Tendinopathy: Why Tendons Hurt and How to Train Through It

I'm Amer, and if there's one injury I've spent more time managing than almost any other, it's the cranky tendon. Achilles, patellar, elbow, rotator cuff, gluteal. The location changes but the story is almost always the same: someone did too much, too soon, the tendon complained, they panicked and stopped everything, and now months later it still hurts. If that's you, I want to explain what's actually going on and, more importantly, how to get you back to training.

Tendinopathy, not tendinitis

For decades we called this "tendinitis", assuming the tendon was inflamed. But when researchers looked at the tissue of people with chronic tendon pain, they found very little classic inflammation. What they found instead was a tendon that had become disorganized: collagen fibers in disarray, extra ground substance, and a nervous system that had turned up the volume on pain signals. That's why the modern term is tendinopathy, meaning a diseased or unhappy tendon, not necessarily an inflamed one.

This isn't just semantics. It completely changes the plan. If the problem were pure inflammation, you'd rest and take anti-inflammatories and wait it out. But because the real issue is a tendon that has lost its capacity to handle load, the solution is to carefully rebuild that capacity. Rest alone makes a tendon weaker, not better.

Why tendons hurt: the load management story

Tendons are remarkably strong, but they're also slow to adapt. Muscle can respond to new training within days. Tendon takes weeks to months. When your training load outpaces your tendon's ability to keep up, you get a mismatch, and that mismatch is where tendinopathy is born.

The classic triggers I see:

• A sudden spike in volume or intensity. New running program, a jump in weekly mileage, a return to lifting after time off, adding plyometrics too fast.
• Repetitive load with poor recovery. The same movement, day after day, without giving the tissue time to remodel.
• Compression. Some tendons hate being squashed against bone, like the Achilles near its insertion or the gluteal tendons at the hip. Deep stretching into that compression often makes things worse.

Notice what these have in common: they're all about load management, not weakness of character or bad luck. The good news is that load is also the medicine. We just have to dose it correctly.

The role of progressive loading and isometrics

Here's the principle that changed how I coach tendon injuries: a tendon needs to be loaded to heal, but it needs to be loaded in a graded, progressive way. Think of it like a dimmer switch, not an on-off switch.

I usually start with isometrics, meaning holds where the muscle contracts but the joint doesn't move. For example, holding a wall sit for a patellar tendon, or a heel-raise hold for the Achilles. Isometrics let us load the tendon heavily without the strain of movement, and for many people they actually reduce pain for a few hours afterward, which is a nice bonus. A typical prescription might be five holds of 30 to 45 seconds, a few times a day.

From there we progress to slow, heavy strength work. Controlled reps with a deliberate tempo, gradually adding weight over weeks. The tendon responds beautifully to this kind of steady, heavy stimulus. Later, if you're an athlete who runs or jumps, we reintroduce faster, spring-like loading so the tendon can store and release energy again. Skip that final stage and you'll feel great in the gym but get bitten the first time you sprint.

Patience and realistic timelines

I won't lie to you: this takes time. Because tendons have a limited blood supply and remodel slowly, most people need three to six months of consistent loading, sometimes more. Progress is rarely a straight line. You'll have good weeks and flare-ups, and a flare-up doesn't mean you've undone your work. It usually just means the dose was slightly too high that week.

I track two things with every client: pain during and after loading, and how the tendon feels the next morning. My rule of thumb is that pain during exercise can sit around a 3 out of 10, but it must settle back to baseline within 24 hours. If your tendon is more irritable the next day, we did too much. If it's calm, we can progress. This simple feedback loop keeps you moving forward without flaring things constantly.

What NOT to do

Just as important as the plan is avoiding the traps that keep people stuck for years:

• Don't rest completely. Total rest feels safe, but it de-conditions the tendon so the pain comes straight back when you return. Relative rest, reducing load rather than removing it, is what works.
• Don't reach for cortisone as your first move. Injections can numb the pain for a few weeks, but the research consistently shows worse outcomes over the long run compared to loading, and repeated shots can weaken the tissue. Save it for specific cases, alongside loading, not instead of it.
• Don't aggressively stretch a compressive tendon. Cranking an already irritated insertional Achilles or gluteal tendon into a deep stretch usually adds fuel to the fire.
• Don't chase passive treatments alone. Massage, ultrasound, and taping can feel good and have their place, but they don't rebuild load capacity. Nothing replaces graded loading.

Let's train through it, together

Tendinopathy is frustrating precisely because it responds to patience, and patience is hard when you just want to train. But I've walked a lot of people from "I can't go up the stairs" back to lifting and running, and the path is almost always the same: reduce the load to something tolerable, load it progressively, respect the 24-hour rule, and don't quit when a flare-up shows up. If you're dealing with a tendon that won't settle, I'd love to build you a proper loading plan and coach you through it step by step. Reach out, and let's get that tendon strong again instead of just resting it and hoping.