Tendinopathy in PadelWhy Tendons Fail and How to Fix Them
The correct science behind chronic tendon pain in padel — from the Cook and Purdam continuum to loading-based treatment that actually works.
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The PadelRevive Team
Written by players, for players — built in Zanzibar · Updated May 2026
6-12+
Weeks to recover — tendons are type I collagen with poor blood supply; moderate tendinopathy heals far slower than muscle.
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Continuum stages — Cook and Purdam (2009) defined reactive, tendon disrepair, and degenerative stages, each needing a different treatment approach.
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Highest-risk tendons in padel — Achilles, patellar, and lateral elbow extensor origin are the most commonly loaded tendons in padel movement.
In short: tendinopathy is the correct term for chronic tendon pain. It is degenerative tissue change — not inflammation. That means “tendinitis” is misleading, anti-inflammatories address the wrong mechanism, and rest delays recovery. The Cook and Purdam continuum tells you which stage you are in and which loading approach to use.
What Is Tendinopathy?
The correct definition — and why the terminology matters clinically
Tendinopathy is a pathological condition of the tendon characterised by localised pain, swelling, and reduced function during and after loading. It is the umbrella term that has largely replaced “tendinitis” in sports medicine and rehabilitation science — and the difference is not semantic.
At the histological level, chronic tendinopathy shows collagen disarray, neovascularisation (new blood vessel ingrowth), and a notable absence of the inflammatory cells that define true tendinitis. The pain comes from mechanosensitive nociceptors responding to structural change in the tendon matrix — not from active inflammation.
Why “Tendinitis” Is a Misleading Label
Treating tendinopathy as tendinitis leads to the wrong interventions. NSAIDs (ibuprofen) and corticosteroid injections target inflammatory pathways that are not the primary driver of chronic tendon pain. In the short term they can mask symptoms; over the longer term, repeated cortisone injections in particular have been shown to accelerate degenerative changes in tendon tissue. If your GP or physio still uses “tendinitis” for a pain that has lasted more than 6 weeks, ask specifically about the Cook and Purdam continuum and loading-based treatment.
The most clinically useful model for understanding and treating tendinopathy in sport is the continuum model proposed by Jill Cook and Craig Purdam in 2009. It provides a framework that connects the structural stage of the tendon to the appropriate type of exercise stimulus — and it explains why one-size-fits-all rest does not work.
Terminology Recap
Tendinopathy = the correct term for chronic tendon pain (structural, not inflammatory). Tendinitis = outdated; implies inflammation that is usually not present in chronic cases. Tendinosis = an older term for the degenerative stage specifically. Use tendinopathy unless a clinician has confirmed acute reactive-stage inflammation.
The Cook and Purdam Continuum Model
Three stages — three different treatment protocols
The continuum model describes tendon pathology as a spectrum rather than a binary healthy/injured state. Understanding which stage you are in is critical — because the loading approach that helps in one stage can harm in another.
Stage 1 — Reactive Tendinopathy
Triggered by: sudden increase in training load, returning after a break, or an acute overload event (hard match on an unfamiliar surface).
Structure: tendon is thickened and swollen but collagen architecture is still largely intact. No structural disarray yet.
Key feature: this stage IS reversible with correct management.
Treatment: relative load reduction (not complete rest) + isometric exercises. Pain-free isometrics held for 45-60 seconds provide an analgesic effect and maintain collagen stimulus without creating further shear load.
What NOT to do: heavy progressive loading in the reactive stage will push the tendon into the next stage — this is why “just train through it” is dangerous here.
Stage 2 — Tendon Disrepair
Triggered by: failed reactive stage management — continued overload without recovery, or incomplete recovery from reactive phase.
Structure: failed healing attempt — some collagen disarray begins, cell matrix shows fibroblast proliferation, some structural disruption visible on imaging.
Key feature: partial reversibility — with the right loading stimulus, the tendon can still reorganise.
Treatment: slow isotonic loading with emphasis on eccentric component (slow lowering phase). Heavy slow resistance protocol: building from 3 x 15 reps to 3 x 6 reps over 12 weeks with increasing load.
Cortisone in this stage: short-term relief is possible but accelerates structural degeneration. One injection for a major competition is a calculated risk; repeated injections are not advisable.
Stage 3 — Degenerative Tendinopathy
Triggered by: years of accumulated damage, repeated failed-healing cycles, age-related collagen changes.
Structure: significant collagen disarray, failed matrix, neovascularisation, areas of cell death (apoptosis). On imaging: hypoechoic regions on ultrasound, signal changes on MRI.
Key feature: this stage is largely irreversible in terms of structural restoration — but the tendon can still be made functional and pain-free.
Treatment: same loading principles as Stage 2 but progress is slower and return-to-sport targets are more conservative. The goal is pain-free function, not structural cure.
Important: degenerative tendons are at higher risk of partial or complete rupture under sudden high load — this is particularly relevant for the Achilles and patellar tendon in padel.
Why Cortisone Is Problematic in Later Stages
Corticosteroid injections work by suppressing inflammatory response. In Stage 1 (reactive), where there is genuine cell reactivity, this can provide real short-term relief.
In Stages 2 and 3, the mechanism driving pain is not inflammation — it is structural disarray and mechanosensitive nociception. Cortisone does not address this, and repeated injections have been associated with tendon rupture risk.
If you are offered a cortisone injection for tendon pain that has lasted more than 6-8 weeks, ask for imaging (ultrasound or MRI) to confirm the stage before proceeding.
You know the feeling — weeks of niggling Achilles pain, then a physio tells you to rest for three weeks and it comes back the moment you start playing again. Most players do not realise that rest is not the treatment for tendinopathy; it is the beginning of a cycle. What actually works is progressive loading — the right kind, at the right stage, at the right tempo.
Which Tendons Are Most at Risk in Padel?
Movement demands and the tendons they load most heavily
Padel places specific mechanical demands on the body that make certain tendons particularly vulnerable. Unlike tennis, padel involves more frequent direction changes, more lower-body explosive actions in a confined space, and a grip-dominant compact swing that creates high vibration forces through the arm. Each of these demands has a corresponding high-risk tendon.
Achilles Tendon
Why padel loads it: jumping at the net, pushing off hard from the back court, rapid acceleration and braking in the lateral shuttle movement.
Typical presentation: pain 2-6 cm above the heel insertion after match play or the morning after a session. Stiffness first thing that loosens with movement is a hallmark of mid-portion Achilles tendinopathy.
Padel-specific risk factor: padel shoes with less heel drop than running shoes change the loading angle on the Achilles — players who switch shoe categories without adapting are vulnerable.
Full guide: see /injuries/padel-achilles-tendon/ for the complete diagnosis and loading protocol.
Why padel loads it: explosive squatting movements when reaching for low balls, landing from jumps at the net, and the repeated deceleration forces during lateral movement.
Typical presentation: localised pain at the inferior pole of the kneecap, worst during and immediately after loading. Classically worsens going down stairs.
Padel-specific risk factor: hard court surfaces provide less energy return than clay — players who play primarily on hard indoor courts have higher patellar tendon load per session.
Full guide: see /injuries/padel-patellar-tendinitis/ for the complete diagnosis and rehabilitation protocol.
Why padel loads it: the compact padel swing creates high deceleration forces through the forearm at ball contact. Vibration from glass walls transfers directly to the extensor tendon attachment at the lateral epicondyle.
Typical presentation: tenderness directly over the lateral epicondyle (bony prominence on the outer elbow), pain gripping the padel handle, weakness when extending the wrist against resistance.
Padel-specific risk factor: players who use a western grip or who hit volleys with an open wrist create higher eccentric loads at the extensor origin.
Full guide: see /injuries/padel-elbow/ for the complete guide including grip adjustments and loading protocol.
Why padel loads it: overhead smash attempts require rapid shoulder external rotation and then forceful internal rotation at ball contact — a high-velocity eccentric load on the rotator cuff.
Typical presentation: pain at the front or outer shoulder with overhead movements, weakness lifting the arm above shoulder height, pain lying on the affected side.
Padel-specific risk factor: players who attempt smashes beyond their current shoulder mobility and strength — particularly those returning to padel from other racket sports with different smash mechanics.
Note: rotator cuff tendinopathy is distinct from a rotator cuff tear — imaging is advisable if symptoms are severe or prolonged.
Loading Is the Treatment
The progressive loading framework for tendinopathy rehabilitation
The central principle of tendinopathy rehabilitation is mechanotherapy: tendons respond to mechanical load by adapting their collagen structure. Load is the stimulus for healing. This means that the correct response to tendinopathy is not rest — it is the right kind of load at the right intensity, applied progressively over time.
Rest leads to tendon atrophy — the collagen network weakens further, the tendon becomes less able to handle load, and when you return to sport the risk of flare-up or rupture increases. This is the cycle most padel players experience: pain, rest, return, re-injury.
Phase 1 — Isometric Loading (Pain Relief and Initial Stimulus)
What it is: static muscle contraction at a fixed joint angle with no movement through range.
How to perform: hold the position for 45-60 seconds at moderate intensity (5-6 out of 10 effort). 4-5 repetitions, once or twice per day.
Why it works: isometric contractions produce an immediate analgesic effect (cortical pain inhibition) and provide a collagen stimulus without the shear forces of dynamic loading.
When to use: reactive stage (Stage 1), acute flare-ups in Stages 2 and 3, and as a pre-match pain management tool.
Example for Achilles: standing calf raise held at mid-range for 45 seconds x 5 reps — can be performed twice daily without worsening the tendon if load is appropriate.
Phase 2 — Isotonic Loading / Heavy Slow Resistance (HSR)
What it is: slow, controlled movement through full range — both the concentric (muscle shortening) and eccentric (muscle lengthening) phases performed at equal slow tempo.
Tempo: 3 seconds concentric + 1 second hold + 3 seconds eccentric. This slow tempo maximises collagen stimulus compared to fast ballistic loading.
Starting protocol: 3 sets x 15 repetitions at a weight that feels moderate (5 out of 10 effort). Rest 2-3 minutes between sets.
Progression: over 12 weeks, increase load and reduce reps — progressing towards 3 sets x 6 reps at higher load. This mirrors the heavy slow resistance (HSR) protocol validated for patellar and Achilles tendinopathy.
Pain rule: up to 3 out of 10 pain during the exercise is acceptable. Pain above 5 out of 10 means load is too high. Pain the following day that has not returned to baseline within 24 hours means you have exceeded capacity.
Phase 3 — Energy Storage and Return (Sport-Specific Loading)
What it is: faster, more explosive loading that mimics the demands of padel — hopping, bounding, lateral deceleration, and racket swing drills.
When to progress to this phase: only after Phase 2 loading is pain-free at full working weight, and the 24-hour rule is consistently satisfied.
Why this phase matters: tendons in padel do not just need to absorb load — they need to store and return elastic energy rapidly. Phase 2 builds the structural base; Phase 3 trains the energy system.
Examples: single-leg calf hops (Achilles), lateral box steps with deceleration (patellar tendon), wrist extension with band (extensor origin).
The 24-Hour Rule
After any loading session, monitor your pain level the following morning. If pain has returned to its pre-session baseline within 24 hours, the load was appropriate. If pain is elevated beyond 24 hours, reduce volume or intensity in the next session. This rule applies throughout rehabilitation — not just in the early stages.
Return to Padel with Tendinopathy
Progressive return criteria and the monitoring framework
A common mistake is waiting for zero pain before returning to court. That standard is both unnecessary and impractical — most mid-season padel players with tendinopathy would never return if zero pain was the criterion. The evidence-based benchmark is managed, monitored pain rather than no pain.
Return-to-Play Criteria
Pain during activity: up to 3 out of 10 is acceptable during court drills and match play. Pain above 5 out of 10 means you are exceeding tendon capacity.
24-hour rule: pain after play must return to pre-session baseline within 24 hours. This is the non-negotiable monitoring standard.
Phase 2 loading completed: you should be able to perform the relevant isotonic loading exercise pain-free at working weight before returning to match play.
Tendon irritability window: in the 24 hours before an important match, avoid heavy loading of the tendon — the reactive window means tissue is more sensitive after a loading stimulus.
Progressive Return Protocol
Week 1-2: rally drills only — controlled ball hitting at reduced intensity. No competitive points.
Week 3-4: cooperative point play — structured rallying with a partner. Monitor with the 24-hour rule after each session.
Week 5-6: full match play at reduced frequency — one match per week maximum, with two full recovery days between sessions.
Week 7+: progressive return to normal match frequency based on sustained 24-hour rule compliance.
Ongoing: continue Phase 2 maintenance loading (2 sessions per week) indefinitely to maintain tendon capacity — tendinopathy tendons require ongoing stimulus or they regress.
Build Tendon Capacity Pre-Season
The best time to treat tendinopathy is before it develops. A 6-8 week progressive loading block at the start of the season — before competition intensity ramps up — significantly reduces the incidence of in-season tendon flare-ups. This is the principle behind the prevention hub programmes at /prevention/.
If you are managing tendinopathy through a padel season, tracking load across the week (total on-court time + training volume) is the single most useful variable to monitor. Spikes in weekly load — more than 10% increase week-on-week — are the most common trigger for reactive flare-ups in players who have a history of tendinopathy.
What is the difference between tendinopathy and tendinitis?
Tendinitis specifically implies inflammation of the tendon (the “-itis” suffix means inflammation). Tendinopathy is the broader, more accurate term for chronic tendon pain and dysfunction. Research has shown that most chronic tendon pain — the kind that has lasted more than a few weeks — does not involve significant inflammation at the histological level. Instead it involves collagen disarray, neovascularisation, and structural change in the tendon matrix. Treating tendinopathy as tendinitis leads to interventions (NSAIDs, cortisone) that address the wrong mechanism. Tendinopathy is the term used by sports medicine specialists and should be the default for any tendon pain that has not resolved within 4-6 weeks.
How long does tendinopathy take to heal?
Tendon healing is significantly slower than muscle healing due to the poor blood supply of tendon tissue (tendons are primarily type I collagen with limited vascularity). Mild reactive tendinopathy managed correctly can resolve in 4-8 weeks. Moderate tendinopathy in the tendon disrepair stage typically requires 12-16 weeks of progressive loading rehabilitation before full return to competitive sport. Degenerative tendinopathy does not “heal” in the structural sense — the goal is pain-free function through loading adaptation. During this time you can often continue modified activity, using the 24-hour rule to guide load management.
Can I play padel with tendinopathy?
In most cases, yes — with appropriate modifications. The key benchmarks are: pain during play should stay at or below 3 out of 10, and pain after play should return to baseline within 24 hours (the 24-hour rule). If either threshold is breached, you are exceeding tendon capacity and need to reduce load. Complete rest is not recommended for tendinopathy; modified play alongside progressive loading is the evidence-based approach. However, if imaging shows a partial or complete tendon tear, the return-to-play decision should be made with a sports medicine clinician.
What is the Cook and Purdam continuum model?
The Cook and Purdam continuum is a model of tendon pathology proposed by researchers Jill Cook and Craig Purdam in 2009. It describes tendinopathy as a spectrum with three stages: reactive tendinopathy (acute overload, intact collagen, reversible), tendon disrepair (failed healing, partial collagen disarray, partially reversible), and degenerative tendinopathy (significant structural damage, largely irreversible but manageable). The model is clinically useful because each stage requires a different treatment approach — isometric loading for the reactive stage, slow isotonic loading for disrepair and degenerative stages. Understanding which stage you are in prevents applying the wrong treatment at the wrong time.
Why is rest bad for tendinopathy?
Rest is counterproductive for tendinopathy because tendons require mechanical load to maintain their collagen structure. Without regular loading stimulus, tendon collagen becomes disorganised, tenocyte activity declines, and the tendon loses the capacity to handle the forces of sport. This means that extended rest typically results in a weaker tendon that is more vulnerable to flare-up when you return to court — which is the classic rest-return-re-injury cycle many padel players experience. The correct approach is relative rest (reducing load to a level that stays within the 24-hour pain rule) combined with progressive loading exercises appropriate to the continuum stage.
What is the heavy slow resistance protocol for tendinopathy?
The heavy slow resistance (HSR) protocol is a progressive loading method validated in research for patellar and Achilles tendinopathy. It uses slow-tempo isotonic exercises (3 seconds concentric, 1 second hold, 3 seconds eccentric) at progressively increasing loads. The protocol typically starts at 3 sets x 15 repetitions at a moderate load and progresses over 12 weeks to 3 sets x 6 repetitions at a heavier load. The slow tempo is key — it maximises collagen mechanical stimulus compared to fast or ballistic loading. HSR is performed 3 times per week with rest days between sessions, using the 24-hour rule to guide load progression.
