Is Tendon Pain Ruining your Running?

Tendon pain, referred to as tendinopathy, is debilitative condition that commonly affects the Achilles and patella tendons. The athlete can initially ‘run through’ the pain in the early stages however this often interferes with the healing stages. 

Common signs and symptoms of tendinopathy include:

  • A stiff and painful tendon in the morning
  • Pain with running that can ease with warming up
  • Latent pain and stiffness post exercise
  • A thickened/ swollen tendon that is tender to touch

Tendon pain and pathology is a response to over load to the tendon unit. This can be from a sudden unaccustomed load or general overuse/ overtraining. 

Examples of unaccustomed load may be: 

  • A long run after a 2-3 weeks off running
  • A short sprint after the bus for some one who seldom runs
  • Altered biomechanics post an injury increasing the load on the tendon
  • The start of pre season training after having 2 months rest
  • A change in footwear or running technique 

It is very important you know the stage of the disorder in order to effectively manage the condition. Your Physiotherapist may opt for imaging (ultrasound) to determine the stage of pathology. 

There are 3 stages of tendinopathy: 

  1. Reactive stage
    1. Acutely sore, stiff and swollen tendon
    2. Due to abusive overload to tendon
  2. Dysrepair stage
    1. A worsening of tendon pathology with tendon matrix breakdown
    2. Transition to the dysrepair stage occurs with continuation of training in the presence of tendon pain
  3. Degenerative stage
    1. “The grumbly old tendon”
    2. Further breakdown of collagen matrix
    3. Typically get ‘flare ups” where healthy part of tendon becomes reactive (stage 1) 

Your Physiotherapist must also consider what else could be the source of your pain other than the tendon. In the Achilles region this may include:

  • The retrocalcaneal busae
  • Enthesopathy: Tendon- bone attachment
  • The para-tendon: surrounds tendon
  • The plantaris muscle- a small thin muscle that runs next to Achilles
  • Kager’s fat pad
  • Referred pain for lumber spine or muscle trigger points


The most important thing in managing tendinopathy is load management. Unfortunately rest alone will not improve your tendon pain. It can in fact make it worse. Tendons require a gradual progression of load to improve the capacity of the musculo-tendinous unit to affectively absorb load. 

Your physiotherapist should prescribe a specific loading program to suit to your requirements, goals and activity levels. For an Achilles tendinopathy this may be in the form of 

  • Isometric (static) calf raises
  • Eccentric (lowering) calf raises
  • Concentric and eccentric (up and down) calf raises

Progressions are then made via increasing repetitions, adding weight; increasing speed and transitioning to sports specific training involving the stretch shorten cycle (jumping, running etc.) for athletes returning to sport. 

Experienced Physiotherapists will also conduct a thorough assessment to identify and correct possible causative factors in the kinetic chain. These may include: 

  • Reduced ankle (dorsi-flexion) range of motion
  • Reduced hip extension
  • Poor pelvic (gluteal) control
  • Muscle weakness/ tightness & imbalance
  • Foot & ankle mechanics (over probation)
  • Training technique & footwear

Unfortunately there is not a quick fix for tendon pain. Improving tendon pathology can take weeks to even a year in some cases. You must committed to the cause, be patient and be positive. 

Take home message

  • Conservative management is your best option
  • Set reasonable expectations: Tendons take time
  • Early diagnosis and management improves long term outcome
  • Must correct pre disposing & biomechanical factors
  • Load management is the key