Tendons do not behave like other tissues, and the two things people instinctively do for tendon pain, rest it and stretch it, are the two things most likely to keep it going. Tendons need load. The skill is in giving them the right amount, in the right order, for long enough.
Below is the four stage loading protocol I use with runners, including the criteria for moving between stages, because the stage you are in matters far less than knowing when you have earned the next one.
The presentation is distinctive enough that most people can recognise it.
In runners it turns up most often in the Achilles, the patellar tendon just below the kneecap, and the gluteal tendons at the outside of the hip. That last one is frequently mistaken for bursitis and treated with an injection that does not solve it.
If your pain is sharp and immediate rather than warm-up dependent, if it is diffuse rather than pinpoint, or if it worsens with impact and is getting earlier in each run, that is a different conversation and it needs assessing rather than loading.
Before any of the stages, you need the pain monitoring rule, because it is what makes the whole protocol self-correcting.
Rate your pain out of 10 during the exercise. Up to 5 out of 10 is acceptable and expected. It should settle back to your baseline within 24 hours, and the following morning should not be worse than the morning before.
If it does not settle by the next day, the dose was too high. Reduce the load or the volume by about 20 percent and repeat that session. If you feel nothing at all and there is no next-day response, you are underloading and the tendon will not adapt.
Complete pain avoidance is the most common reason a rehab program stalls. Discomfort inside that range is part of the treatment, not a sign you are damaging something.
You are here if the tendon is irritable, painful most days, sore in the mornings, and hurts during easy runs.
What you do: isometric holds. A static contraction with no movement. For the Achilles that is holding a calf raise position at the top. For the patellar tendon, a wall sit or a static knee extension hold. For gluteal tendons, an isometric hip abduction press.
Five holds of 30 to 45 seconds, at roughly 70 percent of maximum effort, once or twice a day. These frequently produce a genuine reduction in pain for a couple of hours afterwards, which is useful in itself.
Running: reduce, do not stop. Cut volume to whatever keeps you under the 24 hour rule. Remove hills and speed work, which load the tendon hardest.
Move on when morning stiffness has clearly reduced and you can complete your reduced runs within the pain rule for a week.
Typically 1 to 2 weeks.
This is where the structural change happens, and it is the stage people skip.
What you do: heavy, slow resistance work through range. Slow means about three seconds lowering and three seconds lifting. Heavy means genuinely heavy, working in the range of 6 to 8 repetitions where the last two are difficult.
For the Achilles: calf raises off a step, both straight leg and with the knee bent to bias the soleus. Three to four sets, three times a week, adding weight as you can. Most runners end up loading these far heavier than they expected, and that is the point.
For patellar tendon: slow, loaded squats and split squats through a controlled range.
For gluteal tendons: loaded hip abduction and single leg work, and importantly avoiding positions that compress the tendon against the bone. Which brings me to the thing people get wrong most.
Stretching an Achilles or a gluteal tendon compresses it against the bone underneath. That compression is a known aggravator, and it explains why so many people stretch diligently for months and get steadily worse.
For the same reason, avoid sitting cross legged, standing with your hip dropped to one side, or sleeping with your top leg fallen across the body if it is a gluteal tendon. A pillow between the knees at night helps more than most exercises do.
Move on when you can perform the loaded exercise with good control at a meaningful weight, symptoms have settled substantially day to day, and morning stiffness is minimal.
Typically 4 to 6 weeks. This is the longest stage and rushing it is the single most reliable way to end up back at stage one.
You are here if stage two feels comfortable and you want to run properly again.
Heavy slow work builds a strong tendon. It does not build a springy one, and running is fundamentally an elastic activity. The tendon has to store energy on landing and return it on push off, at speed, thousands of times.
What you do: skipping, pogo hops, double leg then single leg hopping, bounding, and short accelerations. Low volume to begin with. This work is far more provocative than it looks, so introduce it on days you are not doing your heavy loading.
Keep the stage two heavy work running alongside, twice a week. You do not trade one for the other.
Move on when you can hop on the affected leg repeatedly without symptoms and the next-day response stays clean.
Typically 2 to 4 weeks.
Volume first, then intensity, then hills. One variable at a time, with a check against the 24 hour rule each time.
Add roughly 10 percent per week to your distance until you are back at baseline. Then reintroduce faster work. Then hills last, because they load the Achilles and patellar tendon most.
Keep two heavy strength sessions a week indefinitely. This is not a rehab program you graduate from. It is the thing that stops the tendinopathy returning, and the runners who drop it are the ones I see again the following season.
Typically 4 or more weeks, and around 12 weeks all up for a well established tendinopathy.
The protocol above will resolve most tendon pain. It will not stop it happening again unless you work out what caused it.
In my experience it is a training change about 70 percent of the time: a jump in volume, a new session type, a return after a break, a change of surface. The rest is usually a strength deficit further up the chain, most often at the hip, or a footwear change, or a spike in life stress and a collapse in sleep during a training block.
Bring your training log to your appointment. It is more informative than most of the examination.
If you would like the protocol adapted to your specific tendon and your training, book a running assessment. I will test your capacity properly so we start at the right stage.
Not the affected tendon, particularly Achilles and gluteal. Load it, do not lengthen it. Mobility work elsewhere is fine.
Rarely. Imaging findings correlate poorly with symptoms in tendons, and scans routinely show changes in people who have never had pain. The diagnosis is usually clear from history and examination.
Corticosteroid injections can reduce pain in the short term but have poorer long term outcomes in tendons and may weaken the tissue. They are not first line, and if one is offered, ask what the loading plan alongside it is.
Yes, and it helps. Cycling and swimming maintain fitness with far less tendon load. Just be aware that cycling loads the patellar tendon and deep water running loads the Achilles less than you would think, so choose based on which tendon is involved.
Tendons respond to cumulative load with a delay, so a bad Thursday often reflects a heavy Tuesday. Sleep, stress and a busy week all shift your tolerance. Track it across weeks rather than days.
Tendon adaptation is measured in months. That is not a caveat, it is the central fact of the condition, and every shortcut I have seen attempted costs more time than it saves.
Load it properly, progress it patiently, and fix whatever overloaded it. That combination resolves the large majority of tendon pain in runners.
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