Why Your Tendons Hate You, And What You Can Do About It Today

You're watching the game. Crowd is loud.

TV volume is up. Snacks in hand. Star

player plants, pushes off to explode to

the rim. Then suddenly he just stops. No

one touched him. He looks back like

someone kicked his ankle. You and I both

know what that look means. Achilles.

>> And I heard a pop

>> and Durant grabbing that right leg.

>> So I'm like, oh my gosh. And my whole

basketball career just flashed before my

eyes. In the last couple of years, we've

seen Jason Tatum, Tyrese Hallebertton,

Aaron Rogers, Muhammad Shammy, Rashawn

Slater, and a whole list of pros

sideline by tendant injuries. Elite

athletes, worldclass medical teams,

millionaire bodies, and one tiny

structure still says, "Nah, we're done

here, bro." So, no, your tendons don't

hate you. You just treat them like a

disposable Amazon package. Today, we're

going to fix that. Before we dive in,

for returning viewers, do me a solid and

give the video a like and let me know

what's the last tenant injury you heard

about in the comments. If you're new to

the channel, welcome. Watch the video

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arrive there a smarter person. And be

sure to stick around to the end of the

video so you can hear my perspective as

an orthopedic surgeon and how to avoid

seeing someone like me for your own

tendon injury. Also, if you like what

went wrong breakdowns, you might have

also seen the short on the strength

trainer who blew both biceps at the same

time doing preacher curls. Yes,

simultaneous bilateral biceps ruptures.

That is not a PR that you want. We're

going to explain exactly how stuff like

that happens and how you can stop

treating your tendons like Final

Destination extras. Let's get into it.

What tendons actually are and why they

ruin your life. As an orthopedic

surgeon, I spend a lot of time talking

about bones, fractures, joint

replacements, all the fun hardware. But

tendons are the quiet middle child that

actually make you move. Tendons attach

muscle to bone. Ligaments attach bone to

bone. When you move your bones, you

contract your muscles, but it's not your

muscles that pull on that bone. It's

your tendons. All the force goes through

the tendons, and that means they have to

be extremely strong.

>> Tendons are basically high performance

ropes made mostly of type one collagen

organized in parallel bundles like a

superorganized cable management system.

>> Here is a bundle. There are bundles

here, bundles here, bundles here, and

finally here is the collagen fibbral.

Inside that rope, tiny cells called

teninocytes maintain the collagen. They

sense load, stress, and strain. Under

healthy loading, they keep the structure

tight, strong, and aligned. Tendons

don't have a blood supply. They don't

burn a lot of energy, but they handle

massive forces and store elastic energy,

especially ones like the Achilles. These

are your calf muscles. Both of these

muscles though are going to blend into

and turn into this gigantic and massive

tendon here which we call the Achilles

tendon. When you sprint or jump, your

Achilles can see forces six to eight

times your body weight. Every step is

like asking a tired friend to just carry

one more box while you keep adding more

boxes. Most days they just get on with

it until they don't.

How common are tendon injuries really?

Let's zoom out for a second. If we look

at the big epidemiologic studies of

muscularkeeletal injuries, common stuff

like ankle sprains are around 400 plus

cases per 100,000 people per year. Many

tendon or ligament ruptures sit more

around 3 to 20 per 100,000 person years,

depending on which one you look at. So,

in the grand universe of injuries,

tendon ruptures are a small slice of

total injuries, but they make up a big

share of the serious season ending ones.

Within tendon ruptures, Achilles tendon

rupture is king.

>> Achilles tendon is impressively strong,

but it can still tear.

>> Some sports series show Achilles tears

making up more than 1/ half of all

tendon ruptures that show up in

emergency departments. Overuse tendon

problems, what we call tendonopathy,

most often hit Achilles, patellar tendon

or jumper's knee, and rotator cuff in

the shoulder. On the opposite side,

you've got things like distal biceps

tendon ruptures at the elbow. These are

one of the rarest major tendon ruptures.

When I see one, I immediately start

thinking heavy lifting, steroids,

systemic disease, or some weird combo of

all three. So you are much more likely

to sprain your ankle than rip your

Achilles. But if you rip a tendon, it

has a much bigger impact on your life.

Why do these athletes keep popping

tendons? Let's come back to our friends.

Jason Tatum and Tyrese Hallebertton both

tearing Achilles tendons in highstakes

NBA playoff games. Aaron Rodgers

snapping his Achilles four snaps into

his Jets debut. Rashan Slater, Pro Bowl

tackle, losing his season to a patellar

tendon rupture. Muhammad Shammy needing

surgery for a severe Achilles or heel

issue. None of these guys went into the

game thinking today is rupture day. So,

what actually happened? I don't know,

man. From the outside, it looks like

random freak accident. From the inside,

at the tissue level, that tendon has

often been getting sicker for months or

even years. You have some area of

healthy tendon and then you have some

area of damaged tendon. Whenever you do

very fast movements like jumping or

sprinting, your tendon has to lengthen

very quickly. Now, this area of damaged

tendon doesn't want to lengthen quickly

and get injured. So, there's actually a

sort of stress shielding protective

mechanism going on here. That's just a

fancy way of saying your tendon

basically protects the area of damage as

much as it can. But if the stress is too

high, you'll probably still end up

irritating that.

>> It's not that your tendons hate you.

It's that you've ignored the way they

communicate with you for a long time.

Pain, stiffness, morning tightness, the

tendon that needs forever to warm up.

That little pinch when you go down the

stairs, that is your tendon sending you

polite emails marked high importance.

You keep hitting mark is red.

>> OH MY GOD. AND then one day you jump,

cut, plant, or yes, load up that

preacher curl like you're trying to

impress Instagram and the tendant says,

"We sent you 147 warning emails. You did

not respond. We are closing your

account." Pop. Let's talk science, but

in human language. Healthy tendons 101.

In a healthy tendon, collagen fibers are

straight and parallel like uncooked

spaghetti all lined up. mostly type 1

collagen, strong, stiff, good at

handling tension. There's also a little

bit of type three collagen and

proteoglycans for flexibility. The

teninocytes are long, thin cells that

sit between the fibers, constantly

repairing tiny micro damage. When you

train smart, you give that tendon load.

The tenocytes respond by laying down

stronger collagen, thickening the tendon

slightly, increasing its stiffness. Over

time, that tendon becomes more like a

properly tensioned climbing rope and

less like a worn out shoelace. How it

becomes vulnerable?

>> Tell me how.

>> Now, let's add some real life. You sit a

lot. You decide to get back into shape

and go from zero runs per week to five

runs per week. Or you add just one more

leg day and extra pio because Tik Tok

said no days off. Yes, your tendon

suddenly sees way more load than it is

prepared for.

>> Tendons are meant to withstand a lot of

repetitive loading. But if the load

becomes too great, then the tendon gets

stressed. The tendon is repeatedly

strained so that the rate of degradation

exceeds that of regeneration, that is

where the problems start.

>> At the cell level, tenocytes ramp up

activity. The tendon swells a bit. This

is called reactive tendonopathy, early

stage, potentially reversible. If you

respect that, back down and reload

sensibly, it can normalize.

>> Essentially, change up the activities

you're doing to put a bit less stress.

>> If you ignore it and keep hammering, the

tendon starts to fail at repair. Enzymes

called matrix metalloproteinases

or MMPs increase and chew up type 1

collagen. The tendon lays down more type

three collagen, which is weaker. The

nice parallel fibers start to look like

a plate of cooked spaghetti. Imagine

your rope of a tendon not being tightly

packed but frayed, kind of lucid, like

the fibers are kind of coming apart.

They can get splintered and it the

appearance starts to take on the look of

an old worn rope like this picture over

here. Blood vessels and nerves grow into

the tendon where they should not be and

you get pain, thickening, decreased

strength. That is the disrepair and then

degenerative stage. At this point, parts

of the tendon are basically scar tissue,

fatty or mucoid junk that will not carry

load well. So when you finally blow it,

it is almost never a perfect healthy

tendon suddenly exploding out of

nowhere. It is the compromised tendon

finally meeting more load than it can

handle. Quick sidebar because people mix

this up all the time. Tendon equals

muscle to bone movement. Think Achilles,

patellar tendon, distal biceps.

Ligament, bone tobone. Stability. Think

ACL, MCL, lateral ankle ligaments. A

torn ligament often means joint

instability, giving way, swelling and

bruising around the joint. A tendon

injury hurts when you use the connected

muscle, causes weakness more than

looseness, can rupture and recoil like

that classic Popeye deformity with a

biceps tear. The pathology is different

between the two as well. Tendons live in

an overload and degenerative world.

Ligaments are more about acute trauma

and stability. So, the way we treat and

rehab them is different. Same family of

tissues, different personalities. Let's

check your tendon risk bingo card.

First, training and mechanical load.

Sudden jump in training volume or

intensity. Rapid return after time off.

A weekend warrior pattern. Sit all week.

go full send on Saturday. Poor landing

mechanics, bad foot posture, stiff

ankles, terrible shoes. Medical

conditions, several systemic conditions,

weaken tendon biology, diabetes, sugar

cross links, collagen and messes with

micro blood supply, obesity and high

cholesterol, more load plus metabolic

changes in the tendon, thyroid issues,

gout, rheumatoid arthritis, other

autoimmune diseases, chronic kidney

diseases, connective tissue disorders

like Aaylor's Danlos. These do not

guarantee an injury but they lower your

margin for error. Medications. Some meds

are truly tendon unfriendly.

Fluoroquinolone antibiotics like

cyproloxicin or levofluxisonin linked

with tendonopathy and rupture especially

Achilles sometimes even without big

loads. Corticosteroids pills or repeated

injections around a tendon. These are

good at killing inflammation but they

can also weaken collagen. Statins for

cholesterol. A small percentage of users

develop tendon pain or even tears.

Aromatase inhibitors in some cancer

treatments. Some amunosuppressants and

bisphosphinates have signals too. If you

are on any of these, especially combined

with the medical conditions we just

listed, your tendons deserve extra

respect.

lifestyle and previous injury, smoking,

poor sleep, high alcohol intake, and

most importantly, previous tendon

injury. Once a tendon has been through

tendinopathy or rupture, it rarely goes

back to factory settings.

>> Hell no.

>> You can get it close, but its margin for

error shrinks. Let's clean up some

language because this actually affects

treatment. Tendinitis with an itis.

Acute inflammation, red, hot, swollen,

new injury. True tendinitis is

relatively shortterm. Tendinosis,

chronic degeneration, disorganized

collagen, type one replaced with type

three. Neo vessels and scar tissue.

Little to no classic inflammation.

Tendonopathy,

umbrella term for all painful tendon

conditions, inflammatory, degenerative,

partial tears. Most people use

tendinitis for everything. But most

long-term problems are actually

tendinosis, not pure inflammation. Why

does this matter?

>> I don't know, sir.

>> Because inflammation only makes you want

to rest and take anti-inflammatories.

Degeneration means you actually need

progressive loading to remodel the

tendon.

>> In a healthy tendon, those collagen

fibers are packed densely and lined up

perfectly parallel to each other like

organized cables. That parallel

structure is what gives them their

strength. When a tendon gets injured,

that structure falls apart. A healthy

tendon handles normal training, slight

morning stiffness maybe, but warms up

fast. During the reactive phase, you

suddenly ramp up training. The tendon

gets sore, thick, stiff, especially

first thing in the morning or at the

start of workouts. Pain eases as you

warm up. This stage can settle in a few

weeks if you adjust load. Tendon

disrepair, but you keep going. Pain is

now more persistent. There is often a

tender nodule. Sports are possible, but

you are modifying around the pain.

Imaging, ultrasound or MRI shows fiber

disorganization. Degenerative

tendonopathy, that's after months to

years. Structural changes are now more

permanent. Parts of the tendon are

essentially scarred with poor capacity.

Rupture. Sometimes after a sharp

increase in load, other times during a

normal routine movement. You feel the

pop, maybe hear it, often with weakness

or complete loss of function. And then

we start talking about surgery, boots,

casts, and long rehab. How are

non-ruptured tendon problems treated?

This is where people get it wrong all

the time. Step one, calm it down.

Relative rest, stop or reduce the

specific painful activity. Not bed rest.

You do not want total deconditioning.

Short-term use of ice and sometimes

rarely NSAIDs for pain. offloading tools

such as heel lifts for Achilles,

patellar straps for jumper's knee,

bracing for elbow or wrist issues. Step

number two, build it up. The real

treatment for most tendonopathy is

progressive loading in isometric

exercises will help to push the fluid

out of the tendon and return the tendon

back to its normal matrix. Isometrics

for pain relief. Holding a static muscle

contraction. During an isometric muscle

contraction, you're slowly shortening

the muscle and your tendon is slowly

relaxing and lengthening. This is called

stress relaxation. For example, calf

holds 45 to 60 seconds, 3 to five reps a

couple of times per day at a load that

is challenging but tolerable.

>> Very similarly, if you lift really light

weights, you wouldn't expect to see your

muscle remodel or get stronger.

eccentrics and heavy slow resistance.

Think Alfredson style heel drops for the

Achilles. Three to four sets of 15

progressing to heavier slower sets over

12 weeks or more. If you do want to do

slow controlled movements instead of

isometrics, the protocol would be almost

identical.

>> This stimulates tenocytes to lay down

better collagen, reorganize fibers,

improve the tendons capacity. common for

there to be some pain if you have weak

or damaged tendons and you're doing

these challenging exercises. In fact,

strengthening your tendons can happen

faster if you push to about a 4 out of

10 pain level rather than a zero out of

10 pain level. Adjuncts for treatment.

Other things that sometimes help may

include shockwave therapy for chronic

cases, PRP or plateletri plasma

injections, still with mixed evidence,

but some benefit in select tendons.

Okay.

>> Very cautious use of corticosteroid

injections mainly for paritenon or

berscitis, not into the tendon itself

because they can weaken the tissue. Rest

alone does not fix tendinosis. You feel

better when resting. then go right back

to where you started once you load it

again. How are torn tendons treated?

Now, let's talk about when the rope

actually snaps. Non-surgical management

can include for some partial tears and

for certain full ruptures in less active

or older patients. We can treat these

non-operatively with immobilization,

cast, boot or brace, gradual

weightbearing, then structured rehab.

Outcomes can be good, but there is often

more strength loss. R-rupture rates may

be higher in some tendons like the

Achilles if protocols are not followed

perfectly. Then there's surgical repair

for young active healthy people or high

demand tendons especially the Achilles

or patellar or quadriceps tendon distal

biceps and rotator cuff in certain

patterns. We usually recommend surgical

repair. That involves bringing the torn

ends back together, stitching them with

strong sutures, sometimes using anchors

into the bone or tendon grafts if the

tissue is poor or the gap is big. Rehab

and timeline for this rough ballpark for

a complete rupture with repair 0 to 2

weeks immobilized wounds healing. 2 to 6

weeks protected motion, partial

weightbearing. 6 to 12 weeks, more

aggressive strengthening. 3 to six

months, heavier loading, some straight

line running or basic sports drills. Six

to 12 plus months full return to sport

in many athletes. If you go and you

sprain your ankle and you go to the

doctor, very good doctor, very

well-meaning, they're going to give you

a boot. And what is a boot? So, I told

you that a scar forms when we get stress

shielding. What a boot is, it is a

mechanical stress shielder. What it's

designed to do is to take the stress off

the tissue you've injured.

>> If I've told you that the thing that's

going to cause that tissue to get a scar

is that you take off the tension, what

I've just done is I've made the problem

worse. I understand that you cannot put

full load on a surgical repair

immediately. But what you can do is you

can take it out at the beginning of the

day. You can remove it from the boot and

I can do some isometric loads with low

jerk. So, I'm going to develop force

slowly. I am going to make sure that

there's zero pain and I am going to hold

that and then I'm going to let that off

slowly.

>> And no, we cannot speed this up just

because you're impatient or because

social media told you about one guy who

came back in record time. Your biology

does not care about your content

schedule.

>> The key is we're not trying to be I'm

the strongest in the world. We're trying

to say I'm putting a little bit of load

through that. Okay. Yeah, that is the

key is that you don't get all caught up

in the machismo of it and you just say I

just want to feel tension. If you can

feel an ice pick, that means there's a

very specific spot that hurts. Stop.

>> Mhm.

>> If I feel like a warm burning area, like

I'm muscle soreness after exercising,

that's totally okay.

>> Do heel tendons ever go back to 100%.

Short answer, almost never.

Longer answer studies suggest heel

tendons even with good rehab often reach

about 60 to 90% of their original

tensile strength. They usually work fine

for daily life and many athletes do get

back to high level sport but elasticity

changes, stiffness changes, fatigue

resistance changes. Microscopically,

there is more type three collagen, more

disorganization, and more scar tissue.

Tear will always be obvious on MRI or

ultrasound, but that's not to say it's

going to stop you getting bacterial

activity, but it does mean you need to

load the tendon appropriately to make

the remaining fibers strong enough to

deal with a normal load. So yes, you can

absolutely get back to lifting, running,

playing ball. But the idea that surgery

made it stronger than new is mostly a

gym myth. You can make your whole

system, muscle, tendon, nervous system

perform at a very high level again, but

you should treat that tendon with

permanent respect. The aim of any good

tendon rehabilitation program is to

restore your tendon, whether it best be

overworked, swollen, and inflamed,

degenerative, or torn, back to a normal

tendon. And this is absolutely

achievable with the right loading

parameters applied to it and avoiding

rest. How to avoid tenant injury and

optimize tenant health. All right, here

is the part that you came for.

>> Yes, definitely. Let's talk offense, not

defense. Number one, train your tendons

on purpose. Two key tools. Heavy, slow

resistance, two times per week. Three to

four sets of six to eight reps at about

70 to 85% of your max. Slow 3 to 5

second lowering phase. Think heavy calf

raises, squats, RDL's, leg presses,

pressing and pulling. Use isometrics and

basic plyometrics. holds like wall sits,

isometric calf holds for 30 to 60

seconds. Later, add small hops, pogos,

low level jumps once your base is good.

You are not training muscle here. You

are telling the tendons, adapt to this.

Get denser, get stronger. A man just

said that.

>> Number two, respect the 10% rule. Do not

increase your weekly mileage, total

volume, number of sets and jumps by more

than roughly 10% per week. Your heart

and brain might be ready for a bigger

jump. Your tendons are slower. They need

time. Number three, warm up like you

mean it. Forget the 30 second stretch

and go. 10 to 15 minutes of dynamic

warm-up, light jog or bike, leg swings,

body weight squats and lunges, easy

hops. You are prepping the tendon to

handle load. Cold rubber snaps faster

than warm rubber. Number four, fix your

environment. Good footwear replace old

shoes. Avoid super hard surfaces for all

your running and jumping. If your

mechanics are off, get someone qualified

to look at your movement. Number five,

check your health and meds. If you have

diabetes, thyroid problems, gout,

autoimmune diseases, or you are on

fuoricquinolones, repeated steroids, or

other tendon unfriendly meds, talk to

your doctor or pharmacist about tendon

risk. You cannot always change the

medication, but you can be smarter with

your training. Number six, listen early,

not late.

>> Okay?

>> Morning stiffness that lasts more than a

few minutes. Pain at the start of

activity that is getting worse week to

week. A tender lump unattended. Pain

that spikes over three or four out of 10

and lingers more than 24 hours after a

workout. Those are early warning signs.

That is the moment to adjust load, not

to train through it. Remember that

preacher curl guy with both biceps

popping? That story almost never starts

with, "My arms felt amazing during every

workout." How can athletes and regular

humans apply this today? Let's make this

stupid simple so you can start right

now. Pick one tendon that you care

about. If you're a runner or hooper,

your Achilles or your patellar tendon.

If you lift a lot, your patellar,

biceps, or elbow tendons. If you sit and

hunch all day, your rotator cuff. This

week, add two tendon sessions. Heavy,

slow work for that tendons muscle group.

Keep pain during exercise below 3 to

four out of 10. Cap your volume

increase. Do not jump your running

distance or your leg day volume more

than 10%. Monitor your 24-hour response.

If pain spikes and stays elevated the

next day, you did too much. Dial back a

little and progress more slowly.

>> As tendons get bigger and stronger, they

do get more stiff as well. This is

actually a good thing though because it

makes them more resistant to

deformation. Tendons that are stiff and

resistant to deformationation will not

be overloaded and overworked to the

point of being torn as easily. Dial in

recovery sleep 7 to N hours. Eat enough

protein. Stay hydrated. If you want

actual guided stuff, follow my gym,

Human 2.0 Fitness, here on YouTube,

where we post content on moving better

and preventing injury. Or check out the

Human at home channel where we show you

how to be healthy in the space where you

live. These are literally tendon

friendly channels.

>> Okay. Okay. Okay.

>> So, do your tenants hate you? Nah.

They're just brutally honest. They do

not care about your ego, your memes, or

the no days off grind set. They care

about biology, load, time, recovery, and

whether you listen when they talk. If

you treat them well, they will carry you

through sport, lifting, and life for

decades. If you ignore them, I will

happily meet you in my O, but I would

much rather that you stay out of there.

Thanks for joining me in this therapy

session for you and your tendons that

will keep you doing what you love and

out of my O. Let's wrap it up with a

roundt analysis from you, the intern

army. Have you ever had a tendon injury

yourself? And if so, which one? What was

it and how was it treated? What worked

and what absolutely did not? Drop all of

that in the comments below. Your story

might help someone avoid making the same

mistakes. Be sure to join my intern army

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friend that always trains through it

until something pops. As always, that's

been a word from Dr. Chris Rainer, not

your everyday ortho, where we see one,

do one, teach one.