First steps when a joint or tendon suddenly hurts

Pain that comes on suddenly after everyday activity — lifting a suitcase in Grantham, gardening in Sleaford, a first run in months, or a simple ankle twist — is most often a sprain, strain, or tendon flare rather than an emergency. The focus in the first 24–72 hours is usually symptom control and keeping moving within tolerance, rather than immediately chasing a scan or a “perfect” label.

A practical first-step plan that fits many common problems (rotator cuff-related shoulder pain, non-specific low back pain, Achilles tendinopathy, ankle sprain pain, patellofemoral/front-of-knee pain, tennis elbow, and plantar fasciitis) is:

• Relative rest for 48–72 hours: avoiding movements or loads that cause sharp pain spikes, while keeping gentle activity going where possible.
• Simple pain relief if safe: for example paracetamol, or an anti-inflammatory such as ibuprofen, and in some cases topical anti-inflammatory gel (commonly suggested for tennis elbow) rather than “pushing through”.
• Temperature and support: a hot or cold pack can help settle symptoms in the short term; supportive footwear and cushioning can reduce heel strain in plantar fasciitis.
• Early, light exercises: gentle range-of-motion and basic strengthening, progressed over days to weeks, is commonly part of self-care for overuse conditions such as tennis elbow.

Across these conditions, the working diagnosis is usually made from the story and examination (what triggered it, where it hurts, what aggravates it, what functions are limited). Imaging can be useful later, but a scan result on its own is not a full diagnosis; it is one input among symptoms and clinical findings.

Low back pain is a good example of why “more information” is not always better in week 1. Evidence reviews report that routine early X-rays, CT or MRI for acute or subacute non-specific low back pain do not produce clinically meaningful improvements in pain or function, but can increase costs and the chance of incidental findings that do not explain symptoms. Guidance such as the ACR Appropriateness Criteria and Choosing Wisely materials generally reserves imaging for situations where red flags suggest serious pathology, or when symptoms persist despite appropriate conservative care and an intervention is being considered.

Some symptoms are treated as same-day reasons for urgent GP or A&E assessment, especially when they appear after major trauma or are rapidly worsening:

• Back symptoms: new bladder or bowel disturbance, saddle numbness, or progressive/severe leg weakness.
• Systemic illness: fever, feeling very unwell, or concern for infection.
• Trauma and function: major injury, obvious deformity, or inability to bear weight through a leg.
• Joint inflammation: a hot, red, markedly swollen joint.

For less urgent situations, national NHS self-care advice for problems such as tennis elbow and plantar fasciitis commonly uses a simple threshold: consider GP review if symptoms have not improved after about 2 weeks of sensible self-management, or if pain is severe, worsening, or stopping normal activities.

When is targeted physiotherapy usually enough on its own?

Targeted physiotherapy is often “enough” when the pain is load-related (worse with certain movements or tasks) but the joint or tendon is still stable and usable day to day — in other words, when rebuilding capacity is the limiting factor rather than a problem that must be mechanically fixed. To keep this practical (and to avoid repeating the same scan-or-surgery thresholds condition by condition), the common thread across shoulder, knee, elbow, Achilles and heel pain is a structured plan that progresses specific strength and control over a measured period of weeks.

Across these conditions, good-quality rehab usually includes a few non-negotiables: a clear exercise dose (sets/reps or time), planned progression every 1–2 weeks, and an agreed way to judge response (pain during and the day after, plus function such as stairs, lifting, or running drills).

Rotator cuff tears (shoulder)

In a prospective randomised trial of small, acute traumatic rotator cuff tears, early surgical repair and structured physiotherapy both produced successful outcomes, with no major difference in shoulder function at follow-up. Alongside comparative evidence in degenerative and even some large/massive tears showing that exercise-based care can deliver pain and functional outcomes similar to surgery for many people (with surgery offering somewhat greater pain reduction in selected groups), this supports starting with a focused rehab programme rather than defaulting straight to an operation in most cases.

Patellofemoral (front-of-knee) pain

The 2019 JOSPT clinical practice guideline describes patellofemoral pain as largely a clinical diagnosis — typically pain “around or behind the kneecap” that is aggravated by running, squatting or stairs — and places combined hip- and knee-targeted strengthening plus movement retraining at the centre of treatment. In practice, this means building hip abductor/external-rotator strength and quadriceps capacity while also addressing how the leg is loaded during tasks such as step-downs or running.

Midportion Achilles tendinopathy

For Achilles tendinopathy, the cornerstone is progressive calf/Achilles loading (eccentric or heavy slow resistance), with progression guided by symptom behaviour during and after training sessions. Return-to-sport programmes describe a wide window — often from about 6 weeks to 1 year after onset, depending on severity and how consistently loading is built — and one evidence-based “gate” before reintroducing running and jumping is minimal pain with ordinary walking (around 1–2/10).

Tennis elbow and plantar fasciitis

NHS advice for tennis elbow highlights that it often improves after a few weeks of rest from aggravating tasks and simple measures such as analgesia, topical anti-inflammatory gel, hot/cold packs and gentle exercises, with further help considered if it is not settling after 2–6 weeks. For plantar fasciitis, NHS guidance similarly prioritises self-care (supportive shoes, heel pads/insoles, plantar fascia and calf stretching, low-impact activity and weight management) and notes that symptoms commonly last many weeks or months yet still improve without injections or surgery.

When do scans like MRI genuinely add value?

A scan adds the most value when it is likely to change the next decision (for example, urgent treatment, a different diagnosis, or a clear shift from rehabilitation to a procedure), rather than simply “confirming” something that would be managed the same way anyway.

Low back pain is where this has been studied most clearly. In the 2018 review by Wang et al., routine early imaging (X‑ray, CT or MRI) for acute or subacute non-specific low back pain was not linked to meaningful improvements in pain or function, but it did increase cost and the chance of incidental findings. One practical reason is that MRI can show age-related changes (for example disc bulges and “wear and tear” features) that do not always correlate well with symptoms.

Guidance such as the ACR Appropriateness Criteria and Choosing Wisely materials keeps back imaging for situations where a serious cause is more plausible (for example cancer history, unexplained weight loss, fever or infection risk, significant trauma, or progressive/severe neurological deficit including possible cauda equina syndrome), or later when symptoms persist despite appropriate conservative care and an invasive option is being weighed up. The ACEP 2022 review also highlights that “red flags” need clinical judgement, because some are sensitive but not very specific.

A similar “scan only when it changes the plan” logic applies at the knee. The 2019 JOSPT patellofemoral pain guideline describes typical front-of-knee pain as primarily a clinical diagnosis, so imaging is usually saved for situations such as significant trauma, a large effusion, mechanical locking/catching, or failure to improve with a structured rehabilitation programme where an alternative diagnosis (for example a meniscal tear, advanced osteoarthritis, or a stress fracture) becomes more likely.

With an ankle sprain that does not settle, timing matters. Appropriateness criteria define ankle pain lasting 6 weeks or more as “chronic”, and recommend weight-bearing X‑ray as the first-line test. MRI or CT is generally reserved for ongoing pain or mechanical symptoms (such as catching), or when there is suspicion of an osteochondral lesion, tendon tear, or impingement despite normal or inconclusive radiographs.

For heel pain that fits plantar fasciitis, the NHS notes symptoms often last many weeks or months and still usually improve with conservative care, so early imaging is uncommon. Ultrasound or MRI tends to be held back for atypical features (for example neurological symptoms or concern for systemic/inflammatory disease) or when pain remains significantly disabling despite prolonged non-operative management and alternative causes such as stress fracture or nerve entrapment need ruling out.

To address a common frustration without turning this into a clinic brochure: imaging access (including Open MRI in Sleaford, NG34, and tools such as onMRI™ analysis) is most useful when the clinical picture suggests it will genuinely alter diagnosis or treatment, rather than as an automatic first step.

Pain that has not settled after months: when to get it checked

After the first 6–12 weeks, the most helpful way to judge an injury is often the direction of travel: symptoms that are slowly improving with sensible load management are one thing; symptoms that are static, worsening, or repeatedly flaring after each attempt at rehab are another. In this “persistent pain” phase (roughly 6 weeks to 3 months, depending on the body part), the guidance is largely based on clinical consensus and patterns seen in practice rather than a single cut-off supported by one definitive trial.

A classic example is the ankle that was expected to “heal in a few weeks” but is still sore or swollen months later, especially if it feels like it is “giving way” on uneven ground. Reviews of chronic lateral ankle instability describe that ongoing symptoms may reflect not only ligament laxity but also associated problems such as osteochondral (cartilage) lesions, synovitis, peroneal tendon disorders, sinus tarsi syndrome, or neuropraxia. That combination is one reason persistent post-sprain pain can feel out of proportion to what was originally labelled a “simple sprain”, and why specialist assessment may be useful to decide whether targeted imaging (often MRI) is likely to clarify the next step.

With midportion Achilles tendinopathy, the overall time course can be long even with good rehab, so the key question becomes whether a structured progressive loading plan is producing any meaningful change over time. A review by Silbernagel et al. (2020) uses a practical marker for progress in sportier patients: before returning to running and jumping, pain during ordinary walking should be minimal (about 1–2/10). When walking pain remains clearly more than mild, when each loading progression reliably causes a multi-day flare, or when function for work is still significantly limited after a well-followed programme, it is often a prompt to reassess the diagnosis and the loading plan rather than simply “pushing through”.

For tennis elbow, NHS advice is clear on the early checkpoint: a GP review is advised if pain persists after at least 2 weeks of rest and self-care, and physiotherapy may be considered if symptoms have not improved after about 6 weeks. When pain continues to meaningfully affect grip and day-to-day tasks beyond roughly 6–12 weeks, many care pathways escalate to supervised rehabilitation, and consultant referral may be considered if several months of structured conservative care still has not shifted the problem; diagnosis is usually clinical.

With plantar fasciitis, heel pain can last for many weeks or months and still settle gradually. NHS advice flags earlier review when pain is severe, worsening/recurring, or has not improved after 2 weeks of self-care, and also when there is tingling, numbness, or diabetes with foot pain. Pain that remains significantly disabling despite supportive footwear and a consistent stretching/strengthening plan is one scenario where clinicians may revisit alternative causes (for example a stress fracture or nerve entrapment) and consider whether investigations are warranted.

A specialist opinion does not need to wait until symptoms are unbearable: the MSK Doctors team offers consultant-led assessment without referral in Sleaford (NG34) and Grantham (NG31) to clarify whether persistent pain is still within a reasonable healing window or whether it is time to change track; appointments can be booked online at mskdoctors.com.

When to consider injections or surgery after physio

Escalating beyond rehabilitation tends to hinge on two practical questions: is pain still the main limiter, or is there evidence of a problem that stays mechanically unstable or weak despite good rehab? A third, quieter hinge is whether symptoms are repeatedly blocking progress (for example, the same flare pattern after each graded increase over several months), making a procedure a way to enable rehabilitation rather than replace it.

When an injection becomes a reasonable discussion

Injections are generally considered when a clear working diagnosis has been made and symptoms remain function‑limiting despite a properly progressed programme, but the clinician’s aim is still to keep the plan rehabilitation-led. In this context, an injection is usually framed as temporary symptom control (to sleep, work, or train more normally) so that strength, capacity and movement retraining can continue.

For tennis elbow, NHS guidance notes that many cases improve with rest, simple analgesia/topical anti‑inflammatory gel and exercises over a few weeks, with review suggested if pain persists after 2 weeks of self‑care and physiotherapy considered if not improving after about 6 weeks. When pain continues for several months and materially limits grip and daily tasks despite structured rehab and activity modification, some pathways consider injection options; surgery sits further downstream and is only used in a minority of stubborn cases. Diagnosis is usually clinical.

For plantar fasciitis, NHS advice highlights supportive footwear, insoles/heel pads and stretching, and notes symptoms can last many weeks or months while still improving gradually. Procedural options (including injections) are usually held back for people with persistently disabling heel pain despite prolonged conservative management, particularly when footwear and loading strategies have been genuinely optimised.

When surgery starts to make sense

Surgery is usually discussed when the limiting factor looks less like “pain sensitivity” and more like persistent loss of function, objective weakness, recurrent instability, or a repairable structural problem where a procedure is likely to change what is possible in rehab.

For rotator cuff tears, a randomised trial in small, acute traumatic tears found that both early repair and structured physiotherapy produced successful outcomes without major differences in shoulder function at follow‑up, supporting a non‑operative trial in many cases. In degenerative/atraumatic tears (including some large tears), comparative studies and a systematic review suggest exercise-based management often delivers pain and function similar to surgery for many patients, while repair may provide somewhat greater pain reduction in selected cohorts. In practice, surgery is more commonly put on the table earlier for larger or clearly traumatic tears, particularly where there is marked strength loss, higher physical job/sport demands, or persistent pain and disability after a substantial period of well‑supervised rehabilitation.

With chronic ankle instability, imaging guidance defines persistent ankle pain as “chronic” from 6 weeks and places weight‑bearing X‑ray first, with MRI/CT considered when pain persists or when specific intra‑articular or tendon pathology is suspected. Where the ankle continues to “give way” despite bracing and targeted rehab, MRI evidence of associated problems (for example an osteochondral cartilage injury or a tendon tear) can shift the conversation towards arthroscopic procedures and/or ligament reconstruction, especially for sporty patients or physically demanding work.

Planning a safe return to running, work, and sport

A diary date (“it’s been 6 weeks, I should be back”) rarely matches what tissues and movement patterns can actually tolerate. Across common MSK problems, safer return-to-running, work and sport is usually criteria-based: symptoms settle quickly after load, strength and control are returning, and confidence is building without repeated flare-ups.

Worked example: midportion Achilles tendinopathy

In midportion Achilles tendinopathy, progressive loading is the mainstay, and published return-to-sport programmes describe a wide window for return (from roughly 6 weeks to 1 year), depending on severity and how well rehab progresses. A practical threshold used in conservative-management guidance is that pain with ordinary walking is minimal (about 1–2/10) before running and jumping are reintroduced, with progression guided by symptom response during and after exercise rather than “pushing through” a flare. In day-to-day rehab this often looks like a stepwise build: calf loading that is comfortable enough to repeat, then controlled single-leg strengthening, then short flat runs, with hills, speed and plyometrics added later when the tendon is coping.

Front-of-knee (patellofemoral) pain: earn running and hills back

For patellofemoral pain, the 2019 JOSPT guideline places combined hip- and knee-targeted strengthening and movement retraining at the centre of recovery. In practical terms, return to running or hill walking typically follows restoration of hip and knee strength and improved control on single-leg tasks—often reflected in being able to manage stairs and squats with minimal pain and good alignment rather than the knee collapsing inwards under load.

After an ankle sprain: stability before speed

When an ankle still feels unstable months after a sprain—often described as “giving way”—reviews of chronic lateral ankle instability report that ongoing symptoms are frequently linked with associated problems such as osteochondral lesions, synovitis, peroneal tendon disorders, sinus tarsi syndrome or neuropraxia. Because of that, return to cutting and pivoting sports is usually built from observable milestones: steady single-leg balance, controlled single-leg squatting, then straight-line hopping and gentle changes of direction at lower speed—while monitoring for any giving-way episodes.

Upper limb examples: shoulder and elbow

After rotator cuff–related pain (including some tears), trials and comparative studies suggest many people do well with structured rehabilitation, so return to overhead sport or heavy manual work is often paced by near-symmetrical strength and endurance rather than an automatic decision for early surgery. For tennis elbow, NHS advice highlights that most cases improve with rest, simple analgesia/topical anti-inflammatory gel and exercises over weeks; in sport and manual work, a useful readiness marker is whether repeated gripping/lifting can be done without a significant pain flare later the same day or the next.

When progress is hard to judge—particularly for runners and field-sport athletes—MSK Doctors’ consultant-led teams in Sleaford (NG34) and Grantham (NG31) can combine clinical assessment with objective movement review (including MAI Motion® where appropriate) to identify the specific strength, control or loading “bottleneck” that is holding return-to-activity back.

A simple 24-hour return-to-activity checklist

• During activity: symptoms stay mild and controlled (not sharp, escalating pain).
• That evening: function is broadly normal (walking, stairs, basic tasks not markedly worse).
• Next morning (24 hours): no meaningful increase in pain/stiffness compared with the day before.
• Across 2–3 sessions: load can be repeated, then increased gradually, without a pattern of setbacks.

If uncertainty remains about which criteria are missing or whether another diagnosis needs checking, an appointment can be arranged without referral via mskdoctors.com.