I’ve been dealt my fair share of fitness aches and pains, ranging from regular delayed-onset muscle soreness (DOMS) to a microfracture. But the worst injury has to be tendonitis. The gnawing, almost itchy pain started on the inside of my foot (known as posterior tibial tendonitis) and has recently made its way around to my hips in the form of gluteal tendinopathy.

It’s not the most painful injury, but it’s certainly one of the most stubborn. A chronic condition, it tends to flare up at the most inconvenient of times and it’s hard to get rid of the low-level buzz of irritation. And there’s another annoying thing about tendonitis: women are more susceptible to it than men. In fact, it impacts up to 25% of the population and is three times more common in women than men. Gluteal tendinopathy is the most common form of lower-body tendon injury – meaning there are women everywhere stumbling around with painful hips.  

This might sound like an open and shut case but, according to a 2022 systematic review brilliantly titled Women Have Tendons… And Tendinopathy: Gender Bias Is A “Gender Void” In Sports Medicine With A Lack Of Women Data On Patellar Tendinopathy, just 2% of all participants in tendon research are women. So we know it’s a big issue for women but not enough of us have had our sore tendons tested. 

Before we go any further, it’s worth just recapping on what tendonitis is. “Tendonitis, also known as tendinopathy, is a condition characterised by inflammation or irritation of a tendon, which is the thick fibrous tissue that connects muscles to bones,” explains osteopath Anisha Joshi, founder of OsteoAllies. “It typically presents with localised pain, swelling and sometimes restricted movement in the area. The pain is often worse with movement or activity involving the affected tendon. For example, tennis elbow is a form of tendonitis and is made worse when using your forearm for activities like pouring the kettle.”

Typically, tendonitis is thought of as an overuse or repetitive strain injury, which is why it’s often seen in active people and sports players who don’t take enough rest or suddenly change or increase their training. But sedentary people can also experience tendonitis as a result of “a sudden increase in activity level or poor technique” during exercise, says Joshi. “Inadequate warm-up or stretching, muscle imbalances and age-related degeneration can also contribute to tendonitis, as can improper equipment or footwear and conditions like diabetes or rheumatoid arthritis can also contribute to the development of tendonitis.”

My tendonitis flared up just after Christmas, a period during which my exercise routine had plummeted to a couple of short runs a week. I was staying moderately active without dramatically changing anything. But, Joshi says: “Loads of things impact the sensitivity level within a tendon. For instance, it could be that you had a bad night’s sleep or you’re stressed. Pain isn’t always a sign of damage; it can just be your brain’s way of alerting you to an area [before damage] or stress.”

Physiotherapist Florence Penny, founder of Flow Physio, says that the overall prevalence of tendinopathies in her clinic tends to be similar between genders, certain tendinopathies are seen more in women.

“This is partly due to anatomical, hormonal and biomechanical differences alongside differences in occupation and recreational activities. However, further research is needed to fully understand the underlying mechanisms of this difference,” she says.

Female physiology

So what might these biomechanical differences be? Women’s wider hips are often blamed for making us more prone to injuries like gluteal tendonitis because of the way they put increased force on the tendons when performing common movements like walking and running. Other research suggests that our quad-to-hamstring strength ratios are naturally different to men, putting a different strain on our knees and leading to more injury and pain in the joint.

“The wider pelvis and greater Q-angle in the knee (the degree at which it turns in and out) in women can affect lower-extremity alignment and mechanics, leading to increased stress,” says Penny. “Women also naturally have less muscle mass than men, which influences how tendons absorb and respond to force. And then you’ve got the fact that women are more likely to have joint hypermobility; having a greater range of motion can put increased stress on tendons too.”

Our tendons are also less stiff than men’s, Penny points out, something that has both positive and negative outcomes. A 2021 study from Shanghai University of Sports showed that men’s stiffer Achilles tendons helps to produce better force and power but also puts men at risk of tendonitis in the heel because it decreases the ability to withstand repetitive stress. Perhaps this goes some way to explaining why men and women are more or less likely to develop tendonitis in different parts of the body.

Hormones

Our hormonal balance affects just about every function in the body, and injury risk is no different. “Fluctuations during the menstrual cycle, pregnancy or menopause may make certain tendons more prone to inflammation,” says Penny. Women are around six times more likely to get De Quervain’s tendonitis (inflammation in the wrist) than men – a risk that increases dramatically during pregnancy due to hormonal changes that lead to fluid retention during the third trimester.

“Oestrogen, in particular, can affect the structure and repair capacity of connective tissues, including tendons,” Penny explains. While the hormone is vital for strengthening muscles, it can also lead to greater flexibility and lower stiffness of the tendons, which can mean less strength and stability and a greater risk of injury, according to a 2018 Frontiers in Physiology report. 

Environment and lifestyle

The way we live and move is also responsible for the injuries we develop. De Quervain’s is commonly seen in postpartum women who suddenly start lifting and carrying infants.

Poorly designed training guides

Our general lack of understanding about men’s and women’s physiology turns neutral differences into bad outcomes. For instance, the different hamstring strengths wouldn’t lead to more knee injuries if better exercise guidance was given, but most programmes are based on men’s physiology, exacerbating gender differences to the point of injury. “Training guidelines are based on data primarily for male athletes and they may not account for physiological and biomechanical differences in women, leading to an increased injury risk,” says Penny. 

In a 2018 PLOS One study looking at how men’s and women’s muscles and tendons responded to a resistance training programme, researchers found the possibility of a “mal-adapted female tendon relative to male tendon following a period of training”. However, researchers noted that the problem was not the bodies in question, but the programme – a “dynamic, heavy-load resistance training (currently the most conventional and popular form)”. Researchers concluded by asking if this was proof that women need better forms of training centred on women’s bodies. 

Just 6% of sports research is done exclusively on women, so it will take a while until we have established guidance for how women should train and recover for tendon – and overall – health. A 2023 BMJ study showed that tendons generally respond well to higher-rep, lower-intensity work, around three sets of 15 reps, which is in line with the physio guidance Penny issues. She suggests that HIIT may “potentially lead to tendinopathy, especially when it involves repetitive or excessive loads that the tendons are not accustomed to handling”. Instead, she prefers tendonitis clients to move slower, focusing on formand technique, and allowing for progressive overloading.

Until we have women-focused information, the best bet is to keep your routines simple and slow. “Gradually increasing the intensity and duration of exercise will allow the tendons to adapt. Maintaining good overall fitness and strength, particularly in the muscles surrounding the tendons, and using proper technique and body mechanics during activities to minimise excessive stress on the tendons is best,” says Joshi.

Rest is also vital, especially for those who tend to be active in their day-to-day life. “Listen to your body and avoid overexertion or pushing through pain. And incorporating rest and recovery days into your exercise schedule to allow for tissue repair and adaptation,” says Joshi. Again, the BMJ study suggested that resistance training more than once a week helped strengthen the tendons to prevent injury, but stressed the importance of taking adequate rest periods between sessions to enable tissue to repair.

If you think you have tendonitis, always consult a specialist who can properly diagnose you and give you specific exercises to strengthen, stretch and improve the health of the area. “The general principles for recovery are the same regardless of gender, aiming to reduce pain, decrease inflammation and strengthen the affected tendon to prevent a recurrence,” says Penny. “There should be a focus on proper training with correct form, gradual progression in activity, cross-training, strength and conditioning, adequate rest and recovery, and ergonomic adjustments as required.

“We should, however, be more aware of how female anatomical and physiological differences – as well as the influence hormonal or pre- and post-menopausal fluctuations – may have on tendon health and healing.”

Images: Getty