Mobility, Posture & Pain - Common pain
Tendon pain and progressive loading
Last updated 30 September 2026. How we write this .
Long-lasting tendon pain usually responds best to exercise that loads the tendon and builds up over weeks. Trials find different loading programmes work about equally well, while steroid injections fare worse long term.
Start here Long-lasting tendon pain usually responds best to exercise that loads the tendon and builds up over weeks. Trials find different loading programmes work about equally well, while steroid injections fare worse long term.
By the end, you will understand What is tendinopathy, and is it just inflammation? What did trials comparing exercise programmes find? Is there one best type of exercise? Key words used in this lesson Placebo An inactive comparison given so that the effect of expectation can be separated from the effect of the intervention itself. Without one, improvement over time cannot be attributed to the treatment. Full plain-English glossary
Where this information comes from Claim-cited evidence. Central research claims on this lesson are linked to specific studies or official guidance.
This lesson links the specific studies and guidance used for its central claims.
Our standard: expert or athlete opinion may illustrate a viewpoint, but it is never treated as proof. Read the editorial policy .
Report an error or outdated claim .
Long-lasting tendon pain, called tendinopathy, is usually treated with exercise that puts the tendon under load and builds up gradually over weeks or months. Trials comparing different loading programmes find they tend to work about equally well. Stopping all sport is not always necessary, and steroid injections give quick relief but worse results a year later.
What is tendinopathy, and is it just inflammation?
Tendons are the tough cords that connect muscles to bones at joints such as the knee, elbow, heel and shoulder. The NHS describes tendonitis as a tendon swelling after an injury, and says a mild injury should feel better within two to three weeks. Pain that lasts for months, often linked to running, jumping or repeated gripping, is usually called tendinopathy and is treated as an overuse problem. Common sites include the Achilles tendon at the back of the heel, the patellar tendon below the kneecap, the tendons on the outside of the elbow, which cause tennis elbow, and the rotator cuff in the shoulder.
What goes wrong inside the tendon is still debated. In a 2009 paper, the Australian researchers Cook and Purdam pointed out that tendinopathy had been described as degeneration or as failed healing, and that neither label explains why it varies so much between people. Some tendons settle with simple treatment and some resist everything. They proposed a continuum model, in which a tendon moves between stages depending on the load it is put under. It remains a model to be tested rather than settled fact.
What did trials comparing exercise programmes find?
Two main styles of loading have been tested head to head. Eccentric training means loading a muscle while it lengthens, for example slowly lowering the heel off a step. Heavy slow resistance means lifting and lowering a heavy weight slowly in both directions, usually on gym machines. A group at Bispebjerg Hospital in Copenhagen ran two of the best-known comparisons.
In 2009 Kongsgaard and colleagues randomised 39 men with patellar tendinopathy to 12 weeks of steroid injections, eccentric squats on a slope, or heavy slow resistance. All three groups improved in function and pain by 12 weeks. At six months, the two exercise groups had kept their gains, while the injection group had slipped back. The heavy slow resistance group were the most satisfied, and their tendons showed signs of faster collagen turnover, meaning the tendon tissue was being rebuilt.
In 2015 Beyer and the same team tested the two exercise styles in 58 people with long-standing Achilles tendinopathy. After 12 weeks, both groups had large improvements in function and pain, and these lasted to one year. Their tendons also became thinner and showed fewer new blood vessels, both signs of a calmer tendon. There was no difference between the programmes on any of these measures. People in the heavy slow resistance group turned up to more of their sessions, 92% against 78%, and satisfaction tended to be higher at 12 weeks, though that difference was not statistically significant.
Is there one best type of exercise?
Probably not. In 2013 Malliaras and colleagues at Queen Mary University of London reviewed 32 studies, 10 of which compared loading programmes for Achilles or patellar tendons. They found limited evidence for the Achilles, and conflicting evidence for the patellar tendon, that eccentric training beats other approaches. They noted that up to 45% of patients may not respond to eccentric work alone. The one change that consistently went with getting better was improved muscle performance, such as strength and endurance. In the Achilles, changes on scans often did not match how people felt.
A much larger 2023 review in the British Journal of Sports Medicine, led by Pavlova at Robert Gordon University in Aberdeen, pooled 110 studies with 3,953 people across five tendon sites. On average, programmes that added external weight did better than those using body weight only, and programmes done less often than daily did better than daily ones or those done more than once a day. The amount of exercise mattered little. The authors also found that most studies described their exercise poorly. These are averages across studies, not a recipe, and a physiotherapist will tailor any plan to the person.
Do you have to stop running or playing sport?
Not always. In a 2007 Swedish trial, Karin Silbernagel and colleagues randomised 38 people with Achilles tendinopathy. Both groups followed the same strengthening programme. One group kept running and jumping, guided by a pain-monitoring model that set limits on how much pain was acceptable during and after activity. The other group stopped those activities for the first six weeks. Both groups improved by similar amounts, and continuing to run and jump caused no harm that the trial could detect.
What about steroid injections?
Steroid injections work quickly but can backfire. The clearest test comes from a 2013 trial in JAMA by Coombes, Vicenzino and colleagues at the University of Queensland in Brisbane. It enrolled 165 people with tennis elbow lasting more than six weeks. A year later, 83% of those given a steroid injection had recovered completely or improved a lot, compared with 96% of those given a placebo injection. Relapse was far more common after a steroid injection: 54% of that group improved early and then got worse again, against 12% with placebo. The NHS notes that steroid injections may give short-term relief for severe tendon pain.
How confident can we be?
Reasonably confident about the direction, less about the details. Exercise programmes cannot be hidden from the people doing them, so placebo effects are hard to rule out. The key trials were small, with 38 to 165 people, and the Copenhagen patellar trial included only men. The Copenhagen programmes ran for 12 weeks. Even so, the same pattern keeps appearing: gradual loading helps most people, no single programme is clearly best, and quick fixes such as injections do not hold up over a year.
If tendon pain starts suddenly and severely during activity, especially with a pop or snap, you may have torn the tendon. The NHS advises getting help from NHS 111 in that case, or if you are in a lot of pain. See a GP if a joint injury is not improving within a few weeks. In many areas you can refer yourself to NHS physiotherapy without seeing a GP first.
This lesson is for education only and is not medical advice. A GP or physiotherapist can assess your tendon and suggest a plan that suits you.
Related in this classroom Related in other classrooms The studies behind this page Tendonitis - NHS, 2023Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy - British Journal of Sports Medicine, 2009Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy - Scandinavian Journal of Medicine and Science in Sports, 2009Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial - American Journal of Sports Medicine, 2015Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness - Sports Medicine, 2013Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis - British Journal of Sports Medicine, 2023Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study - American Journal of Sports Medicine, 2007Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial - JAMA, 2013Sources for this classroom
Educational content only. Not medical advice, diagnosis or treatment. Always consult a qualified healthcare professional before changing your health regimen.