Overuse Injuries and Tendinopathies
Overuse injuries develop without a single traumatic event, when repeated loading exceeds the tissue’s capacity to recover. Tendinopathies, stress fractures and impingement syndromes belong to this group. Athletes often describe it as “nothing happened, but the pain will not go away” — and that description is an important clue.
Why Do They Occur?
Tissues become stronger as they are loaded; however, this adaptation requires sufficient recovery time. When the balance between load and recovery is disturbed, the tissue is loaded again before it has repaired, and structural deterioration develops over time. The most common trigger is increasing training volume or intensity over a short period.
Other contributing factors include inadequate sleep and nutrition, changes of surface or equipment, imbalances in muscle strength and flexibility, differences in alignment, and previous injuries.
What Is Tendinopathy?
In what used to be called “tendinitis”, it has been understood that there is not as much inflammation in the tissue as expected; the real problem is deterioration of the collagen structure and a reduction in the tissue’s load-bearing capacity. For this reason the term tendinopathy is used today.
This distinction changes treatment: because the problem is not inflammation, complete rest and painkillers alone are not the answer. At the centre of treatment is gradual, controlled loading.
Commonly Seen Conditions
- Achilles tendinopathy — common in runners; morning stiffness is typical
- Patellar tendinopathy (jumper’s knee) — in jumping sports such as basketball and volleyball
- Tennis elbow — in racquet sports and gripping occupations
- Rotator cuff tendinopathy and impingement — in overhead sports
- Plantar fasciitis — heel pain on the first steps in the morning
- Stress fractures — in the shin bone and foot bones; with sudden increases in running distance
- Shin splints — common in those new to running
- Tendinopathies around the hip — described as pain on the outer side of the hip
Symptoms and Distinguishing Features
- Insidious onset; there is no clear moment of injury
- Pain at the start of activity, easing once warmed up, then returning afterwards
- Morning stiffness (particularly in tendinopathies)
- Tenderness concentrated at one specific point
- Over time, pain appearing earlier and persisting at rest
Warning: in stress fractures the pain is typically pinpoint and sharpens with loading; night pain and pain that does not settle at rest should not be ignored. X-rays can appear normal in the early period.
Diagnosis
- Training history: volume, intensity, surface, footwear and programme changes over recent weeks.
- Physical examination: the exact site of tenderness, loading tests, muscle strength and flexibility assessment.
- Imaging: ultrasound and MRI for tendon tissue; MRI and, where needed, bone scan/CT for stress fractures.
Not every structural change seen on imaging is the cause of pain; tendon changes can also be seen in athletes with no symptoms at all. Findings are therefore interpreted together with the clinical picture.
Treatment
The basis of treatment is load management and gradual strengthening. The aim is not to suppress pain but to restore the tissue’s load-bearing capacity.
- Adjusting load: temporarily reducing the activity that markedly increases pain — not stopping altogether.
- Isometric work: maintaining muscle activation during the painful period.
- Eccentric and heavy–slow resistance work: the method with the best-known effectiveness in tendinopathies.
- Surrounding muscle and chain work: hip and trunk control is decisive in lower-limb tendinopathies.
- Gradual reloading: planned progression of running, jumping and sport-specific movements.
These programmes take weeks to months to produce results; improvement should not be expected within a few days. Consistency is the most decisive part of treatment.
In resistant cases additional treatment options and, in selected situations, surgery may be considered. Corticosteroid injection into a tendon is assessed with care, as it may increase the risk of rupture in some tendons.
How Should Load Be Increased?
The most practical way to prevent overuse injuries is to increase load gradually. Increasing weekly training volume in small, regular steps rather than large jumps, and planning a recovery week every three to four weeks, is a widely accepted approach. Pain is the earliest indicator that the load is too high; a “push through the pain” approach prolongs the process.
Return to Sport
The decision to return to sport is made with measurable goals, not with the calendar. Time alone is not a sufficient criterion; returning early increases the risk of re-injury.
- Full, pain-free range of movement
- Muscle strength and endurance close to the uninjured side
- Regained balance and position sense (proprioception)
- Ability to perform sport-specific movements without pain and under control
- The athlete feeling ready — psychological readiness is also a criterion
These criteria are assessed by your physician and physiotherapist. Outcomes vary from person to person; no guarantee of a specific timeframe or result is given on this page.
When to Seek Medical Help Without Delay
- Being unable to bear any weight on the injured area, or unable to take a few steps
- Obvious deformity (a bone or joint appearing out of place)
- Rapidly developing, tense and painful swelling
- Bluish discolouration, paleness, coldness or increasing numbness in the fingers or toes
- Hearing a “snap/pop” followed by loss of strength
- Joint redness and warmth together with fever
- Progressively increasing pinpoint bone pain that persists at rest and at night
- Joint pain together with fever, redness and swelling
These findings require urgent assessment. Outside office hours, go to the nearest emergency department.
Frequently Asked Questions
I have pain — can I continue training?
In overuse injuries it is generally not necessary to stop completely; however, the load needs to be adjusted. Activities that markedly increase pain and leave it persisting the next day are reduced, while pain-free alternatives are maintained. This adjustment is planned individually after examination.
Tendinitis or tendinopathy — does it matter?
Yes, because it changes treatment. Since the problem is predominantly deterioration of tissue structure and reduced load-bearing capacity rather than inflammation, rest and painkillers alone are not enough. Gradual loading and strengthening are at the centre of treatment.
How long does it take to settle?
Recovery in tendinopathies can take weeks to months and varies from person to person. Staying with the programme regularly is the most decisive factor. It would not be appropriate to state a specific timeframe here.
Should I have a corticosteroid injection?
Corticosteroid can reduce pain in the short term; however, it is assessed with care, as it may increase the risk of rupture in some tendons and has been reported not to improve long-term outcome. The decision is made by your physician according to the site to be treated and the clinical situation.
How do I recognise a stress fracture?
Bone pain that sharpens with loading, is concentrated at a specific point and may persist at rest and at night suggests a stress fracture. X-rays can be normal in the early period, so advanced imaging such as MRI may be needed when it is suspected.
How much should I increase my training load?
It is recommended to increase load in small, regular steps rather than large jumps, and to plan recovery weeks at intervals. Remember that pain is an early warning. Your individual programme should be planned according to your discipline and history.
Academic Work
Assoc. Prof. Bertan Cengiz, MD has scientific work published in national and international peer-reviewed journals in the field of tendinopathies and sports injuries and related areas. The publication list and verifiable academic sources are available on the Publications page.
Related Pages
- Sports Injuries
- Muscle Injuries and Strains
- Achilles Tendon Injuries
- Tennis Elbow and Golfer’s Elbow (Epicondylitis)
- Heel Spur and Plantar Fasciitis
The information on this page is for general guidance and does not replace an in-person medical examination. Diagnosis and treatment require a physician’s clinical assessment. Outcomes of any treatment or surgical intervention may vary from person to person; no guarantee of a specific result or timeframe is given on this page.