Loading comes first, and it is not close

A tendon that has hurt for eight months does not need rest. It needs load. That is the part patients resist, and the part clinicians sometimes soften to keep people happy. Chronic tendinopathy is a tendon that has stopped tolerating the demands you put on it, and the fix is to rebuild that tolerance under controlled, progressive stress. Passive treatments feel like progress. On their own, they rarely are.

The evidence has been consistent for years. Progressive loading, whether framed as eccentric work or heavy slow resistance (or a blend of the two), is the intervention with the most support across the common tendinopathies. It is dull and slow. It works.

What progressive loading actually looks like

The specifics vary by tendon, but the shape is the same. Start at a load the tendon tolerates and confirm it against the 24-hour pain response, then add load over weeks.

A working toolkit:

• Isometrics early when the tendon is irritable and you want pain relief without much movement (long holds of 30 to 45 seconds, repeated)
• Heavy slow resistance, three sessions a week, loads climbing from around 15RM toward 6RM over roughly 12 weeks
• Eccentric protocols where they suit the site; the classic Alfredson calf work for midportion Achilles is the obvious example
• A pain-monitoring rule so patients keep going: discomfort during and after is acceptable up to a point, as long as it settles by the next morning

Here is where people go wrong. They stop when it stops hurting. The tendon feels better at week six and the program quietly dies. Symptoms come back in month four and everyone blames the exercises. The exercises were fine. Nobody finished them.

Where shockwave fits alongside loading

Some tendons do not play along. You load them properly, the patient is compliant, the pain diary is honest, and twelve weeks in nothing much has moved. That is the tendon where a second modality earns a look.

For most midportion Achilles and gluteal tendinopathies, and for tennis elbow, the evidence still puts progressive loading first, and shockwave earns its place as an adjunct for the load-resistant cases that plateau after a fair trial of exercise. Clinics that treat tendinopathy this way sequence the two deliberately: weeks of progressive loading first, with shockwave layered in only when a stubborn tendon stalls, which is roughly the pattern Eastside Physio + Co, a physiotherapy and shockwave therapy clinic in Surrey Hills, Melbourne, runs across its services. The clinic pairs hands-on physiotherapy and exercise prescription with extracorporeal shockwave, a non-invasive treatment that delivers shock waves to injured tendon and soft tissue to reduce pain and prompt healing, so the passive modality supports the loading program rather than replacing it.

That order matters. Shockwave on its own, with no loading behind it, treats the symptom and leaves the tendon just as intolerant as it was. Shockwave on top of a stalled loading program can be the thing that drops pain far enough for the patient to load harder, which is what actually changes the tissue.

How the sequence runs in practice

Rough version of what a sensible protocol looks like:

• Weeks 0 to 6: settle the irritability and establish the loading program, then fix the training or gait errors that drove the tendon over the edge
• Weeks 6 to 12: progress load steadily. Review the pain diary and keep compliance up at each visit
• Around week 12: if the tendon has genuinely plateaued despite good loading, add extracorporeal shockwave, typically three to five sessions about a week apart
• Throughout the shockwave block: keep loading

That last point is the one people miss. Shockwave is not a rest period. The course buys a window, and you use that window to load.

The tendons that stall, and the ones that don’t

Not every site responds the same. Insertional Achilles tendinopathy is fussier than midportion and dislikes the deep dorsiflexion of a full Alfredson protocol, so you modify the range and sometimes reach for shockwave sooner. Gluteal tendinopathy hates compression, which means the loading has to avoid hip adduction and the patient has to stop crossing their legs and sleeping on the sore side. Common extensor tendinopathy at the elbow is the one where people burn months on braces and injections before anyone hands them a wrist extensor program. Makes sense, right? The passive stuff is easy to sell and easy to accept.

Shockwave has better support in some of these than others. The signal is reasonable for recalcitrant gluteal presentations and calcific shoulder tendinopathy. It is thinner elsewhere. The honest position is that it works as an adjunct with moderate evidence rather than a headline treatment, and anyone selling it as a standalone cure is overselling.

What shockwave will not do

It will not build capacity. A stronger tendon is a loaded tendon, and shockwave loads nothing. It will not fix a training error, a spike in running volume, a strength deficit at the hip or calf, or the deconditioning that let the tendon get overwhelmed in the first place. Used as a shortcut past the loading work, it fails, and it fails predictably.

Used the other way, as the thing you add when a well-loaded tendon still will not settle, it has a place. That is the whole argument. Load first, and load for longer than feels necessary, before you reach for the machine. When the tendon has told you clearly that loading alone is not getting there, that is when shockwave is worth the sessions.

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