb, but not upper-limb, tendinopathy."
The findings support a patient-centred approach that addresses the specific psychological challenges faced by individuals with tendinopathy, rather than applying models developed for other chronic pain conditions.
One key insight from this research
"People with tendinopathy had higher pain catastrophizing than those without tendinopathy, but there was no difference in kinesiophobia (fear of movement). This challenges the fear avoidance model's applicability to tendinopathy. Depression and anxiety were higher in lower-limb tendinopathy, but not upper-limb, possibly because lower-limb pain is harder to avoid during daily activities like walking."
Frequently asked questions
Does this mean tendinopathy is psychological?
No. Tendinopathy is a biological condition involving changes to the tendon structure and function. However, like all persistent pain conditions, it has psychological and social dimensions. This study shows that people with tendinopathy have different psychological profiles than people without tendinopathy, but this does not mean the pain is "in their head." Pain is always real, regardless of contributing factors.
Did the study find that psychological factors cause tendinopathy?
No. This was a cross-sectional study designed to compare psychological profiles between people with and without tendinopathy. It cannot establish causation. The available evidence suggests that the psychological differences observed are most likely a consequence of living with persistent pain, rather than a cause of the tendinopathy itself. The site-specific findings (depression and anxiety only in lower-limb tendinopathy) support this interpretation.
Why are depression and anxiety only higher in lower-limb tendinopathy?
The authors suggest that lower-limb tendinopathies affect activities that are harder to avoid - walking, standing, and propulsive activities. When pain is unavoidable during daily activities, the psychological burden may be greater. Upper-limb tendinopathies may be easier to "work around" by avoiding using the affected arm.
What is pain catastrophizing and how do I know if I do it?
Pain catastrophizing is a pattern of thinking characterised by magnifying the threat of pain, ruminating about it, and feeling helpless. Common signs include thinking "this pain will never get better," "I can't cope with this," or "this pain means something is seriously wrong." A validated questionnaire called the Pain Catastrophizing Scale can help identify this pattern.
Should I be worried if I have depression or anxiety with my tendinopathy?
Not necessarily. Depression and anxiety are common responses to persistent pain and disability. The study found that depression and anxiety were part of the psychological profile of lower-limb tendinopathy, meaning they are common but not universal. If you are experiencing significant distress, it is worth discussing with your healthcare provider. Addressing these factors may improve your overall outcome.
This study confirms what I have observed in clinical practice: tendinopathy is not just a tissue problem. It affects how people think, feel, and function. The frustration, the helplessness, the worry that things will never get better - these are real and they matter.
But it also shows that tendinopathy is different from other chronic pain conditions. The fear avoidance model, which works well for chronic low back pain, does not fit tendinopathy neatly. People with tendinopathy are not usually afraid to move. They are frustrated that movement hurts, and they do not know how to make it stop.
This means that treatment needs to be different too. Education about the normal healing process of tendons, realistic expectations about recovery, and graded loading that respects the tendon's capacity are essential. And if you are struggling with the psychological burden of tendinopathy, do not be afraid to talk about it.
I see patients in Port Macquarie and via telehealth for comprehensive tendinopathy management that addresses both the physical and psychological aspects of recovery. If you would like to discuss your specific situation, I am here to help.
- Grant
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Disclaimer: This information is for educational purposes and does not replace individualised medical advice. If you have tendinopathy, persistent pain, or concerning psychological symptoms, consult a qualified healthcare professional. This blog post summarises a published research study (Mc Auliffe J, Fearon A, Flood A, et al. Differences in psychological factors between people with persistent tendinopathy and those without tendinopathy: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2025;55(12):752-769); the original source should be consulted for full methodological details.
