Tendons are incredibly strong, fibrous tissues made primarily of collagen. Their main role is to connect muscles to bones and transmit forces that create movement. When a muscle contracts, the tendon pulls on the bone, allowing actions such as walking, running, lifting and jumping. Because tendons manage such high loads, they are vulnerable to irritation when overloaded.
Tendon pain typically develops gradually, usually caused by repetitive stress or sudden increases in load. When tendons are overworked without adequate recovery, small portions of the collagen fibres begin to break down. This results in pain, stiffness, and reduced ability to tolerate normal daily or sporting activities. The medical term for this condition is tendinopathy.
Although any tendon in the body can develop symptoms, tendinopathy is especially common in the lower limb, where tendons manage large forces during movement and locomotion. The most frequent sites include:
Gluteus medius tendon – common in runners, walkers and those who stand for long periods.
Psoas (hip flexor) tendon – often irritated during repetitive hip flexion movements such as running uphill.
Adductor tendons – often affected in sports involving cutting, kicking and rapid direction changes.
Hamstring tendon – especially where the tendon attaches near the pelvis.
Patella tendon – common in jumping athletes or during rapid increases in squatting, stair-climbing or lifting activities.
Achilles tendon – one of the most common tendinopathies in active adults.
Peroneal tendons – located on the outer ankle, often irritated after ankle sprains or excessive walking on uneven surfaces.
Tibialis posterior tendon – critical for arch support; often irritated by walking, running or prolonged standing and often more likely if you have a flattened arch.
Tendons are designed to tolerate load, but when the load applied to the tendon exceeds its capacity, microscopic damage develops. Tendinopathy occurs when:Activity volume increases too quickly
Training intensity spikes
Biomechanics place extra stress on the tendon
Muscle weakness increases strain on nearby tissues
Poor recovery or sleep limits healing
Footwear is inadequate
Age-related changes affect collagen qualityCertain health conditions can increase the risk for the development of lower limb tendinopathies.
Over time, the tendon becomes sensitive and painful when stressed, especially during activities that compress or load the tissue.
Common symptoms include:Localised tendon pain
Morning stiffness or “first-step” discomfort
Pain during or after exercise
Reduced tolerance to load (running, jumping, stairs, hills)
Tenderness to touch
Swelling or thickening (in some cases)Tendons often “warm up” and get less sore during exercise
Symptoms are often persistent without proper management, which is why targeted physiotherapy is essential.
Physiotherapy is the first-line, evidence-based treatment for tendinopathy. It focuses on restoring tendon capacity, managing load, and addressing individual factors that contribute to overload.
Key components include:
Understanding how tendon pain works is one of the most important aspects of recovery.Your physiotherapist will help you:Identify which activities are aggravating the tendon
Modify load without complete rest
Maintain fitness during recovery
Understand the difference between acceptable and unacceptable pain levels
This prevents further irritation and creates the right environment for the tendon to adapt.
Research consistently shows that a graded, progressive strengthening programme is the most effective way to improve tendon health.Building strength gradually helps the tendon adapt and become more resilient. This process normally requires 12+ weeks, as tendons remodel slowly in response to load.Evidence for Strength Training Strength programmes have been proven to significantly improve pain and function in multiple tendinopathies, including:Achilles tendinopathy
Patella tendinopathy
Gluteus medius tendinopathy
These results are consistent across numerous clinical studies and form the foundation of modern physiotherapy treatment see here.
Your physiotherapist will assess and treat other elements that influence tendon load, such as:Muscle weakness
Reduced hip or foot control
Stiffness in surrounding joints
Gait or running technique
Footwear suitability
Training errors
Correcting these factors reduces strain on the tendon and ensures long-term improvement.
Hands-on physiotherapy may help reduce discomfort and improve movement in nearby joints or muscles. While manual therapy does not “fix” a tendon, it can help restore mobility and reduce sensitivity during the rehab process.
A structured plan helps you safely return to:Running
Gym training
Walking
Sport-specific movements
Occupational tasks
Your physiotherapist will guide your progress to prevent reinjury and build long-term tendon resilience.
Do not completely rest as this generally weakens the tendon.
Avoid stretching the tendon early on as stretching often compresses and irritates the tissue.
Don’t rely on passive treatments alone. Ultrasound, needling, and massage are not effective on their own without strengthening.
Don’t ignore ongoing symptoms. Early intervention generally leads to faster recovery.
