Tendinopathy
what it is, its three stages, and how smart progressive overload gets you back to doing what you love
If you’ve ever battled stubborn Achilles pain on a morning run, felt your patellar tendon complain after squats, or noticed a dull ache in your elbow after long hours at the keyboard, you’ve met tendinopathy. Unlike the old “-itis” label (which implied inflammation), tendinopathy is best thought of as a continuum of structural and functional change inside the tendon in response to load.
Australian researchers Jill Cook and Craig Purdam popularised a three-stage model that helps clinicians match treatment to tendon biology. Understanding where you (or your client) sit on this continuum is the key to prescribing the right amount and type of load.
Figure 1 - Pathology Continuum Cook & Purdham 2009
1. Reactive tendinopathy
The tendon’s “alarm-bell” phase
What’s happening inside? A short-term, non-inflammatory thickening of the tendon as it soaks up water to spread the stress.
Typical trigger: Sudden spike in load—e.g., adding hill sprints, a weekend tournament, or an impromptu DIY marathon of home renovations.
How it feels: Sharp, focally tender, often within 24–48 h of the load spike.
Primary goal: Calm the tendon and restore its load tolerance without complete unloading.
Relative rest (reduce—but don’t eliminate—stressful tasks).
Isometric holds (5×45 s at mid-range, pain ≤ 3/10) to modulate pain and maintain some mechanical stimulus.
2. Tendon dysrepair (failed healing)
The “remodelling in progress” phase
What’s happening inside? Collagen becomes disorganised; new but less efficient blood vessels and nerves creep in.
Typical trigger: Repeated overload episodes without enough recovery.
How it feels: Achy stiffness that “warms up” with movement, then bites back later.
Primary goal: Promote quality remodelling with progressive mechanical loading.
Transition from isometric to slow, heavy isotonic work (e.g., 3 s up/3 s down calf raises; 3–4 × 8–12 reps, 3–4 times/week).
Increment load by ~5–10 % only when pain during exercise stays ≤ 4/10 and settles within 24 h. Wexner Medical CenterBMJ Open
3. Degenerative tendinopathy
The “mileage on the clock” phase
What’s happening inside? Areas of cell death and scar-like tissue reduce the tendon’s capacity, but healthier fibres remain.
Typical population: 35 + recreational and elite athletes or anyone with a long-standing tendon grumble.
How it feels: Thickened, nodular tendon, variable pain—sometimes more about lost performance than soreness.
Primary goal: Re-condition the remaining healthy tissue and reroute force through it.
Heavy-slow resistance (HSR): 3 × 6 reps at 6-RM, 3 days/week for ≥ 12 weeks has similar or better outcomes than classic eccentrics and suits in-season schedules. SpringerOpenWexner Medical Center
Energy-storage drills: Once HSR is comfortable, add skipping, hops, or decelerations to retrain the tendon’s spring.
Why progressive overload is non-negotiable
Tendon cells are mechano-sensitive: appropriate load is medicine, and too little load is as harmful as too much. The art is to start at the tendon’s current capacity (matching its stage) and progress one variable at a time—usually load magnitude first, then speed, then volume, and finally complexity (e.g., multi-directional hops). Monitoring pain response 24 h post-session is your built-in gauge: small, short-lived discomfort is okay; lingering or escalating pain is a sign to dial it back.
Ready to reclaim springy, pain-free movement?
I combine physiotherapy assessment with strength & movement coaching to take you from “can’t-train” to “back-at-it—and stronger”.
Here’s what working together looks like:
1-on-1 telehealth or in-person assessment to pinpoint your spot on the tendon continuum.
Custom progressive-overload program delivered via my online platform—videos, sets, reps, and built-in pain/check-in tracking.
Weekly progress reviews so your plan evolves as your tendon adapts.
Holistic performance coaching: movement skills, load management, and the mindset shifts that keep you consistent.
Let’s rebuild your tendon’s capacity—so you can sprint, lift, jump, and live without that nagging pain.
Book your first appointment and let’s get you moving again.
Movement is medicine—let’s dose it right together.
References
Cook JL, Rio E, Purdam CR, et al
Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?
British Journal of Sports Medicine 2016;50:1187-1191.
https://bjsm.bmj.com/content/50/19/1187Cook JL, Purdam CR
Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy
British Journal of Sports Medicine 2009;43:409-416.