Tendon Pain: What It Is and How to Recover
Tendon pain, or tendinopathy, can be frustrating, but with the right understanding and approach, you can manage your symptoms and get back to doing the things you love. Watch this short video as Dr. Jill Cook explains tendon health, injury, and effective recovery strategies:
Full video at Kinetic Labs
Jill Cook, PhD, is a professor at the La Trobe Sport and Exercise Medicine Research Centre in Melbourne, Australia. With over 20 years of clinical experience as a physiotherapist, she now focuses on tendon health research. Jill has become a leading expert in tendon pathology and treatment, sharing her expertise through workshops and lectures worldwide.
Understanding Tendons: Not Just Simple Cables
Tendons aren’t just ropes that connect muscles to bones—they’re more like springs. They store and release energy to help you move efficiently, especially during activities like running or jumping. For example, a healthy Achilles tendon acts like a spring that propels you forward with each step allowing for more efficient movement with less effort.
Is Tendon Pain Really Inflammation (Tendinitis)?
The term "tendinitis" suggests inflammation as the primary issue, but research now shows that most tendon pain involves structural changes, like collagen disorganization and degeneration, rather than active inflammation. This has led to the term “tendinopathy,” focusing on managing tendon strength and function through gradual loading rather than just reducing inflammation.

Why Do Tendons Hurt?
Tendon pain, or tendinopathy, often starts when tendons experience too much stress or load too quickly, leading to tissue changes and degeneration over time.

Understanding the Continuum of Tendon Pathology
  • Reactive Tendinopathy: An initial response to overload, common in younger individuals or after a sudden change in activity.
  • Tendon Dysrepair: As tendinopathy progresses, the tendon shows collagen disorganization and increased protein production, indicating a struggle to keep up with repair.
  • Degenerative Tendinopathy: In advanced cases, the tendon has disorganized, weakened tissue that no longer fully recovers, common in older adults or those with chronic tendinopathy.
​This image shows pathological changes in tendon tissue, including increased vascularization and disorganized collagen fibers. These changes are typical in tendinopathy, where failed healing responses lead to altered tissue structure and persistent symptoms.
Taken from: The roles and therapeutic potential of mesenchymal stem/stromal cells and their extracellular vesicles in tendinopathies.
How Exercise Helps: The Key to Recovery
Exercise is crucial for making your tendons stronger and reducing pain, even if some tissue remains damaged. It helps the healthy parts of the tendon become more resilient, easing discomfort and improving function. Slow, controlled movements are especially effective in the early stages of rehab, offering a safe way to build strength.
Step-by-Step Tendon Rehabilitation
  1. Start with Isometrics: Exercises like wall sits or holding a calf raise can help manage pain and build initial strength without moving the tendon.
  2. Progress to Heavy Slow Resistance (HSR): Slow exercises like calf raises or leg presses help build tendon and muscle strength. These should feel challenging but shouldn’t cause sharp pain.
  3. Include Plyometrics When Ready: If your goal is to return to sports, gradually add jumping exercises to prepare your tendon for faster movements.
  4. Fast Loading for Athletes: Exercises like stair running or skipping can be introduced once your tendon is stronger and needs to handle quick, dynamic movements.
Examples of starting isometrics.
​Full video at Running Rehab.
Avoiding Setbacks During Recovery
Avoid fast, explosive movements until your tendon is stronger, and focus on progressive loading to build resilience. Tendons adapt more slowly than muscles, so gradual loading is key. Be cautious with deep stretching over bones (like deep calf stretches), as this can compress the tendon and worsen pain. Remember, complete rest can delay recovery.
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How to Track Your Progress
  • Tendons often show their response to exercise 24 hours after a session. If your pain worsens the next day, it means the load might have been too high, and it’s time to adjust.
  • Stick to your program until you can perform activities without pain. Rushing back to high-intensity sports too soon can cause pain to return.
  • Focus on how you feel rather than what the scan says. A tendon can look damaged on a scan but still be strong and pain-free with the right exercise.

Aging and Tendon Health
Aging reduces collagen production, making tendons less adaptable and more injury-prone. This effect is may be more pronounced in post-menopausal women due to decreased estrogen. However, regular exercise helps tendons adapt and regain strength, keeping them more resilient.
The following image illustrates collagen fiber changes in tendons as we age, which can be influenced by factors like reduced physical activity or under-loading:​
  • Left - collagen bundles in younger tendons
  • Right - collagen bundles in older tendons
​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.
  • ​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.​​

​Guiding Your Recovery
Start slowly, increase your activity level gradually, and pay attention to your body's feedback. Addressing muscle strength (for example, strengthen feet and calves to handle walking and running loads for achilles issues) and overall movement patterns is crucial for long-term recovery and preventing future tendon issues. 
Courtney Conley talking with Dr. Peter Attia ​about tendon healing.  Full video here.
Sources:
Compiled by Joe Liguori