Muscle and joint symptoms are increasingly recognised as part of the menopause transition. Research involving more than 93,000 women has shown that musculoskeletal symptoms are common during perimenopause, and emerging research is beginning to explore how changing hormones may also influence our tendons.

But does this mean menopause causes tendinopathy?

The answer is more complicated than that.

What exactly is a tendon?

Tendons are strong bands of connective tissue that attach muscles to bones.

Every time you walk, run, lift weights, climb stairs or jump, your tendons transfer force from your muscles to your skeleton.

Like muscles and bones, tendons are living, adaptable tissue. When they are exposed to appropriate loading, they adapt and become better able to tolerate that load.

Problems can develop when the demands placed on a tendon exceed its current capacity to recover and adapt.

This can result in tendinopathy – a condition involving tendon pain and reduced ability to tolerate load.

Common examples include:

- Achilles tendinopathy

- Guteal tendinopathy at the outside of the hip

- Rotator cuff-related shoulder pain

- Patellar tendinopathy around the knee

- Pain involving the plantar fascia underneath the foot.

What does oestrogen have to do with tendons?

We know that oestrogen has effects throughout the musculoskeletal system – not just on reproductive tissues.

Tendons contain collagen, and oestrogen appears to influence collagen turnover, connective tissue metabolism and tendon properties.

As women move through perimenopause and into postmenopause, circulating oestrogen levels ultimately decline. Researchers have therefore questioned whether these hormonal changes could contribute to changes in tendon health.

There is biological evidence to support this possibility, and recent literature suggests declining oestrogen may be one factor influencing tendon structure and function during midlife.

However, there is an important catch:

Our evidence in women is still limited.

Historically, women have been underrepresented in tendon research, and a 2024 systematic review examining Achilles tendinopathy research identified a significant gender data gap.

So while hormones may be part of the picture, we shouldn't automatically assume that every sore tendon in a woman over 40 is caused by menopause.

Why might tendon pain suddenly appear?

Tendinopathy is usually multifactorial.

Hormonal changes may occur at the same time as changes in:

• physical activity

• muscle strength

• body composition

• sleep and recovery

• previous injuries

• training volume

• general health

• and the amount or type of load placed on the tendon.

Sometimes the trigger is surprisingly simple.

You may suddenly increase your walking, start running again, add hills, return to the gym, increase your weights or spend a weekend doing far more activity than usual.

The tendon simply hasn't had time to build the capacity required for the new demand.

Should I rest the tendon?

Usually, complete rest isn't the long-term answer.

Temporarily reducing an aggravating activity may help settle symptoms, but avoiding load altogether can also reduce the tendon's capacity.

One of our most useful tools for treating tendinopathy is therefore something very simple:

load.

Research consistently supports exercise-based loading as a cornerstone of tendon rehabilitation. Importantly, there doesn't appear to be one magical exercise program that works for everybody.

The goal is to progressively expose the tendon to enough resistance to stimulate adaptation without repeatedly overwhelming it.

Depending on the tendon and stage of rehabilitation, this might include:

• isometric exercises

• slow resistance exercises

• heavier strength training

• gradually increasing walking or running

• and eventually faster movements, jumping or sport-specific activities.

Can I exercise through tendon pain?

Some discomfort during tendon rehabilitation does not necessarily mean you are causing damage.

What matters is how much pain you experience, how the tendon responds afterwards and whether symptoms progressively worsen.

A good rehabilitation program considers the 24-hour response to exercise and adjusts the load accordingly.

This is very different from simply pushing through severe pain.

What about menopausal hormone therapy?

This is an interesting area of research, but we need to be cautious.

Although oestrogen influences connective tissue biology, studies examining menopausal hormone therapy and tendon outcomes have produced mixed and sometimes conflicting findings.

At present, MHT should not be viewed as a treatment for tendinopathy itself.

Decisions about menopausal hormone therapy should instead be made with your GP or menopause clinician based on your overall symptoms, medical history, risks and potential benefits.

How can physiotherapy help?

If a tendon has been painful for weeks or months, simply resting and hoping it disappears isn't always enough.

A physiotherapist can help identify why the tendon may have become overloaded, assess strength and movement capacity, modify aggravating activities and develop a progressive loading program.

For women in midlife, we can also consider the bigger picture – including menopause, muscle strength, bone health, pelvic health, recovery and your overall exercise program.

The goal isn't simply to make the pain disappear.

It's to build a tendon – and a body – that can confidently tolerate the activities you want to keep doing.

Your tendons still adapt in midlife. They just need the right reason to.

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References

Bourhill, J., Carslaw, H., Alexanderson, T., & Cross, A. (2026). Tendinopathies in physically active post-menopausal women: A concise review. Post Reproductive Health. Advance online publication.

Ganderton, C., Semciw, A., Cook, J., & Pizzari, T. (2016). The effect of female sex hormone supplementation on tendon in pre and postmenopausal women: A systematic review. Journal of Musculoskeletal & Neuronal Interactions, 16(2), 92–104.

Kruse, C., McKechnie, T., Dworsky-Fried, J., et al. (2026). Musculoskeletal manifestations of perimenopause: A systematic review and meta-analysis of 93,021 women. JBJS Open Access.

Maetz, R., Dubé, M. O., Tougas, A., et al. (2023). Systematic review and meta-analyses of randomized controlled trials comparing exercise loading protocols with passive treatment modalities or other loading protocols for the management of midportion Achilles tendinopathy. Orthopaedic Journal of Sports Medicine, 11(5).

Merry, K., MacPherson, M., Vis-Dunbar, M., et al. (2023). Identifying characteristics of resistance-based therapeutic exercise interventions for Achilles tendinopathy: A scoping review. Physical Therapy in Sport, 63, 73–94.

Pavlova, A. V., Shim, J. S. C., Moss, R., et al. (2023). Effect of resistance exercise dose components for tendinopathy management: A systematic review with meta-analysis. *British Journal of Sports Medicine

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