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What Endurance Athletes Need to Know About Tendon Pain

Updated: Apr 16

We often see the same repeated issues in our patients, and when it comes to endurance athletes, tendon issues are very common. Knee pain from running or squatting often comes from patellar tendinitis, and runners also frequently deal with Achilles tendon pain. Both of these problems are typically an overuse injury, and healing while maintaining an active lifestyle can be a frustrating process for an athlete.

Tendinopathy symptoms can often be nagging and hard to calm down. Understanding the process that's occurring can be incredibly helpful in rehabilitation and return to sport.

The first thing to understand is that treating tendinopathy can be a highly variable process. There's no one-size-fits-all treatment, and long-term healing depends on having a thorough and strategic treatment plan that will give your body the best opportunity to heal and adapt.

Tendinopathy usually begins with an abrupt change in load.

Runners, you know what I am talking about - We change our shoes, switch out our inserts, or commit common training errors like increasing load too quickly without adequate recovery. Tendons are incredibly strong, but they love consistency and recovery. Too much change too quickly can irritate the tendon and land athletes on my doorstep.

1. Tendinopathy begins in the first stage known as REACTIVE TENDINOPATHY. During this stage, the tendon is responding to an acute overload in stress. Tendon cells are held together by something known as the “extracellular matrix.” This matrix helps keep cells together as well as protect them from outside forces. When the tendon has been acutely overloaded, it stresses the matrix beyond its capabilities. Your body attempts to repair it by sending in structural proteins to help rebuild the matrix, and this often leads to swelling.

During this phase, modifying load is incredibly important. This does NOT necessarily mean immobilization in a boot! Immobilization can often worsen tendon strength and contribute to symptom return when the tendon is stressed once again. During this stage, modifying activity and strategically loading the tendon are crucial to allow the tendon to return to normal.

2. If the tendon continues to be overloaded during reactive tendinopathy it will lead to further tendon breakdown. This stage is known as TENDON DYSREPAIR. The matrix that protects the tendon cells themselves continues to become weaker. Fibers separate and become disorganized. The body knows this area is struggling to heal and can increase blood and nerve supply to this area. This can potentially be another cause of pain in chronic tendon overloading.

3. If overloading continues, the tendinopathy can progress to a DEGENERATIVE TENDINOPATHY. In this phase, the protective matrix, as well as the tendon cells themselves, have been damaged enough to cause areas of cell death and breakdown. Functional return from this stage may not be possible and in some athletes can be career-ending.


Understanding this continuum is incredibly important, especially for the endurance athlete.

Treating tendinopathy early increases the likelihood to return to normal tendon function. With early treatment, proper activity modification, and appropriate load, tendons have a good healing capacity and can return to the strength necessary for high impact and loaded sports.

If you've been struggling with pain that may be caused by a tendon issue or are worried that this could be your problem, we can help.

Tendinopathy can be an incredibly frustrating and difficult thing to rehabilitate both for the athlete, and it's not the type of injury that will successfully heal without a comprehensive plan from a specialist.

Ultimately, loading is the primary antidote to tendinopathy but has to be applied carefully and strategically. We can get you there and help you stay active in your sport for the long-run, so if you have any questions, please reach out.

Tell us what's going on below, and we can give you advice on your best next step.

Don't let tendon problems sideline you from your sport! You can heal and be better than ever, and we can get you there.


Cook, J. L., & Purdam, C. R. (2008). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409–416. doi: 10.1136/bjsm.2008.051193


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