Tendon pain can be stubborn. It often lingers longer than people expect, can settle and flare again, and does not always behave like a simple muscle strain. But with the right understanding and approach, tendons can become stronger, calmer, and more reliable again.
Watch this short video as tendon researcher Dr Jill Cook explains tendon health and recovery. Full video at Kinetic Labs.
Dr Jill Cook, PhD, is a professor at the La Trobe Sport and Exercise Medicine Research Centre in Melbourne, Australia. She is one of the leading researchers helping clinicians understand how tendons change, why they become painful, and how rehabilitation works (Publications).
Tendons are often thought of as just the ends of muscles, but they are their own tissue with their own behavior. While muscles contract and generate force, tendons are designed to handle that force and act more like living springs. They also respond differently depending on how quickly and how long they are loaded. A healthy tendon stores and releases energy to help movement feel efficient and effortless. When a tendon becomes irritated or overloaded, that spring system can become more sensitive, and movements that once felt easy can start to feel uncomfortable.
Tendons connect muscle to bone and are made of collagen—strong, rope-like fibres that line up to handle load. The better aligned these fibres are, the stronger the tendon becomes. A thin, slippery sheath surrounds the tendon, helping it glide smoothly against nearby tissues.
Tendon pain reflects a tendon that has been asked to do more than it was ready for. This can happen when activity increases quickly, when returning to sport after a break, or when the surrounding muscles and joints are not sharing the load well. Tendons also do not always give clear early warning signs in the way muscles sometimes do, so pain can seem to appear after the tissue has already been under strain for some time.
Common tendon pain locations: Achilles tendon (like in this image), patellar tendon (knee), rotator cuff (shoulder), and elbow tendons (tennis/golfer’s elbow). These areas are prone to irritation when tissues are overloaded or not gliding well.
If the tendon continues to be asked for more than it can comfortably manage, it may begin to react and change over time. This broader pattern is generally described as tendinopathy. One helpful way to understand tendinopathy is to see it as part of a continuum. Early on, a tendon may become reactive and sensitive. Over time, it may develop some structural changes. That does not mean the tendon is damaged beyond repair. It usually means it needs the right kind of input to rebuild its capacity.
Healthy tendons are designed to be collagen-dense, well-organized, and relatively sparsely vascularized. When tendinopathy develops, extra blood vessels, nerve ingrowth, and collagen disorganization can appear, reflecting a more reactive tissue state that is usually less efficient at handling force. Taken from: The roles and therapeutic potential of mesenchymal stem/stromal cells and their extracellular vesicles in tendinopathies.
For most tendon problems, one of the most important parts of recovery is carefully graded loading. Tendons need load to stay healthy. When they are given the right amount of tension, they begin to adapt. Too little load, and they lose capacity. Too much, too soon, or too dynamic, and they become more reactive. Recovery tends to sit in the middle, where the tendon is challenged enough to improve without being overwhelmed. This is why rehabilitation often begins with slow, controlled strengthening.
In the early stages, it can help to introduce load in a steady and controlled way. Sometimes this includes simple holds where the muscle is working but the joint is not moving very much. These kinds of exercises are often easier for sensitive tendons to tolerate and can help settle pain enough to begin rebuilding strength. From there, rehabilitation gradually progresses into more demanding or dynamic strengthening.
Early Tendon Rehab Example: Isometric Holds
Some researchers are exploring whether specific loading strategies may help deliver a more targeted repair signal into the tendon tissue. One early-stage option for an irritable tendon is to use isometric holds, exercises that load the tendon steadily without much movement.

Dr Keith Baar, PhD, is a professor at the University of California, Davis, whose research focuses on how muscles, tendons, and ligaments adapt to exercise, loading, and nutrition. His lab-based work has helped shape the idea that connective tissues may respond best to a brief loading signal, followed by several hours of recovery before the tissue is ready to respond strongly again. In Keith Baar’s model, one reason longer steady holds may help is that they may allow load to be shared through the tendon in a different way, potentially helping deliver a useful signal into tissue that has been damaged.
Dr Keith Baar speaks with Dr Yonatan Whitten about tendon injuries and recovery (full video)
A common early-stage framework is:
  • 4 holds of about 30 seconds
  • using a position that loads the sore tendon
  • at a tolerable intensity (eg half maximum strength)
  • with short rests between
  • roughly 6-8 hours between sessions (once a day is a good rule of thumb)
This kind of early tendon loading is often continued for around 8 weeks as a practical safeguard while the tissue is still rebuilding tolerance before progressing into heavier strengthening and more dynamic loading such as calf raises, squats, hopping, running, or sport-specific drills. Steady loading is often easier for a painful tendon to tolerate than fast or bouncy movement. Tendon rehab should be adapted to the specific tendon involved, how reactive or settled it is, where you are in the recovery process, and the goals or activities you need to return to.
Watch this video to see some examples of tendon loading for beginners with Dr. Keith Baar (UC Davis Health)
As strength improves, the tendon can begin to handle more dynamic tasks. For some people, this might include returning to walking longer distances, lifting, climbing hills, or eventually running and sport. This progression takes time. Tendons usually adapt and recover more slowly than muscles, especially when they have been irritated for a while. Recovery often takes weeks to months rather than days, and tends to respond best to consistent, repeatable loading rather than sudden increases in intensity.
Hormones and Tendons
Hormones can influence tendon stiffness and resilience. Higher estrogen states, such as around ovulation, may make connective tissues feel a little more elastic or compliant, partly because estrogen appears to inhibit lysyl oxidase, an enzyme involved in collagen cross-linking and tissue stiffness. Lower estrogen states, especially after menopause, may be associated with more stiffness, lower collagen support, and reduced tendon resilience.

Some research suggests testosterone is associated with greater tendon stiffness, and anabolic steroid use has been linked with a higher risk of tendon rupture. One proposed reason is that if a tendon becomes stiffer and less compliant while muscle strength is rising quickly, the tissue may become less able to absorb and distribute force safely.
One of the most important ideas in tendon rehab is that more is not always better. Tendons often respond better to shorter, well-dosed, repeatable loading than to big, inconsistent bursts of effort. If symptoms are clearly worse the next day, it is usually a sign that the load needs adjusting.
Beyond Tendinopathy
Tendon pain is not always only about tendon pathology. Tendons also depend on good glide between their fibres, surrounding connective tissues, and in some areas the tendon sheath. If local tissues become stiff, compressed, or do not move well, this may add irritation and extra strain to the area. This is one reason manual therapy can be helpful alongside exercise — to improve movement, reduce local sensitivity, and support the tendon as strength and capacity are rebuilt.
When tendons, fascia, and surrounding tissues do not glide well, local strain and irritation can build more easily.
Image: ultrasound showing tissues (fascia in white) around the achilles tendon, adapted from Diagnostic Musculoskeletal Ultrasound of the Achilles Tendon.
Tendon recovery is rarely about doing nothing, and it is rarely about pushing through pain. It is about finding the right level of load, building strength gradually, and progressing toward the activities that matter to you. With time and consistency, tendons can become more resilient, allowing you to move pain-free and with greater confidence again.
​Key Takeaways for Tendon Recovery
  • Tendons need the right kind of gradual loading to heal.
  • Focus on slow, controlled exercises before progressing to more dynamic movements (spring-like activities are the most demanding).
  • ​Pay attention to your day-after symptoms and adjust your routine accordingly.
  • Tendons are slower to heal, it’s essential to give tendons time to adapt to new activities or exercises.​​
Further Reading:
Compiled by Joe Liguori
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