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For years, chronic tendinopathy has been treated as a tendon problem — load it, strengthen it, remodel it. But what if, for some runners, the tendon itself isn’t the main driver of pain anymore?

In this episode, Brodie breaks down a new 2026 systematic review that may reshape how we think about stubborn, long-standing tendon pain. The paper explores whether nerve ingrowth and abnormal blood vessels around tendons — not degeneration of the tendon tissue itself — may be the real pain source in chronic cases.

We unpack the emerging research, explain each intervention in plain language, and discuss who this may (and may not) apply to — especially runners stuck in repeated rehab cycles despite “doing everything right.”

This is early, evolving science. But it’s a fascinating glimpse into where chronic tendon treatment may be heading next.

What You’ll Learn in This Episode

• Why some chronic tendon pain may be neuropathic (nerve-driven) rather than structural
• How abnormal blood vessels and nerves grow into painful tendons over time
• Why traditional loading programs sometimes stop working in very chronic cases
• What “neural modification” treatments aim to do — and why they’re gaining interest
• The six intervention categories reviewed in the paper (explained simply)
• How strong (or limited) the current evidence actually is
• Where this research fits alongside exercise-based rehab, not against it

Interventions Reviewed (Plain-English Overview)

1. High-Volume Injections (HVIGI / HVDI)

Large volumes of fluid are injected around the tendon (not into it) under ultrasound guidance to mechanically disrupt abnormal blood vessels and pain-sensitive nerves.

Key takeaway:
Consistent short- to medium-term pain and function improvements, especially in people who had failed exercise-based rehab.

2. Sclerosing Polidocanol Injections

A chemical agent is injected directly into abnormal blood vessels to deliberately close them down, cutting off blood supply to pain-producing nerves.

Key takeaway:
Moderate to strong pain reductions in very chronic cases, with outcomes comparable to surgery in some studies.

3. Radiofrequency Microtenotomy

A minimally invasive procedure using controlled heat to disrupt nerve ingrowth and abnormal vessels at the tendon–paratenon interface.

Key takeaway:
Very strong results in a small cohort, but higher risk and limited evidence so far.

4. Minimally Invasive Paratenon Release

Scar-like adhesions between the tendon and surrounding tissue are mechanically released to restore tendon movement and reduce nerve irritation.

Key takeaway:
Large pain reductions and high rates of pain-free outcomes in non-insertional Achilles tendinopathy.

5. Electrocoagulation Therapy

Electrical energy is used to seal off abnormal blood vessels surrounding the tendon under ultrasound guidance.

Key takeaway:
Promising early results, but evidence limited to one small study.

6. Surgical Interventions (Open & Endoscopic)

Surgery physically separates the tendon from irritated surrounding tissue and removes abnormal vessels and nerves.

Key takeaway:
Effective for some, but invasive, with longer recovery and higher risk.

The Big Picture Takeaway

Across very different procedures, outcomes were surprisingly similar.

That points to a common mechanism:
👉 Modifying the neural (nerve-driven) pain environment around the tendon, rather than “fixing” tendon structure itself.

This doesn’t replace exercise-based rehab — but it may explain why a subset of runners with long-standing, highly sensitive tendinopathy stop responding to load alone.

This research is best viewed as a future direction, not a replacement for good rehab principles.

🎉 Sign up for the FREE PHT 5-Day Course HERE 🎉
🗓️ Book a free 20-minute Injury Chat with Brodie 📞
📄Learn more about Brodie's PHT AI Assistant 🔍

Check out Lasse's website here: https://www.lasselempainen.fi/?lang=en

In this episode, Brodie sits down with world-leading orthopedic surgeon Dr. Lasse Lempainen, a specialist in complex hamstring injuries, to answer one of the most confusing and anxiety-provoking questions runners face:

“How do I know if I actually need surgery — or if rehab is still the right path?”

Drawing on decades of surgical experience and extensive research into hamstring avulsions and proximal hamstring tendinopathy (PHT), Dr. Lempainen walks through how he actually makes decisions in real clinical practice — not just what MRI scans show, but how symptoms, function, timelines, and rehab quality all fit together.

Together, Brodie and Lasse unpack the gray area that most runners live in: partial tears, chronic pain, mixed scan results, failed rehab attempts, and fear-based decision-making. The result is a balanced, evidence-informed discussion that helps runners understand where surgery fits — and where it doesn’t.

What You’ll Learn in This Episode:
How Surgeons Decide Who Actually Needs Surgery

• Why MRI findings alone are never enough
• The importance of correlating scans with clinical function and symptoms
• Why some complete avulsions heal well conservatively — and others don’t

Hamstring Avulsion vs Proximal Hamstring Tendinopathy (PHT)

• Key differences between acute avulsions, chronic avulsions, and tendinopathy
• Why not all “avulsions” are the same (1-tendon vs 3-tendon injuries)
• When retraction distance matters — and when it doesn’t

Critical Timing Windows

• Why acute avulsions should ideally be operated on within 2–3 weeks
• What happens when diagnosis is delayed
• When chronic injuries become harder (or impossible) to fully restore surgically

“Failed Rehab” — What That Really Means

• Why many runners are told they’ve “failed rehab” when they actually haven’t
• Common mistakes in conservative treatment (under-loading, poor progression)
• When even excellent rehab is unlikely to succeed due to tendon biology

What Surgery for PHT Actually Involves

• What surgeons look for during surgery beyond “tendon thickening”
• The role of semi-membranosus release, scar tissue, and sciatic nerve involvement
• Why surgeons often find structural issues not obvious on standard MRI

Common Pre- and Post-Op Mistakes

• Why under-diagnosis is one of the biggest pre-op risks
• Why returning to running too early post-op leads to setbacks
• The importance of fixing why the injury happened — not just repairing tissue

Key Takeaway

This episode helps you understand which group you fall into, without fear-based decisions or false hope.

🎉 Sign up for the FREE PHT 5-Day Course HERE 🎉
🗓️ Book a free 20-minute Injury Chat with Brodie 📞
📄Learn more about Brodie's PHT AI Assistant 🔍

In this episode, Brodie breaks down a newly published review paper that takes a deep dive into what’s actually happening inside painful tendons — far beyond the usual “overuse” explanation. You’ll learn how healthy tendons are structured, what changes at a microscopic level when tendinopathy develops, and why pain severity often doesn’t match what shows up on scans. The episode explores how factors like load management, low-grade inflammation, oxidative stress, ageing tendon cells, and overall metabolic health all interact to influence tendon pain and recovery.

Brodie also discusses what this emerging science means for real-world rehab — including why rest alone doesn’t work, why exercises sometimes stall progress, and why a more holistic approach is often needed. The episode finishes by looking ahead at future treatment directions, from improved diagnostics to regenerative and molecular therapies, while grounding everything in practical takeaways runners can apply right now. If you’re dealing with persistent tendon pain — especially proximal hamstring or Achilles tendinopathy — this episode will help you understand why recovery can be slow and what actually gives you the best chance of long-term success.