Understanding Tendinopathy: What are the Risk Factors?

Why Do Tendinopathies Develop?

One of the most common questions patients ask is:

“Why has this happened now? I’ve been doing this for years.”

In many cases, there isn’t one single event to blame.

Instead, tendinopathy usually develops because several smaller factors come together until the tendon reaches its limit.

Perhaps you’ve become slightly less active over the past few years. Maybe you’ve put on a little weight. Perhaps work has become busier, you’ve started looking after grandchildren, you’ve recently had a baby, or you’ve decided to return to the gym after years away.

Each of these changes may seem insignificant on its own. Together, however, they can alter the amount of force travelling through a tendon every day.

Eventually the tendon simply struggles to keep up.

One of the most important principles to understand is that tendinopathy is usually a problem of load management rather than simply a problem of damage.

The tendon hasn’t necessarily “failed.”

Instead, it has been asked to tolerate more than it has been prepared for.

Why Middle Age Is the Peak Time for Tendinopathy

Although tendon injuries can occur at any age, they become increasingly common between approximately 30 and 70 years of age.

There are several reasons for this.

As we age, tendons naturally become a little stiffer and less elastic.

The collagen fibres gradually lose some of the flexibility they possessed when we were younger.

This doesn’t mean tendons suddenly become weak.

Rather, they become slightly less forgiving when exposed to sudden increases in load.

Many people in their forties and fifties still expect their bodies to tolerate exactly the same workload they managed in their twenties.

Sometimes they can.

Sometimes the tendon politely reminds them that it now needs a little more preparation.

The encouraging news is that tendons remain remarkably adaptable throughout life.

Age increases risk—it does not prevent recovery.

Given the right rehabilitation programme, tendons can continue becoming stronger well into older adulthood.

The Biggest Cause of Tendinopathy: Load Management

If there is one concept I hope every patient remembers after reading this article, it is this:

Healthy tendons love consistent load. Injured tendons dislike sudden changes in load.

This principle explains why tendinopathy develops, why it persists, and ultimately how we rehabilitate it.

Your tendon is constantly trying to match the amount of work you regularly ask it to perform.

If you consistently walk 8,000 steps every day, your Achilles tendon gradually adapts to tolerate approximately that workload.

If you regularly lift weights three times per week, your shoulder and elbow tendons adapt to those demands.

Likewise, if you play tennis every Saturday, your elbow gradually becomes conditioned to those repetitive movements.

Problems arise when this loading changes suddenly.

Imagine somebody who has stopped running for six months.

During that time, the Achilles tendon gradually loses some of its ability to tolerate running loads.

The person then decides to return to running exactly where they left off.

From the person’s perspective, nothing has changed.

From the tendon’s perspective, however, the workload has increased dramatically.

The tendon is no longer prepared for what is being asked of it.

The result is often pain.

Load Spikes Don’t Only Come From Exercise

One of the biggest misconceptions is that tendinopathy only affects athletes.

In reality, we commonly see tendon problems in people who have never considered themselves sporty.

A sudden increase in tendon loading doesn’t have to come from running a marathon.

It can occur because life changes.

Some examples I frequently see include:

A new parent repeatedly lifting a baby from a cot.
Grandparents spending more time carrying grandchildren.
Starting a new job involving prolonged standing.
Beginning a renovation project around the house.
A promotion requiring longer hours at a computer.
Tradies taking on heavier manual work.
Returning to gardening after winter.
Taking up pickleball, golf or tennis after years away.
Increasing gym training too quickly.
Suddenly deciding to walk 20,000 steps every day for fitness.

Many patients can identify a change like this once they stop and think about it.

Often, that change occurred several weeks before the pain actually began.

That’s because tendinopathy usually develops gradually rather than overnight.

Other Factors That Increase the Risk

Although load management is the primary driver for most tendinopathies, it isn’t the only factor.

Some people have a reduced capacity for tendon repair.

Several medical conditions can increase the likelihood of developing tendon problems, including:

Diabetes
Obesity
Metabolic syndrome
High cholesterol
Certain inflammatory conditions
Smoking

These conditions don’t automatically cause tendinopathy.

However, they may reduce the tendon’s ability to recover from normal daily loading.

Likewise, some medications are known to increase the risk of tendon injury and, in some cases, tendon rupture. These include certain antibiotics (particularly fluoroquinolones) and long-term corticosteroid exposure.

This is one reason why good tendon management often involves looking beyond the tendon itself.

Sometimes improving overall health also improves the tendon’s ability to heal.

Common Areas Where Tendinopathy Occurs

Tendons exist throughout the body, so tendinopathy can occur almost anywhere.

However, certain tendons are exposed to particularly high loads and are therefore much more commonly affected.

Some of the most frequent examples include:

Tennis Elbow

Despite the name, most people with tennis elbow have never played tennis.

Tennis elbow is a tendinopathy affecting the wrist and finger extensor tendons where they attach to the outside of the elbow.

Historically it became associated with tennis because repetitive single-handed backhand strokes placed large loads through these tendons.

Today, we more commonly see it in office workers, tradies, mechanics, gardeners and people performing repetitive gripping tasks.

Golfer’s Elbow

Golfer’s elbow affects the tendons on the inner side of the elbow.

These tendons are responsible for wrist flexion and gripping.

Although golf can certainly cause it, many patients develop it through repetitive manual work, lifting or prolonged gripping activities.

Rotator Cuff Tendinopathy

The rotator cuff consists of four muscles and their tendons, which help stabilise and move the shoulder.

These tendons frequently become painful in people performing repetitive overhead work, swimming, throwing sports and even prolonged desk work when shoulder mechanics become altered.

Gluteal Tendinopathy

Gluteal tendinopathy affects the tendons on the outside of the hip.

These muscles play an essential role in stabilising the pelvis every time we walk.

Pain is often felt while lying on the affected side, climbing stairs or walking longer distances.

It is one of the most common causes of persistent lateral hip pain, particularly in middle-aged women.

Patellar Tendinopathy

Often called jumper’s knee, this affects the tendon connecting the kneecap to the shin.

It is particularly common in sports involving repeated jumping and landing, including basketball, volleyball and football.

However, it can also develop in recreational athletes whose training load has increased too quickly.

Achilles Tendinopathy

The Achilles tendon is the largest tendon in the human body.

Every step places several times your body weight through it.

Running, hill walking, sudden increases in exercise and prolonged standing can all contribute to Achilles tendinopathy.

Plantar Fasciopathy

Strictly speaking, the plantar fascia isn’t a tendon.

It is a thick band of connective tissue supporting the arch of the foot.

Nevertheless, plantar heel pain behaves very similarly to tendinopathy.

Many of the same rehabilitation principles—including appropriate loading, progressive strengthening and patience—apply equally well.