It's Not Just the Tendon: The Surprising Psychological Profile of Persistent Tendinopathy
Key findings: 60-second read
- Pain catastrophizing was higher in people with tendinopathy compared with people without tendinopathy, although the difference was relatively small.
- Depression and anxiety were higher in lower-limb tendinopathy, but this difference was not demonstrated for upper-limb tendinopathy.
- Kinesiophobia was not significantly different between people with and without tendinopathy.
- General self-efficacy and personality traits, including extraversion and neuroticism, were also not significantly different.
- The findings suggest tendinopathy has a distinct psychological profile, but the study cannot determine whether psychological factors cause tendinopathy or result from living with it.
If you have ever dealt with persistent tendinopathy - whether it is in your Achilles, patellar tendon, rotator cuff, or elbow - you may know that it can affect much more than the tendon itself. Persistent pain can influence mood, confidence, activity and quality of life.
A 2025 systematic review and meta-analysis published in the Journal of Orthopaedic & Sports Physical Therapy examined psychological factors in people with persistent tendinopathy compared with people without tendinopathy.
The review found important differences in some psychological factors, but also challenged the assumption that tendinopathy necessarily follows the classic fear-avoidance pattern seen in some other persistent pain conditions.
People with tendinopathy had different psychological profiles than people without tendinopathy. Pain catastrophizing was higher overall, while depression and anxiety were particularly elevated in lower-limb tendinopathy.
On this page
Pain catastrophizing: higher in tendinopathy
Pain catastrophizing describes a pattern of thinking involving magnification of pain, rumination and feelings of helplessness.
The meta-analysis found that people with tendinopathy had higher pain catastrophizing than people without tendinopathy.
Importantly, the authors noted that this difference was relatively small. It should therefore not automatically be interpreted as evidence that people with tendinopathy have a clinically significant maladaptive psychological response.
What is pain catastrophizing?
It is a specific pattern of thinking characterised by magnifying the threat of pain, repeatedly thinking about it, and feeling unable to cope with it. It is different from simply experiencing concern or frustration about pain.
Depression and anxiety: lower-limb tendinopathy
Interestingly, the psychological profile differed according to tendon location.
Depression and anxiety were higher in people with lower-limb tendinopathy compared with controls. The review did not find the same significant differences for upper-limb tendinopathy.
The authors discuss the possibility that lower-limb tendinopathies may have a greater impact because activities such as walking and running can be difficult to avoid. However, this is an interpretation of the findings rather than something the study proved.
Depression and anxiety were part of the psychological profile observed in lower-limb, but not upper-limb, tendinopathy.
Kinesiophobia: no significant difference
Kinesiophobia refers to fear of movement based on a perceived vulnerability or susceptibility to injury.
Despite higher pain catastrophizing, the meta-analysis found no significant difference in kinesiophobia between people with and without tendinopathy.
This is important because it suggests that the psychological profile of tendinopathy may not follow the same pattern assumed by traditional fear-avoidance models.
Key takeaway
People with tendinopathy may experience more negative thoughts about their pain without necessarily developing a greater fear of movement.
What this means for the fear-avoidance model
The fear-avoidance model proposes that pain catastrophizing can contribute to fear of movement, avoidance and disability. It has been influential in the understanding and management of several persistent pain conditions.
This review suggests that tendinopathy does not necessarily fit this model neatly. Pain catastrophizing was higher, but kinesiophobia was not significantly different.
This does not mean the fear-avoidance model is irrelevant to every person with tendinopathy. Rather, the findings suggest that psychological factors in tendinopathy may be more complex than simply assuming that pain catastrophizing leads to fear and avoidance.
Cause or consequence? What the study actually tells us
The important question is whether psychological differences existed before tendinopathy developed or emerged after people had been living with persistent symptoms.
This study cannot answer that question. The included evidence was predominantly observational, and the review was designed to compare psychological factors between people with and without tendinopathy rather than determine causation.
Therefore, it would be inappropriate to conclude that psychological factors cause tendinopathy - or that they are necessarily caused by tendinopathy.
The site-specific findings are interesting and may suggest that the burden of living with persistent symptoms contributes to psychological wellbeing, particularly when symptoms interfere with everyday activities. However, this remains an interpretation rather than a demonstrated causal relationship.
The safest interpretation is that people with persistent tendinopathy show different psychological profiles from people without tendinopathy. The direction of causation remains uncertain.
Implications for people with tendinopathy
This study has several practical implications:
1. Consider psychological factors. Pain catastrophizing, depression and anxiety may be relevant, particularly in lower-limb tendinopathy.
2. Don't automatically assume fear avoidance. The absence of a significant difference in kinesiophobia suggests that fear of movement should not simply be assumed because someone has persistent tendon pain.
3. Consider the location of the tendinopathy. Lower-limb tendinopathy may have a different psychological burden from upper-limb tendinopathy.
4. Take psychological wellbeing seriously. Persistent pain can be frustrating and disruptive. Recognising this is part of patient-centred care and does not mean suggesting that symptoms are "all in the head."
5. Treat the whole person. Tendon rehabilitation should remain focused on appropriate loading and functional recovery while also considering the individual psychological and social factors that may influence their experience.
Study limitations
- Observational evidence: Much of the included research was cross-sectional, meaning causation cannot be established.
- Clinical heterogeneity: Different tendon sites may have different clinical and psychological profiles.
- Risk of bias and imprecision: The certainty of evidence varied across outcomes and was limited by methodological issues in the available studies.
- Limited evidence for some factors: Several psychological outcomes were assessed in only a small number of studies.
- Potential confounding: Differences between groups may reflect factors other than tendinopathy itself.
From my clinical experience
As a physiotherapist, I see the psychological impact of persistent tendinopathy regularly. Patients can become frustrated, demoralised and uncertain about what they should or should not do.
This research reinforces the importance of recognising these experiences without assuming that someone with tendinopathy is necessarily afraid of movement.
For me, the key distinction is that experiencing pain-related worry is not the same thing as being afraid to move. Good rehabilitation should help people understand their symptoms, develop confidence in their capacity and progressively return to meaningful activities.
Psychological factors should therefore be considered alongside, rather than instead of, appropriate tendon loading and physical rehabilitation.
The findings suggest that tendinopathy has a complex psychological profile that cannot be explained by fear of movement alone.
Conclusions
This systematic review and meta-analysis found that people with tendinopathy had higher pain catastrophizing than people without tendinopathy. Depression and anxiety were also higher in people with lower-limb tendinopathy, while no significant differences were found for kinesiophobia, general self-efficacy, extraversion or neuroticism.
The findings challenge the assumption that tendinopathy necessarily follows a classic fear-avoidance pattern. However, the study cannot determine whether psychological factors contribute to the development of tendinopathy or arise as a consequence of living with persistent symptoms.
Overall, the research supports a patient-centred approach that considers both the physical and psychological dimensions of persistent tendinopathy.
One key insight from this research
People with tendinopathy had higher pain catastrophizing, but not higher kinesiophobia. Depression and anxiety were higher in lower-limb tendinopathy, highlighting that the psychological profile of tendinopathy may be more complex than a simple fear-avoidance model.
Frequently asked questions
Does this mean tendinopathy is psychological?
No. Tendinopathy is a physical condition, but persistent symptoms can have psychological and social dimensions. This study found differences in psychological factors between people with and without tendinopathy; it does not suggest that symptoms are "all in the head."
Did the study find that psychological factors cause tendinopathy?
No. The available evidence cannot establish causation. The review compared psychological factors between people with and without tendinopathy, but it cannot determine whether psychological factors preceded or followed the condition.
Why were depression and anxiety higher in lower-limb tendinopathy?
The authors discuss the possibility that lower-limb symptoms can interfere with activities such as walking and running, which may be harder to avoid. However, this is a possible explanation rather than something the study can prove.
What is pain catastrophizing?
Pain catastrophizing is a pattern of thinking involving magnification of the threat of pain, rumination and feelings of helplessness. It is different from simply being concerned or frustrated about persistent pain.
Should I be worried if I have depression or anxiety with tendinopathy?
Not necessarily. Psychological distress can occur alongside persistent pain, particularly when symptoms interfere with daily life. If you are experiencing significant distress, discussing it with an appropriate healthcare professional may be helpful.
This research reinforces an important clinical point: tendinopathy is not simply about the tendon. Persistent symptoms can affect how people think, feel and function.
At the same time, the findings remind us not to automatically label people with tendinopathy as fearful of movement. The psychological profile appears more nuanced, and good treatment should consider the individual rather than applying a single model to everyone.
Education, appropriate tendon loading, realistic expectations and patient-centred care all have an important role in recovery.
- Grant
Living With Persistent Pain?
If your pain has lasted longer than expected, feels disproportionate to the original injury, or has not responded to standard treatment, you may benefit from a more individualised approach. Learn more about our physiotherapy services in Port Macquarie.
Want personalised guidance?
If you would like help making sense of your aches, pains, or ongoing symptoms, you can book with Grant either in Port Macquarie or via telehealth.
Research reference: Mest J, Flood A, Toufexis C, Waddington G, Malliaras P, Fearon AM. Differences in Psychological Factors Between People With Persistent Tendinopathy and Those Without Tendinopathy: A Systematic Review With Meta-Analysis. Journal of Orthopaedic & Sports Physical Therapy. 2025;55(12):752–769. doi:10.2519/jospt.2025.13307
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; the original source should be consulted for full methodological details.
