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Tendon pain is the most common reason people come to see me. Most of it is self-inflicted — from doing too much, too soon, or from doing too little for too long. Let's review what most people (including many doctors) don't understand about why tendons hurt and how to fix them. 🧵
Tendinitis is a myth (mostly) When your tendon hurts, most people assume "tendinitis" — inflammation, swelling, immune cells. That's not accurate for most adults with tendon pain. Under the microscope, those tendons rarely show the classic signs of inflammation. What they show is something different entirely.
What's actually going on... chronic tendon pain shows: disorganized collagen, microruptures, increased ground substance, excessive vascular and nerve ingrowth, and degenerative changes. The preferred term is tendinopathy — a broader concept that captures failed adaptation, structural change, and pain. The tendon isn't "inflamed." It's struggling.
The continuum... Tendinopathy isn't binary (healthy vs. broken). It's a spectrum. Stage 1 — Reactive: tendon thickens and swells in response to overload. Collagen is still intact. This is the best/easiest phase to treat. Most people rest or stretch here instead. That's the wrong move.
Open a box of spaghetti. Grab a handful — that's how collagen should be arranged in a healthy tendon. Organized, parallel, strong. Now drop it on the floor. That disorganized mess is what the latter stages of tendinopathy looks like under the microscope.
The most common cause of tendinopathy... asking a tendon to handle more stress than it's adapted to. Microdamage accumulates faster than it can be repaired. This is one of the reasons why the 10% rule exists — don't increase training volume, distance, or load by more than 10% in any given week.
Doing too little hurts us too... Tendons also fail from too little load. Without regular stress, tendons lose stiffness and resilience. The collagen becomes less organized. The matrix weakens. Then when load returns — even normal load — the tendon can't handle it. Inactivity is its own risk factor.
In some tendons — gluteal tendons at the hip especially— compression combined with tension accelerates degeneration. This is why stretching certain tendons is a mistake, not a treatment. Stretching certain tendons causes compression and can cause damage and worsen pain. I get a lot of skeptical looks when I say this.
Intrinsic factors: Diabetes, metabolic syndrome, menopause, certain medications (fluoroquinolone antibiotics), genetics — all impair tendon health. This is the primary reason menopausal women see a significant increase in tendon pain. The tendon's biology is not isolated from the body's systemic environment. Glucose and glycated end products (AGEs) are serious troublemakers... same with uric acid.
Rest does not fix tendons... This is important. This is also where most people go wrong. Rest may reduce symptoms temporarily. It does not heal the tendon. Tendons require load for healing. Worse — rest deconditions the tissue, makes it more vulnerable to load when activity resumes, and deprives the tendon of the stimulus it needs to remodel. Put complete rest on the list of things not to do.
Steroid injections: short gain, long cost... Steroid injections offer rapid pain relief — for 4–6 weeks. At 6–12 months, outcomes are often worse than exercise-based programs. Higher recurrence rates. Impaired healing. Risk of tendon weakening or rupture with repeated injections. They have a limited role. They are not a treatment plan.
What actually heals tendons? Load !! Progressive loading sends mechanical signals to tendon cells to realign collagen, strengthen the matrix, and rebuild capacity. Start with isometrics — static holds — when the tendon is very irritable. A wall sit. A static calf raise. These reduce pain and initiate adaptation without high strain.
Heavy slow resistance... Once the tendon tolerates isometrics, progress to heavy slow resistance (HSR). Slow, controlled movement under real load. This has strong support in the literature (as does other forms of loading... HSR is not the only way forward) for Achilles, patellar, and other tendinopathies. Tendons need heavy loads to heal. The key is knowing how to progress that load gradually.
The rehab progression: Isometrics → controlled strength loading (HSR) → dynamic/plyometric loading. Don't rush to plyometrics. That phase comes after months of strength loading, when the tendon has rebuilt enough capacity to handle faster, more reactive demands. Each transition should be gradual.
Pain is a guide, not a stop sign!! Rehab will not be pain-free. Not all pain implies harm. The key barometer... how do you feel the next morning? A mild flare that recovers overnight is acceptable. Pain that persists beyond 24 hours means the load was too aggressive. Adjust and continue. Never let today's workout ruin tomorrow's.
Tendon adaptation is slow!! This is the part that frustrates people most. Full recovery from tendinopathy often takes 4-12+ months. Some cases take more. I tell patients this on day one. They still look surprised when they're not better at 6 weeks. Patience is not optional — it is part of the treatment.
Don't overreact to imaging... Many radiologists report tendinopathy as "partial tears." Most of the time, they are not tears in the clinical sense. Many people with tendinopathy on MRI have no pain. Imaging and symptoms are poorly correlated. If you are improving functionally, do not let an MRI report derail a good program.
Very few tendinopathies... even the ones with partial tears never need surgery. Most all will get better with a loading program. They're not going to get better in a brace or a boot. But that brace or boot will set you back monetarily and it will lengthen your recovery dramatically.
Chronic tendon pain is one of the most frustrating problems I treat. It takes months. It requires load, not rest. It requires patience most people don't expect to need. For far more depth and detail... <a target="_blank" href="https://howardluksmd.substack.com/p/painful-tendons-want-load-not-rest" color="blue">howardluksmd.substack.com/p/painful-tend…</a>
For the full series of tendons posts... <a target="_blank" href="https://howardluksmd.substack.com/p/tendon-health-series?utm_source=publication-search" color="blue">howardluksmd.substack.com/p/tendon-healt…</a>