Tendon pain has a reputation for being stubborn — and it often is, if it’s managed the wrong way. For years, standard advice was rest, ice, and anti-inflammatories. The evidence now points firmly in a different direction: progressive, targeted loading — not rest — is the most effective path back to pain-free movement for the vast majority of tendon conditions.
Understanding tendon pain (tendinopathy)
Tendons transmit huge forces between muscle and bone, and they adapt to load slowly compared to muscle tissue. When load increases faster than a tendon can adapt — a new training block, a change in surface, a sudden volume spike — the tendon’s structure and cell response begin to change, producing the pain, stiffness, and reduced capacity we call tendinopathy. Persistent inflammation is rarely the main driver in longstanding cases, which is why anti-inflammatory approaches alone often fall short.
Tendons we commonly treat
- Achilles tendinopathy — pain in the tendon at the back of the ankle, often worse with the first steps in the morning and during running or jumping
- Patellar tendinopathy (“jumper’s knee”) — pain just below the kneecap, common in basketball, volleyball, and other jump-heavy sports
- Gluteal tendinopathy — pain over the outer hip, more common in runners and those who stand or walk a lot for work
- Hamstring tendinopathy — pain at the sit bone, aggravated by sitting, sprinting, or stretching-type loads
- Rotator cuff tendinopathy — shoulder tendon pain, discussed further on our shoulder pain page
Symptoms of tendon pain
- Pain that’s localised to a specific tendon, often described as sharp or “stiff and sore” rather than diffuse
- A recognisable pattern of being worse with the first load of the day (getting out of bed, first few steps), easing with warm-up, then sometimes returning after activity
- Pain that increases in a fairly predictable, dose-related way with specific loaded movements (jumping, running, stairs)
- Gradual onset over weeks, rather than a single traumatic moment
Our evidence-based approach
Systematic reviews consistently support progressive tendon-loading exercise as more effective than eccentric exercise alone, with structured load progression improving both pain and function over time. Alfredson’s classic eccentric loading protocol remains a foundation, but current best practice adapts intensity, exercise selection, and pace to the individual rather than applying a fixed protocol to everyone. Our approach includes:
- Confirming the diagnosis and ruling out other contributing structures
- Education on the loading model — understanding why rest alone won’t fix tendon pain helps patients stay consistent with a program that can initially feel counterintuitive
- Staged loading, typically progressing through isometric, isotonic (heavy slow resistance), then energy-storage (plyometric/sport-specific) phases as tolerated
- Addressing kinetic chain deficits — for example, hip and calf strength for Achilles or patellar tendinopathy
- Dry needling, where appropriate, alongside — not instead of — active loading
What to expect: recovery timeline
- Early-stage or reactive tendinopathy: pain often eases within 2–4 weeks of appropriate load modification
- Established tendinopathy: meaningful structural and functional change typically takes 3–6 months of consistent, progressive loading
- Return to sport-specific/energy-storage loading (running, jumping): usually the final phase, introduced once basic strength benchmarks are met
When to seek help
Persistent tendon pain that hasn’t improved despite rest, or pain accompanied by a sudden “pop” and loss of function (which can indicate a tendon rupture), warrants prompt assessment.