Tendon pain that appears or becomes harder to settle during perimenopause is sometimes attributed entirely to “low oestrogen". The relationship is more complex. Oestrogen influences collagen metabolism, tendon cells, muscle mass and recovery, so hormonal change may modify tendon capacity. However, tendinopathy remains a clinical disorder characterised by persistent, localised tendon pain and loss of function related to mechanical loading—not a diagnosis made from menopausal status or imaging alone (Scott et al., 2020).

For physiotherapists, the practical question is not whether hormones or load is solely responsible. It is how hormonal, metabolic and mechanical factors may combine to create a mismatch between current tendon capacity and the demands placed on it. Management should address that mismatch without promoting fear, complete rest or unsupported hormone-based claims.

Why Oestrogen Decline May Matter to Tendons

Tendons transmit force from muscle to bone and adapt to repeated mechanical loading through collagen synthesis, remodelling and changes in mechanical properties. Oestrogen receptors are present in musculoskeletal tissues, and experimental and human evidence indicates that sex hormones can influence tendon collagen turnover and stiffness. The direction and clinical importance of these effects vary with age, tissue, endogenous hormone exposure and use of exogenous hormones (Hansen, 2018).

During the menopausal transition, fluctuating and eventually lower oestrogen levels occur alongside age-related changes in muscle mass, strength, sleep, body composition and physical activity. Reduced muscle capacity may increase the relative demand placed on a tendon during the same task. Poor sleep and vasomotor symptoms may also affect pain sensitivity, recovery and confidence with exercise. Therefore, oestrogen decline is best understood as one possible contributor to a wider change in the muscle–tendon system rather than a single proven cause of tendon pain (Wright et al., 2024).

Evidence specific to menopausal hormone therapy (MHT) and tendon outcomes remains limited. A systematic review found possible benefits for some tendon-related outcomes, particularly when MHT was combined with exercise, but the evidence was heterogeneous and insufficient to prescribe MHT as a treatment for tendinopathy (McMillan et al., 2022). Decisions about MHT should be made with an appropriately qualified medical clinician after considering the patient’s overall menopausal symptoms, preferences, risks and benefits.

Clinical Presentation and Differential Diagnosis

Common midlife presentations include Achilles, gluteal, proximal hamstring and rotator-cuff tendinopathy. The typical pattern is localised pain reproduced by tendon loading, such as heel raises, walking uphill, running, stair climbing, lying on the affected hip or reaching overhead. Morning stiffness and pain after a sudden increase in activity are also common. Symptoms may follow a change in exercise, return to sport, altered work demands or a period of reduced activity followed by rapid reloading.

Assessment should establish the pain location, behaviour over 24 hours, recent load changes and functional limitations. Palpation and region-specific loading tests can support the diagnosis, but findings must be interpreted with the history. Imaging is not routinely required when the presentation is typical because structural abnormalities may be present without pain, and imaging severity does not dictate loading tolerance (Magee & Manske, 2021).

The clinician should also ask about menstrual stage, vasomotor symptoms, sleep, MHT, nutrition, medication, smoking and relevant comorbidities. Diabetes, dyslipidaemia and higher adiposity may influence tendon health, while fluoroquinolone or systemic corticosteroid exposure can increase concern about tendon injury. Diffuse pain, marked joint swelling, prolonged morning stiffness, neurological symptoms or constitutional illness suggests a diagnosis beyond isolated tendinopathy.

Urgent medical assessment is warranted after a sudden snap with loss of function, suspected complete rupture, a hot swollen joint, fever, unexplained systemic symptoms or rapidly progressive weakness. Persistent night pain unrelated to position or load also requires careful review.

Load Management Without Complete Rest

The goal of load management is to reduce the gap between demand and capacity while maintaining useful activity. Complete rest may temporarily reduce pain but also lowers muscle and tendon capacity, making recurrence more likely when normal activity resumes. Contemporary guidelines instead recommend education and progressive tendon-loading exercise as first-line care (Chimenti et al., 2024; de Vos et al., 2021).

Begin by identifying the most provocative loads. These may involve high force, rapid energy storage, repeated impact or compression. Temporarily reduce their volume, intensity or frequency rather than removing all movement. For example, a runner may shorten running distance, reduce hills and separate harder sessions while retaining tolerable walking, cycling or strength work. A patient with gluteal tendon pain may temporarily reduce prolonged hip adduction, such as leg crossing or lying directly on the painful side.

A pain-monitoring approach can guide dosage. Mild, tolerable discomfort during exercise may be acceptable when symptoms settle soon afterward and return to the usual baseline by the following day. A clear increase in morning stiffness, night pain or next-day functional limitation indicates that the recent dose exceeded current capacity. Pain rules are guides rather than universal thresholds; irritability, diagnosis, patient confidence and response over time matter more than one number.

Response to loading	Clinical decision
Mild, tolerable symptoms with no meaningful next-day increase	Continue and progress gradually
Symptoms rise during exercise but settle promptly	Maintain or slightly modify the dose
Clear increase in next-day pain, stiffness or functional difficulty	Reduce load, range, speed or volume
Sudden sharp pain, loss of power or suspected rupture	Stop and arrange medical assessment

Progressive Exercise Prescription

Exercise should match the involved tendon and the patient’s required activities. Isometric exercise can provide an accessible starting point when dynamic loading is poorly tolerated, although it is not consistently superior for pain relief. Progress to slow isotonic resistance through a tolerable range, then heavier strength work, and finally faster energy-storage tasks when relevant. Eccentric-only programmes are not mandatory; combined concentric–eccentric and progressive resistance approaches are also effective options (Malliaras et al., 2013).

A practical progression is the following:

Establish tolerance: use isometric or controlled isotonic exercise and modify provocative daily loads.
Build strength: progressively increase resistance while maintaining good technique and an acceptable 24-hour response.
Develop tendon-specific capacity: add work through larger ranges and positions relevant to the tendon, while respecting compression-sensitive presentations.
Restore speed and energy storage: introduce faster contractions, hopping, running, throwing or change-of-direction tasks when required.
Reintegrate meaningful activity: increase only one major variable—load, volume, speed or frequency—at a time where practical.

Dosage cannot be identical for every tendon. A useful starting structure is two to four exercises performed two or three times weekly, with adequate recovery between heavier sessions. Load should become challenging enough to drive adaptation rather than remaining indefinitely at a low resistance. For midlife patients who have also lost general strength, programmes should include the surrounding kinetic chain and major muscle groups, not only the painful tendon.

Midlife Factors That Modify Rehabilitation

Menopause-informed care broadens rehabilitation without making it hormone-determined. Sleep disruption, hot flushes, caregiving demands and reduced recovery time may affect adherence and symptom sensitivity; these factors can guide session timing and progression. Adequate energy and protein intake support training adaptation, while general resistance and weight-bearing exercise benefit muscle and bone health. A dietitian or physician may be appropriate when nutritional deficiency, low energy availability or metabolic disease is suspected.

Body weight should be discussed sensitively. Higher mechanical demand can influence some lower-limb tendons, but weight-centred messaging may increase stigma and distract from modifiable capacity. Emphasise strength, gradual activity exposure and cardiometabolic health. Likewise, passive treatments may offer short-term symptom relief but should not replace education and active loading. Repeated corticosteroid injections require caution because short-term pain improvement does not necessarily translate into durable tendon recovery.

Progress should be judged using the patient’s goals, a tendon-specific patient-reported measure where appropriate, load-related pain, strength and functional tests. Meaningful improvement often takes weeks to months. Plateaus should prompt reassessment of diagnosis, adherence, dosage, recovery, comorbidities and psychosocial barriers—not an assumption that menopause makes recovery impossible.

Viva-Ready Summary

Tendinopathy is persistent, localised tendon pain and impaired function related to mechanical loading.
Oestrogen decline may influence collagen turnover and muscle–tendon properties, but causation and the clinical effect of MHT remain uncertain.
Diagnosis is primarily clinical; imaging is reserved for diagnostic uncertainty, suspected tear or failure to progress when results may change management.
First-line care combines education, temporary modification of provocative loads and progressive tendon-loading exercise.
Use the immediate and 24-hour symptom response to adjust load while avoiding unnecessary complete rest.
Progress from tolerable slow loading to heavier resistance and then energy-storage or sport-specific tasks when required.
Screen midlife contributors, including sleep, metabolic health, nutrition, medication and general muscle capacity, and refer when red flags or systemic disease is suspected.

One-line recall point: In midlife tendinopathy, recognise hormonal context; reduce overload—not all load; and rebuild muscle–tendon capacity progressively.

References

Chimenti, R. L., Cychosz, C. C., Hall, M. M., & Phisitkul, P. (2024). Achilles pain, stiffness, and muscle power deficits: Midportion Achilles tendinopathy revision 2024. Journal of Orthopaedic & Sports Physical Therapy, 54(12), CPG1–CPG32. https://doi.org/10.2519/jospt.2024.0302

de Vos, R.-J., van der Vlist, A. C., Zwerver, J., Meuffels, D. E., Smithuis, F., van Ingen, R., van der Giesen, F., Visser, E., Balemans, A., & Pols, M. (2021). Dutch multidisciplinary guideline on Achilles tendinopathy. British Journal of Sports Medicine, 55(20), 1125–1134. https://doi.org/10.1136/bjsports-2020-103867

Hansen, M. (2018). Female hormones: Do they influence muscle and tendon protein metabolism? Proceedings of the Nutrition Society, 77(1), 32–41. https://doi.org/10.1017/S0029665117001951

Magee, D. J., & Manske, R. C. (2021). Orthopaedic physical assessment (7th ed.). Elsevier.

Malliaras, P., Barton, C. J., Reeves, N. D., & Langberg, H. (2013). Achilles and patellar tendinopathy loading programmes: A systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Medicine, 43(4), 267–286. https://doi.org/10.1007/s40279-013-0019-z

McMillan, L. B., Zengin, A., Ebeling, P. R., & Scott, D. (2022). Does menopausal hormone therapy, exercise, or both improve muscle mass and strength and tendon outcomes in postmenopausal women? A systematic review and meta-analysis. Clinical Endocrinology, 96(4), 443–456. https://doi.org/10.1111/cen.14618

Scott, A., Squier, K., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., de Vos, R.-J., Fu, S. N., Grimaldi, A., Lewis, J. S., Maffulli, N., Magnusson, S. P., Malliaras, P., Mc Auliffe, S., Oei, E. H. G., Purdam, C. R., Rees, J. D., Rio, E. K., Gravare Silbernagel, K., ... Zwerver, J. (2020). ICON 2019: International Scientific Tendinopathy Symposium consensus: Clinical terminology. British Journal of Sports Medicine, 54(5), 260–262. https://doi.org/10.1136/bjsports-2019-100885

Wright, V. J., Schwartz, J. I., & Lobo, R. A. (2024). The musculoskeletal syndrome of menopause. Climacteric, 27(5), 466–472. https://doi.org/10.1080/13697137.2024.2380363