Tendon Injuries: Understand the Cause, Take Control of your injury
Tendon injuries are frustrating. Whether you're a weekend warrior, an elite athlete, or just someone trying to stay active, tendon pain can feel like a major setback. But here’s the truth: tendon injuries aren’t a life sentence. With the right approach, you can rehab, rebuild, and come back stronger than ever.
In this blog, we’ll break down what tendons are, why they get injured, and most importantly, how you can manage and overcome tendon pain.
What Are Tendons?
Tendons are thick, fibrous tissues that connect muscle to bone (not to be confused with ligaments, which connect bone to bone). They are essential for movement, acting like strong ropes that transfer force from your muscles to your bones.
The Different Types of Tendons
Cord-like tendons: e.g., the Achilles tendon.
Bowstring tendons: e.g., the finger pulleys, common in climbers.
Sheet-like tendons: e.g., the rotator cuff tendons.
No matter the type, tendons are incredibly robust, designed to handle huge forces. For example:
The patellar tendon can take up to 66 times your body weight.
The Achilles tendon can handle an astounding 120 times your body weight.
Why Tendons Are Vital to Performance
Tendons play two major roles:
Store and absorb energy (like a slingshot stretching).
Tendons are elastic which allows them to store energy. In order to capture energy, sufficient muscular strength is needed to transfer our bodyweight to the tendon.
Release and transfer force
Your tendon will release energy / transmit force to propel you for- ward as you stride.
Without healthy tendons, we lose our ability to move efficiently, powerfully, and pain-free.
Why Do Tendons Hurt?
The Truth About Tendon Pain
The cause of tendon pain is complex and not fully understood. It’s important to know that pain isn’t always linked to imaging findings (e.g., degeneration on an ultrasound doesn’t automatically mean pain).
Most tendon issues result from doing too much, too fast, leading to a spike in load that the tendon wasn’t ready to handle.
Types of Loads That Stress Tendons
Compressive Load: Compressive load occurs at the end of a range of motion, or when the tendon is wound over a bone or pressed against a firm surface. For example, this could be pushing off as your leg passes the ankle, where the achilles tendon is stretched over bone.
Tensile Load: Tensile load occurs when our muscles are generating force, which loads the tendon associated with it. For example, this would be performing a heavy calf raise, which places a tensile load onto the achilles tendon.
Friction Load: Friction load occurs when the painful tendon is sliding between tendon sheaths or in areas of ‘high tendon traffic’. A good example of this is painful forearm flexor tendons, which can get irritated as they slide repeatedly through their tendon sheaths.
learn more about common mistakes people make when rehabbing tendons
Load Tolerance vs. Load Exposure
Tendon pain often occurs when your current activity load exceeds your tendon’s capacity. This mismatch can happen suddenly (acute) or gradually over time (chronic).
Acute Vs Chronic Load
Acute Spike: This occurs when there is a big spike in load to the tendon that it is not prepared to tolerate. a drastic example of this would be going from not running at all to running a marathon within a few weeks
Chronic Build: This is often a slower build over time in which the load places upon the tendon cumulatively builds without enough proper recovery and the current load exceeds the tendons capacity. An example fo this would be building you weekly running milage over time without an deload weeks.
The "Cup" Analogy: Why Tendon Pain Isn’t Just Physical
Your tendon’s load tolerance is impacted by more than just exercise. Stress, poor sleep, nutrition, and even your beliefs about pain can “fill your cup.” Once the cup overflows, pain is often the result.
The good news? You can control many of these factors, reducing your risk of tendon pain.
How to Manage Tendon Pain
Quick Fixes vs. Real Solutions
Modalities like massage, taping, or ultrasound might help calm things down temporarily, but they won’t fix tendon pain. The real solution is progressive loading and adaptation.
Load is Both the Poison and the Antidote
Too much load causes tendon pain.
Appropriate load is what adapts the tendon.
The goal is to build your tendon’s tolerance to exceed your current load demands.
How to Safely Load Tendons: The Stoplight System
Green Zone (0-3/10 pain)
Mild symptoms—continue loading.
Yellow Zone (3-5/10 pain)
Moderate symptoms—proceed with caution. Some discomfort is okay
.
Red Zone (6-10/10 pain)
High symptoms—back off and modify.
Use this system before, during, and after loading to track your progress.
Early Stage vs. Late Stage Tendon Rehab
Early Stage Rehab: Desensitization and Control
Multiple lighter loading bouts per day.
Aim to reduce sensitivity and calm the tendon.
Example: wall sit holds for patellar tendinopathy, spaced out over the day.
Late Stage Rehab: Build Load Capacity
Heavier, slower resistance training with longer rest.
Start reducing frequency and introducing rest days to allow remodeling.
Heavy Slow Resistance (HSR) exercises are key to strengthening the tendon and reducing re-injury risk.
The Importance of Heavy Slow Resistance Training (HSR)
Why Tendons Love Heavy Slow Resistance
Stimulates tendon remodeling.
Increases strength and capacity.
Prepares tendons for high-load sports and activities.
Progressive Loading Example for Achilles Tendon
Start with slow calf raises (Tempo 3-0-3-0).
Gradually add weight and decrease reps (e.g., from 15 reps to 8 reps).
Benchmark goal: 3 sets of 15 single-leg calf raises with half your body weight.
Don't Skip Plyometrics!
Before returning to sport, it’s essential to add plyometric exercises:
Jumping, hopping, and landing drills retrain the tendon to handle explosive loads.
Neglecting this phase increases the risk of re-injury.
Key Takeaways
5 Essential Points About Tendon Pain & Rehab
Tendons are robust and adaptable.
Tendon pain is a load management problem that needs a load management solution.
Load is both the poison and the antidote.
Rest and passive treatments aren’t enough—progressive loading is key.
Complete the full rehab process, including heavy strength training and plyometrics, to prevent recurrence.
Final Thoughts: Tendon Pain Doesn't Have to Be Forever
Tendon injuries are tough, but they’re not permanent. With the right guidance, you can rebuild your tendons, return to the activities you love, and even improve your performance.
If you're struggling with a tendon injury and want help, we’re here for you. At The Movement Physiotherapy & Performance, we guide people through every phase of rehab, from pain relief to peak performance.
