top of page

Book a video consultation with our physios

Body Hack #4: Tendon Pain

Updated: Feb 17, 2023



In this article I specifically discuss overstrain injuries of tendons, including how they’re caused and what you can do to recover. This type of tendon injury is commonly referred to as tendinitis, tendinosis or tendonitis. All three these terms refer to the same thing. Check out our online service for treating Achilles tendonitis.

Body Hack #4: Tendon pain - Learn about the causes and how to treat it.

In this article:

  • Examples of common tendon injuries

  • What happens when a tendon gets injured?

  • Causes of tendon pain

  • How do you know it’s a tendon that you’ve injured?

  • What to do about tendon pain

I've also discussed it in detail in this video:

Examples of tendon injuries

A tendon is the thick sinewy bit that attaches your muscles to your bones. In theory you’re able to develop tendinosis in any tendon in the body, but there are certain ones that are more prone to injury than others. Check out the picture below the list to see where this is. These include:

  1. Tennis elbow – This is caused by an injury to the common extensor tendon of the wrist

  2. Golfer’s elbow – This is caused by an injury to the common flexor tendon of the wrist where it attaches to the inside of the elbow.

  3. Biceps tendon where it runs over the front of the shoulder

  4. Rotator cuff tendons in the shoulder joint

  5. Iliopsoas (hip flexor) tendon where it runs over the front of the hip

  6. Hamstring tendon where it attaches to the sit-bone

  7. Glute med tendinopathy can be felt deep inside the buttock – usually more towards the side.

  8. Adductor tendons where they attach on to your pelvic bone in your groin

  9. Patellar tendon where it attaches into the lower end of your kneecap

  10. Achilles tendon – This can get tendinosis either where it attaches into the heel bone or in the middle of the tendon.

  11. Tibialis posterior tendon that wraps around the inside of the ankle

The most common areas of the body to develop tendon pain.

What happens when a tendon gets injured?

Tendons mainly consists (70%) of tightly packed collagen bundles that are aligned in parallel. Collagen is pretty tuff stuff to start with but this parallel alignment ads to the tendon’s strength.

Think of a piece of sewing thread. When single, it’s quite easy to break but if you take 5 pieces of thread together (in parallel) it becomes significantly stronger and more difficult to snap.

When you injure a tendon, it affects the collagen in the following ways:

  • The collagen fibres become thinner.

  • They become wavier and lose their parallel alignment in certain areas.

  • The overall density of the collagen fibres in certain parts of the tendon decreases.

Tendons also contain cells (e.g. tenocytes). Some of these cells change shape when a tendon is injured.

When you look at an injured tendon using an ultrasound scanner, you often see little blood vessels that are present in the injured part. Healthy tendons don’t tend to have blood vessels growing inside them.

The end result of all of these changes is that you end up with a painful tendon that isn’t quite as strong as it used to be. The tendon may also appear to have a thickened bump in it – this is most prominent when you have Achilles tendinosis.

Causes of tendon pain

The number one cause of tendinosis or tendon pain is when you overwork the tendon. This can be done suddenly or slowly over time. Let me explain.

Sudden overload

This is when you do an activity that is much harder than what the tendon has been trained to cope with.

Examples include increasing your training volume too quickly e.g. you’re only used to running 5 and 10km and then suddenly do a 20km run. Or you do a more intense training session e.g. you lift a much heavier weight than what you normally lift; or you’re used to running mainly on the flat and suddenly jump into a hard hill session; or you’re used to running only slowly and suddenly do a hard speed session.

When your tendon pain is caused by sudden overload, you usually develop quite intense pain within hours of your last training session or wake up with a painful tendon the next morning.

Gradual overload

When we train or exercise our bodies undergo micro-damage in our muscles, bones, ligaments and also our tendons. This micro-damage acts as the stimulant to tell the brain to make your body stronger. If you give yourself enough recovery time after exercise, the body repairs this exercise induced damage and you end up with stronger tendons etc.

BUT if you don’t allow it to recover fully and train too often, this micro-damage accumulates and can cause a wide variety of injuries.

This is how you can developed a tennis elbow by working long hours on a computer and repeating the same wrist movements for hours on end. The poor wrist muscles and tendons also need a break!

Poor technique can cause tendons to overstrain over time. Thinking of tennis elbow again. A tennis player may develop it if they don’t use their hips enough and try to create all the force for their backhand shots with their arms.

Muscle weakness in other parts of the body can cause trouble. Glute med weakness may cause your leg to turn in more when running which in turn can cause your foot to turn in or pronate excessively. This whipping action can often contribute to Achilles and Tibialis Posterior tendinopathy.

Tendon pain caused by gradual or cumulative overload usually develops over a period of weeks.

Other causes of tendinosis include:

  • Conditions like diabetes and very high cholesterol

  • Inflammatory conditions e.g. psoriasis can cause tendon pain

  • The menopause (yip, another symptoms to add to the list ladies…sigh)

  • Certain antibiotics (Fluoroquinolones) can cause tendon damage

How do you know it’s a tendon that you’ve injured?

  • The pain is usually pretty much localised to the specific tendon and does not tend to refer into other body parts – see the picture.

  • It often feels worse after you’ve stretched it. This is not always the case but is especially true for glute med tendinopathy, tennis elbow, hamstring, tib post and insertional Achilles tendinopathy.

  • If gradual overload is causing your tendon pain, you may find that it follows a pattern where you can feel the pain at the beginning of an exercise session, it then improves as you continue to train, but then comes back worse later in the day.

  • If you caused your tendon injury through a sudden overload, you will likely find that you cannot exercise it due to the pain.

  • You may find that the tendon feels very stiff after you’ve sat still for a period of time or first thing in the morning. Depending on your injury, this stiffness may disappear quickly with movement or stay there for most of the day.

When it may not be tendinopathy

  • If the pain came on as a sudden sharp pain while exercising – this usually means that you’ve torn something and it’s best to go and see a physio.

  • If you’re getting any pins and needles or funny sensations in your arm or leg. Chances are that you’ve injured a nerve and I would again consult a physio for a proper diagnosis.

  • If the pain refers up or down your arm or leg e.g. you have buttock and heel pain or you have shoulder and elbow pain. I would once again want to make sure that your pain is not coming from a nerve rather than your tendon.

  • If the injury throbs or feels hot, please go and see your doctor. These are signs of infection and will likely need medical attention.

What to do about tendon pain

  1. Figure out the cause. You have to know the cause if you want your tendon injury to recover and not come back in the future.

  2. Relative rest. You don’t necessarily have to stop all exercise. You can often just adjust your training volume, intensity or even the terrain you train on. The important thing is to establish a baseline of training that you can perform that does not make your pain worse. It’s OK to feel some discomfort while exercising but it should not increase it by more than about 3/10 in the 24 hours afterwards. I tend to spend a large portion of my consultation time on making sure that I fully understand my patient’s training schedule and history as this part of the treatment is key to making a successful recovery.

  3. Follow a carefully graded strengthening programme to help the tendon recover. Those damaged collagen fibres has to be replaced by healthy well organized ones. The only way to do this is by exercising them, but the level of exercise has to be pitched at the right intensity for your specific tendon. There is no one-size-fits all.

  4. Fix the other things that may have contributed e.g. poor technique, muscle weakness in other parts of the body, shoes or equipment etc.

Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.

About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate.


  • Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports medicine and arthroscopy review 2018;26(1):16-30.


bottom of page