Who would win: surgery versus physiotherapy for treatment of tendinopathy?


Tendinopathy continues to plague athletes at all levels of sport. As such, it comprises up to 30% of all musculoskeletal complaints seen in general medical practices(1). In a previous article, Alicia Filley explores the combined theory of inflammation and degeneration within an injured tendon. She then reviews the current thinking on the many approaches toward tendon treatment such as loading, shock therapy, electrocoagulation, and platelet-rich plasma. Tracy Ward builds upon that work by reviewing the degeneration process and evaluating the evidence for eccentric loading versus heavy and slow resistance training.

Researchers at the University of Glasgow looked at the treatment of tendinopathy from another angle(1). They conducted a thorough systemic review comparing the effectiveness of surgery, sham surgery, and physiotherapy (PT) in the treatment of tendinopathy. They defined tendinopathy as a,

“…result from an imbalance between the protective/regenerative changes and the pathological responses that result from tendon overuse.”(1)

The investigators defined PT as,

“any tendon rehabilitation regime administered regularly aiming to strengthen the affected tendon including supervised exercises and eccentric training.”(1)

The review initially identified 874 research articles, yet only 12 met the criteria for eligibility, which included randomization, participants over 18 years of age, and a clinical diagnosis of tendinopathy. Of those 12, six compared treatments with surgery to those with PT, five of which studied shoulder tendinopathy and one patellar tendinopathy. None of these studies were considered ‘high’ quality by the researchers. Rather, three were of ‘moderate’ quality, and three of ‘poor’ quality due to factors such as data handling and internal and external validity.

Despite the limitations of the studies in the review, the sports scientists noticed some interesting outcomes in those of moderate quality. In a study comparing arthroscopic surgery to supervised exercises in patients with stage II rotator cuff impingement, the reduction in pain and function proved slightly, though not significantly, better with the surgical subjects(2). However, two and a half years later, the outcomes between the two groups were indistinguishable.

Another study comparing outcomes in shoulder tendinopathy patients found similar results. After one, four, and eight years, the outcomes measures were similar between the group treated with surgery and those treated with physiotherapy(3). In an investigation comparing outcomes in patellar tendinopathy treated either surgically or with PT, investigators found similarly significant improvement in both groups at 12 months follow up(4).

So who would win surgery versus physiotherapy?

This review revealed that there are numerous studies comparing management approaches to tendinopathy. However, very few of them are of high methodological quality. In those comparing surgery, usually reserved for cases of tendinopathy that fail conservative treatment, and PT, only three studies were deemed to have ‘moderate’ quality. Of those studies, the researchers failed to find any significant difference between the approaches. The scientists drew the same conclusions from the evaluation of the studies of less quality. The investigators concluded that at 12 months follow up, and longer, subjects who receive PT for the treatment of tendinopathy demonstrate outcomes just as good as those who undergo surgery.

Yes, these studies were few and somewhat flawed.  However, the researchers suggest that patients consider surgery only after at least 12 months of PT guided loading exercises. The verdict in the matchup between surgery and PT for the management of tendinopathy is a tie!

Tendons are complex, and significant injuries take a substantial amount of time to heal. The challenge for clinicians is managing patient expectations, especially those of athletes itching to return to play. Many may see surgery as a ‘quick fix’ to get them back on the field. However, when one weighs the pain and expense of a surgical approach, with the fact that the outcomes may not be any better than PT, taking the conservative route is worth the wait for a full return to function. For more on how to manage tendinopathy and initiate a progressive loading program, see Lachlan Wilmot’s article on midsubstance Achilles’ tendinopathy.


  1. BMJ Open Sport Exerc Med. 2019;5:e000528
  2. 1993;307:899
  3. Ann Rheum Dis. 2005;64:760-4
  4. J Bone Joint Surg Am. 2006;88:1689-98
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