Injury & Rehab
Tendinopathy: the slow injury that responds to load
Tendon problems frustrate people because rest makes them feel better and then they return worse. The mechanism explains why, and it points to what actually works.
Tendinopathy — the modern term for what used to be called tendinitis — is one of the most common problems in lifters and one of the most badly managed, largely because the intuitive response is exactly wrong.
Why the name changed
The old term implied inflammation. When researchers looked at chronic tendon tissue, they found relatively little classic inflammation and instead found disorganised collagen, increased ground substance and abnormal blood vessel and nerve ingrowth — a failed healing response rather than an inflammatory one.
This matters practically. If the problem is not primarily inflammatory, anti-inflammatory treatment addresses symptoms rather than cause, and rest — which reduces the irritation — does nothing to fix the underlying tissue quality.
The frustrating pattern
It hurts, so you rest. Resting reduces the pain, because you have removed the stimulus. You feel better and return to training at the previous load. The tendon, which has become weaker during the rest, is now less capable than before, and the symptoms return quickly and worse.
This cycle can repeat for years and it is the single most common reason tendon problems become chronic.
What actually works
Progressive loading. The tendon adapts to load, and controlled, progressive loading is the intervention with the best evidence across essentially every tendon studied.
The specific protocols have evolved. Heavy slow resistance training — controlled, heavy repetitions with slow tempos on both the lifting and lowering phases — has performed as well as or better than the eccentric-only protocols that dominated for a period, and it is generally better tolerated and easier to fit into a training programme.
The general shape: load the tendon through the range, heavily enough to stimulate adaptation, slowly enough to control, at a dose that produces acceptable symptoms, progressed over months.
The pain rules
Pain during and after loading is expected and acceptable within limits. The widely used guidance:
Pain up to around three or four out of ten during the exercise is acceptable. Pain should settle within twenty-four hours. Pain and stiffness the next morning should not be worse than the previous morning.
If those conditions are met, continue and progress. If they are not, reduce the load and stay there for a while.
This tolerance for symptoms is what distinguishes tendon rehabilitation from most other injury management, and it is the part people find hardest to accept.
The timeline
Tendon adaptation is slow. Collagen turnover takes months, and rehabilitation programmes in the research typically run twelve weeks or considerably longer, with continued improvement well beyond that.
Meaningful change in three weeks is unrealistic. This is the single most important expectation to set, because the most common failure is abandoning a programme just before it works.
Managing load elsewhere
Reduce the aggravating activity rather than eliminating it. If the problem is patellar tendinopathy, reduce jumping and deep loaded knee flexion volume temporarily while continuing to load the knee in a tolerable range.
Keep training everything else fully. There is no reason a lifter with elbow tendinopathy should stop squatting.
The common sites in lifters
Elbow — lateral or medial, associated with gripping, pulling and pressing volume. Often responds well to heavy slow wrist extension or flexion work and to reducing grip-intensive volume temporarily.
Patellar tendon — pain at the bottom of the kneecap, aggravated by squatting and jumping. Responds to heavy slow squatting variations in a tolerable range, often with a reduced depth initially.
Achilles — responds to progressive calf loading, both straight and bent knee.
Rotator cuff related — progressive loading in external rotation and in the pressing pattern.
Proximal hamstring — pain at the sitting bone, aggravated by hinging and sitting. Notoriously slow and responsive to progressive hinge loading, often starting with a very limited range.
What has weaker evidence
Passive treatments — ultrasound, most manual therapy, taping — may help symptoms briefly and do not change the tissue.
Corticosteroid injections reduce pain in the short term and several studies show worse outcomes at longer follow-up compared with exercise. They have a role in specific circumstances and are not a first-line answer for a lifter.
Stretching a painful tendon, particularly a compressive one like the proximal hamstring or the Achilles at its insertion, frequently makes things worse.
The one-line version
Do not rest it. Load it, heavily enough to matter and lightly enough to tolerate, slowly, for months. That is boring advice and it is what the evidence supports.
