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Tendinopathy is a common affliction among runners, often characterised by pain, stiffness, and reduced performance. Tendon pain in runners can be attributed to various factors, each associated with specific stages on the tendinopathy continuum. Tenosynovitis, acute reactive tendinopathy, and chronic overload tendinopathy are three key components.


Tenosynovitis: This refers to inflammation of the tendon sheath, a protective layer surrounding the tendon. Tenosynovitis often arises from overuse, improper running techniques, or sudden increases in training intensity. Runners experiencing tenosynovitis may notice localised pain, swelling, and crepitus during movement. Not every tendon has a tendon sheath, therefore only certain tendons can suffer tenosynovitis. It’s important for your physio to understand this and help give the correct diagnosis as this type of tendon pain is best treated with ice and anti-inflammtories.


Acute Reactive Tendinopathy: This occurs when the tendon undergoes a sudden and significant increase in load. This can result from abrupt changes in training routines, excessive stress during a run, or inadequate recovery. Runners with acute reactive tendinopathy may experience pain during activity that subsides with rest. On ultrasound this tendon may look quite normal and helps to determine this from an overload chronic tendon disrepair.


Chronic Overload Tendinopathy: Prolonged exposure to repetitive stress and insufficient recovery can lead to chronic overload tendinopathy. In this stage, the tendon undergoes structural changes and degeneration. Runners may experience persistent pain, stiffness, and reduced performance, even during daily activities. On ultrasound we typically see a thickened tendon with a loss of fibrillar pattern and blood vessel ingrowth into tendon.


Distinguishing Insertional from Mid-Portion Tendinopathy


Understanding the specific type of tendinopathy is crucial for effective management. Two primary classifications are insertional tendinopathy, affecting the tendon where it attaches to the bone, and mid-portion tendinopathy, occurring within the body of the tendon.


Insertional Tendinopathy: This type involves the tendon’s attachment to the bone. Runners with insertional tendinopathy often experience pain at the point where the tendon meets the bone, and this pain can be exacerbated by activities like running or jumping. Causes include repetitive stress, age-related changes, and improper footwear. We also think that one of the causes of insertional tendinopathy is from tendon compression on its enthesis (attachment).


Mid-Portion Tendinopathy: Mid-portion tendinopathy affects the central part of the tendon. Runners may experience pain during or after running, which is typically localised to the mid-portion of the tendon. Contributing factors include overuse, biomechanical issues and poor running technique.


Common Running Tendinopathies


Three main tendinopathies frequently affect runners: Achilles tendinopathy, high hamstring tendinopathy, and gluteus medius tendinopathy.


Achilles Tendinopathy treatment


Achilles Tendon Pain

The Achilles tendon, connecting the calf muscles to the heel bone, is prone to tendinopathy due to its role in propulsion during running. Runners with Achilles tendinopathy may experience pain, stiffness, and swelling near the heel. Contributing factors include overtraining, improper footwear, and biomechanical issues.


The Achilles has a tendon sheath so is susceptible to tenosynovitis. It may also suffer insertional tendinopathy, with pain arising right down on the insertion to the heel bone. This type of tendon pain will be worsened by running uphill as it leads to greater insertion compression on the heel bone. It may also be aggravated by overstriding and using a trainer with a slightly higher heel drop and increasing running cadence can be useful to manage it. Mid portion tendinopathy might be exacerbated by changing running gait to a forefoot heel strike as it significantly increases peak force through the Achilles and calf.


High Hamstring Tendinopathy management


The proximal hamstring tendon connects the hamstring muscles to the pelvis. Runners with high hamstring tendinopathy often report deep buttock pain, especially during activities like running, sitting, or climbing stairs. Poor running biomechanics such as leaning forward in the trunk, doing lots of uphill running or over striding, and hamstrings weakness contribute to this condition.

Hamstring Tendon Pain

Gluteus Medius Tendinopathy treatment

Gluteal Tendon Pain

The gluteus medius tendon, crucial for hip stability during running, can develop tendinopathy. Runners may experience pain on the outer hip or buttock, particularly during running or lateral movements. Weakness in the gluteus medius, poor running mechanics such as a narrow running gait and contralateral hip drop, as well as sudden increases in training intensity are common contributors.


Treating tendon pain

Tendon Pain Management

There are two very important things that need to be done to get tendon pain under control. The first is load management. This means getting the amount of load through the tendon down to a tolerable level. Sometimes we might need to stop running for a week or two and use non-impact exercises instead, such as cycling or cross training. Or we may be able to keep you running but by reducing your load by a significant amount, sometimes up to 50%. The next thing we need to do is start a strength training programme. Over the year various strength training programmes have been reported to be best for tendon loading – isometrics, eccentrics, heavy slow resistance. In reality all of these can be used in a periodised programme focussing on overall strengthening of the lower limbs.


Then we can think about treatment adjuncts such as running gait re-training, soft tissue massage, insoles and running shoes and, perhaps the most beneficial tendon pain treatment – shockwave therapy.




Tendinopathy is a complex and multifaceted issue for runners, with various factors contributing to its development. Recognising the causes, distinguishing between insertional and mid-portion tendinopathy, and understanding the specifics of Achilles, high hamstring, and gluteus medius tendinopathy are essential for effective prevention and management.

About Wandsworth Physiotherapy

infoAt Wandsworth Physiotherapy and Osteopathy we are focused on getting you out of pain and back to what you love doing. Whether it's playing with your kids or simply being able to sit on the train comfortably; whether it's being able to get back into the gym class or to run 5k again; whether it's to banish the Tena Lady or being able to lift your child without pain our expert physiotherapists and osteopaths are here to help.