What Every Runner Should Know About Tendon Rehab
A Very Common Running Injury
You might have felt it: a dull ache in your heel after you run or an annoying stiffness in your outer hip when you wake up. Those nagging injuries are often signs of tendon pain, which can evolve into injuries that set runners back. In fact, A 2021 review found that Achilles tendon injuries account for roughly 1 in every 10 new running-related injuries. Other sites include your patellar tendon (beneath your kneecap) and your gluteal tendons (side of your hip).
Tendon pain is common, but it’s often misunderstood. To treat it effectively, we first need to understand what tendons actually do, especially in runners.
Reframing the Approach to Tendon Rehab
I explain tendons with a simple analogy: imagine a group of people pulling on a rope to move a tree. The people represent your muscles—they generate the force. The rope is your tendon—it doesn’t create force itself, but it transmits the muscle’s effort to the tree, which is the bone. The harder and faster the muscles pull, the more tension runs through the rope. It takes a certain amount of force to move the tree or keep it stable. In runners, tendons are more than just connectors. They act like elastic springs, storing and releasing energy with every step to help propel us forward more efficiently.
Where I diverge from many clinicians is in how I explain and treat tendon pain. The standard explanation sounds something like this: “your tendon is injured, so we need to build that strength back up in the muscle to support it...” Sound familiar? I don’t think that’s wrong, but it’s incomplete. Tendon pain doesn’t happen because you’re weak. It hurts because it’s sensitive to being pulled on.
Every painful tendon has a limit to how much force it will tolerate, and if you exceed that, it lets you know. For example, if your Achilles is irritated, I might ask you to bodyweight squat or do calf raises and you’ll tolerate them just fine because they generate slow and gentle loading. But if I have you stretch it or try hopping or running, you’ll likely feel a sharper pain. That’s not damage, it’s your tendon saying, “I’m not ready for that yet.”
To get a tendon better, you do have to progressively load it, but if the tendon itself remains sensitive, the pain won’t go away. You can’t just crank out the heaviest set you can expecting it to feel better. That’s why I place the emphasis on desensitization over strength. Your rehab will feel far more effective, and a lot less frustrating, when that is your guiding principle.
How Long Do Tendons Take to Heal?
Tendon recovery usually takes months, not weeks. No one believes me when I say that, but it’s true, and it’s rarely a quick process. Don’t panic. Just because recovery takes months doesn’t mean you’ll be in pain the whole time. Week by week, your symptoms will improve and go away. Rehab is not about sitting out. It’s an active process and running is part of the solution, not the problem. With the right approach, you’ll likely be doing more than you expect, even early on.
The timeline typically depends on two big factors: how early you start and how much limitation you have. The longer you wait, the more protective your nervous system becomes. And the more function you’ve lost, the more you’ll need to earn back. Even then, progress just requires a plan built around patience, consistency, and the right kind of loading.
Can I Run With a Tendinopathy?
In most cases, yes, you can run with a tendinopathy. As long as you follow the rules of rehab (which I’ve listed below), I find continuing to run beneficial. In fact, I’ve found that people who stop running completely actually end up worse off. Total rest can make the tendon even more sensitive and coming back becomes more difficult.
That being said, how you run matters. You’ll need to modify your training schedule, add some rehab in, and adjust certain elements of your run based on where your pain is. For example:
Achilles Tendinopathy: minimize uphill running, flat shoes, and treadmills, all of which increase Achilles load.
Patellar Tendinopathy: minimize downhill running or steep descents, which increases load on the front of the knee.
Running with tendon pain requires strategy. If you can learn to work with the tendon instead of gritting your teeth through symptoms, your recovery can move forward, and your fitness can stay intact.
Rules of Tendon Pain
These guidelines are based on a great article by Sibernagel et al., a group deeply involved with Achilles tendon rehab research. These rules are broadly applicable to other tendons. Their definitions use pain rating scales (which I hate), so I’ve adapted them into my own language.
During and after exercise, your symptoms must remain in a “safe” range. This is something you would describe as uncomfortable, but tolerable. Any pain that crosses into “danger” territory or makes you limp is a no-go and you need to adjust what you’re doing or stop.
Note: A little tendon pain or stiffness when you start moving is common. If it improves as you get going, that’s a good sign. If pain worsens outside the safe zone, it’s your cue to stop loading it for the day.
By the next morning, your symptoms should remain in that safe range or have reduced back to their baseline. If they’re worse, you pushed it too far and need to adjust next time.
Week by week, your symptoms should get better. It should become less noticeable, less frequent, or less constant.
FYI, I guarantee that you’ll have a few bad days (or a rough week) or accidentally push it too much on a workout. It’s a normal part of the process and does not mean you’re failing rehab. You just have to learn from it.
If you’re dealing with tendon pain and unsure what to do next, you don’t need to guess. Reach out any time. I can help.
Kakouris N, Yener N, Fong DTP. A systematic review of running-related musculoskeletal injuries in runners. J Sport Health Sci. 2021 Sep;10(5):513-522. doi: 10.1016/j.jshs.2021.04.001. Epub 2021 Apr 20. PMID: 33862272; PMCID: PMC8500811.
Silbernagel KG, Hanlon S, Sprague A. Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. J Athl Train. 2020 May;55(5):438-447. doi: 10.4085/1062-6050-356-19. Epub 2020 Apr 8. PMID: 32267723; PMCID: PMC7249277.
Disclaimer:
This blog is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment. Every runner is different, and what works for one person may not be appropriate for another. Always consult with a qualified healthcare provider before starting or changing your training or rehab program. If you're dealing with pain or injury, reach out to a licensed physical therapist or medical professional.
