Tendinopathy

The one rule: how much pain is allowed

Pain during loading is allowed. That surprises people, so here's the number. Up to about 5 out of 10 during the exercise is acceptable and does not mean you're doing damage. Stop if it climbs past that.

What actually tells you whether the dose was right is the next 24 hours. Pain should settle back to your normal baseline, and the following morning should be no stiffer than usual. If both of those are true, the load was right — even if it hurt at the time. If the next morning is worse, the load was too much: drop it by about 20% and repeat, rather than stopping altogether.

So the honest check, before you decide to skip a session, is how the tendon feels the morning after compared with a normal morning:

• About the same — it settled overnight. That's a green light.
• A little stiff but loosens within 10–15 minutes — still fine.
• Noticeably worse, or still sore by the afternoon — that was too much. Ease the dose back.

The four phases of loading

Everyone starts where their symptoms put them, not at phase one by default. Your exact dose gets set in clinic based on what your tendon tolerates today.

• 1. Isometrics — if it's very irritable. Sustained holds against resistance, 5 sets of 30–45 seconds, up to twice a day. This can take the edge off for hours afterward. It's a bridge to get a very angry tendon moving, not a destination.
• 2. Heavy slow resistance — weeks 1–12. This is the part that actually works. Three seconds lifting, three seconds lowering, 3–4 sets of 6–15 reps, three times a week with at least a day between. The weight should be genuinely heavy — the last two reps difficult. This is the phase people cut short, and it's the one doing the work.
• 3. Energy storage — once strength is symmetric. Reintroduce spring: hopping, bounding, faster tempo, change of direction. Start at low volume, twice a week, on non-consecutive days. This is where most tendons get re-aggravated, because it gets added too early.
• 4. Return to sport, then maintenance — for as long as you keep doing the thing. Full return to your activity, plus one or two heavy-slow sessions a week kept in permanently if you're still doing what provoked it. That maintenance dose is the difference between fixed and fixed-for-now.

You're done when your strength matches the other side (tested, not guessed), you've tolerated the specific demand you're returning to — speed, spring, end-range positions — and you've kept loading for at least 12 weeks total, regardless of when the pain stopped.

Loading by tendon

These are general frameworks. The starting load, the range you can safely use, and how fast you progress get set in clinic — getting those wrong is why most people stall.

Achilles (back of the heel). Slow calf raises, both straight-knee and bent-knee, 3–4 sets of 6–15, three times weekly; progress by adding weight, not endless reps. For insertional pain (right at the heel bone), keep the heel level or elevated — no dropping below flat off a step, since that end-range position compresses the tendon against bone — and add a small heel lift in your shoes. Mid-portion Achilles can use the full range.

Patellar — jumper's knee (just below the kneecap). Spanish squats or wall sits for isometric relief, then slow squats, leg press, and decline squats. A decline board increases tendon load — useful, and worth building up to rather than starting on. Reduce jumping, deep landing, and sprint work until strength is restored. This one is aggravated by long periods of sitting with the knee bent — get up and move. See also knee pain.

Gluteal tendons — lateral hip pain, often mislabeled as bursitis. Isometric hip abduction, then progressive loaded work: banded abduction, step-ups, single-leg bridges, offset carries, slow tempo throughout. Compression is the aggravator here — stop crossing your legs, stop standing hipped-out on one side, put a pillow between your knees when side-lying, and skip the stretches that pull the knee across the body. That stretch feels productive and makes it worse.

Proximal hamstring (deep pain at the sitting bone). Isometric bridges, then long-lever bridges, then Romanian deadlifts and Nordic curls. Build in shallow hip flexion first, then gradually deepen the range. Deep hip flexion compresses the tendon, so limit prolonged sitting on hard surfaces, deep forward folds, and full-range deadlifts until it settles. Aggressive hamstring stretching is the most common self-treatment mistake with this one.

Lateral elbow — tennis elbow (outside of the elbow). Isometric wrist-extension holds, then slow wrist extension with a light dumbbell or resistance bar, 3 sets of 15. Add grip strengthening — grip is almost always weak and almost always missed. Reduce sustained gripping with the palm down and elbow straight; change the grip size on tools and rackets, and carry things palm-up where you can. See also elbow pain.

Rotator cuff (shoulder pain with reaching or overhead work). Isometric external rotation, then progressive rotation and press work below shoulder height, building toward full overhead. Strength work, not band-and-ball rehab. Limit end-range overhead and reaching behind your back at first. Sleeping on that side often flares it — support the arm on a pillow.

Plantar fascia (heel pain, worst with the first steps in the morning). Heel raises with a rolled towel under the toes, on a step, three seconds up and three seconds down, every other day, progressing from around 12 reps toward heavier weight and fewer reps. High load beats stretching and rolling. Cut back on barefoot walking on hard floors and long walks on concrete while you build. Morning stiffness lasting more than 15 minutes means yesterday was too much. See also plantar fasciitis.

When to get it assessed first

These protocols assume tendinopathy has actually been identified — several conditions look similar and need different management. Get it looked at before loading if any of these fit, because they don't match the tendinopathy pattern:

• Pain at rest, or waking you at night
• A sudden sharp onset with a pop, or a clear moment of injury
• Visible swelling, bruising, or a gap you can feel in the tendon
• You can't put weight on it, or you've lost obvious strength
• Pain that isn't tracking with load — worse on rest days than training days
• Twelve weeks of consistent loading with no change

This page is general education, not a diagnosis. These protocols assume tendinopathy has been correctly identified — get assessed before starting, and we'll test what your tendon currently tolerates and build the plan from there.