If you’ve ever experienced tendon pain, you may have been told to stop exercising until the pain completely disappears. But does tendon pain always mean you need to stop?
Not necessarily.
For many tendon problems, particularly tendinopathies, rehabilitation involves gradually loading the tendon rather than avoiding activity altogether. The important part is finding the right balance between enough load to encourage adaptation and too much load to continually aggravate symptoms. [1,2]
Does Pain Mean You’re Making the Injury Worse?
Pain doesn’t always mean that you are causing further tissue damage.
Research into chronic musculoskeletal pain suggests that pain experienced during therapeutic exercise does not necessarily prevent successful outcomes. In some circumstances, exercise that allows a degree of pain can produce similar, or even slightly better, short-term outcomes than completely pain-free exercise. [3]
However, this doesn’t mean you should simply push through any amount of pain. Pain needs to be monitored alongside your symptoms and how you respond in the hours and days following exercise.
This is particularly important with tendon rehabilitation, where the response to loading can provide useful information about whether the current exercise dose is appropriate. [2,5]
Why Is Tendon Loading Important?
Tendons adapt to the loads placed upon them. Completely stopping activity may reduce symptoms in the short term, but prolonged avoidance can also reduce the tendon’s tolerance to the demands of sport and everyday activity. [2]
The aim of rehabilitation is therefore to gradually increase the amount of load your tendon can tolerate.
This is particularly important for athletes who eventually need their tendon to cope with high-speed running, jumping, landing or changes of direction. [5]
What Does Progressive Tendon Loading Look Like?
Rehabilitation will depend on the individual and the tendon involved, but a typical progression can include:
● Isometric exercise: static contractions used to introduce or maintain tendon loading.
● Strength exercises: progressively increasing resistance through controlled movement.
● Energy-storage exercises: introducing faster and more explosive movements such as hopping and jumping.
● Sport-specific exercises: gradually preparing the tendon for the demands of your sport. [1,5]
The key is progressive overload. You don’t need to go from resting to full-intensity sport overnight.
Evidence from a randomised clinical trial found that a progressive tendon-loading programme produced greater improvements in patellar tendon function than eccentric exercise therapy after 24 weeks, supporting the use of progressive loading rather than relying on a single type of exercise. [1]
How Much Pain Is Acceptable?
There isn’t one universal pain threshold that applies to everyone.
Research into patellar tendinopathy has used pain-monitoring approaches to allow some discomfort during rehabilitation. One progressive loading programme used a progression criterion of 3/10 pain or less, alongside monitoring symptoms during rehabilitation. [1]
Other approaches have allowed athletes to continue some of their usual activities while using their pain response to guide the intensity of those activities. A feasibility trial found that this pain-guided approach was practical, although larger clinical trials are still needed to determine its effectiveness compared with other approaches. [2]
For this reason, your response over the following 24 hours can be just as important as how the tendon feels during the exercise itself. [2,5]
If your pain settles reasonably quickly and isn’t progressively worsening, the current load may be appropriate. If symptoms remain significantly aggravated for days, the load may need to be reduced. [5]
What If Your Tendon Is Very Irritable?
Not every tendon responds in the same way.
If even small increases in activity cause a significant flare-up lasting several days, your tendon may currently have a low load tolerance. In this situation, rehabilitation may initially focus on lower-load exercises, such as isometrics, before gradually progressing towards more demanding movements. [5]
Isometric exercises can be particularly useful during the early stages of patellar tendinopathy rehabilitation when pain limits the ability to perform isotonic exercises. One proposed programme used five 45-second isometric contractions, with progression based on individual tolerance and symptom response. [5]
The important principle is that the exercise needs to be appropriately dosed, rather than simply being labelled as “good” or “bad” for the tendon.
What About Sport?
One of the biggest mistakes we see is going from “my tendon feels better” straight back to full training. Feeling better doesn’t necessarily mean the tendon is ready for maximum loads.
For athletes, rehabilitation should eventually progress towards the specific demands of their sport. This might mean gradually introducing:
● Running
● Sprinting
● Jumping
● Landing
● Deceleration
● Changes of direction
● Sport-specific drills
The volume of these activities can initially be increased before their intensity, allowing the tendon to progressively adapt to higher demands. [5]
For example, in patellar tendinopathy rehabilitation, jumping volume may be progressed before increasing jump height or speed. Sport-specific training can then gradually replace rehabilitation exercises as the athlete becomes capable of tolerating the demands of their sport. [5]
Why Is Load Management So Important?
Tendon rehabilitation isn’t just about what you do in the gym. What you do outside of your rehabilitation sessions matters too.
Patellar tendinopathy is commonly associated with repeated high tendon loads, particularly activities involving jumping, landing and other energy-storage movements. Managing the volume and frequency of these activities can therefore be an important part of rehabilitation. [2,5]
Completely stopping sport isn’t necessarily the answer either. Prolonged activity cessation can reduce fitness and the tendon’s tolerance to sport-specific loads, whilst continuing at full intensity may not provide enough recovery between loading sessions. [2]
The goal is therefore to find the middle ground: maintaining as much appropriate activity as possible while giving the tendon enough time and capacity to adapt.
The Bottom Line
Tendon pain doesn’t always mean you should stop exercising. The goal is to find the right level of load, monitor how your symptoms respond and gradually build your tendon’s capacity.
A successful rehabilitation programme should progress from appropriate strengthening towards the higher-speed, higher-load activities required for your specific goals or sport. [1,5]
If you’re struggling with persistent tendon pain, a physiotherapist can help assess your symptoms, identify your current load tolerance and develop a progressive rehabilitation programme tailored to you.
Our Barnet, Cockfosters & Enfield Physio’s have tons of experience and are specialists in treating all types of tendon pain. Have confidence that our specialist Physiotherapists will closely assess, diagnose & treat you in the correct & evidence-based way for all injuries. You can book an appointment here.
Blog By: Emre Oz (Head of Integrated MSK & Sports Medicine Operations at Crouch Physio/Specialist MSK Physiotherapist).
References
1. Breda SJ, Oei EHG, Zwerver J, et al. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. British Journal of Sports Medicine. 2021;55:501–509.
2. Sprague AL, et al. Pain-guided activity modification during treatment for patellar tendinopathy: a feasibility and pilot randomized clinical trial. Pilot and Feasibility Studies. 2021;7:58.
3. Smith BE, Hendrick P, Smith TO, et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. British Journal of Sports Medicine. 2017;51:1679–1687.
4. Smith BE, Hendrick P, Bateman M, et al. Musculoskeletal pain and exercise—challenging existing paradigms and introducing new. British Journal of Sports Medicine. 2019;53:907–912.
5. Malliaras P, Cook J, Purdam C, Rio E. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. Journal of Orthopaedic & Sports Physical Therapy. 2015;45(11):887–898.
