Menopause and Tendon Injuries: An Evidence-Based Guide for Women’s Health by Megan Schneider Senior APA Physiotherapist

Menopause is a natural life stage, but its hormonal changes can significantly impact musculoskeletal health, especially tendons. While hot flushes and mood swings often dominate the conversation, tendon injuries are an overlooked consequence of estrogen decline. This blog explores why tendon health changes during menopause and how physiotherapy can help women stay active and pain-free.

Why Menopause Affects Tendons

Estrogen is more than a reproductive hormone; it plays a vital role in tendon structure and function. Research shows estrogen influences collagen synthesis, vascular supply, and tendon elasticity. When estrogen levels drop during menopause:

·      Collagen turnover slows, reducing tendon flexibility.

o   Collagen is the most abundant protein in the human body and a major structural component of connective tissues, including tendons, ligaments, cartilage, and skin. In tendons, collagen fibers provide strength, flexibility, and resistance to tensile forces. As collagen synthesis slows, it reduces tendon strength and elasticity. This also means that healing after injury becomes prolonged, increasing the risk of chronic tendinopathy.

Research shows that postmenopausal women have lower collagen density in tendons, which correlates with higher injury rates and slower recovery.

·      Healing capacity declines, increasing susceptibility to micro-tears.

o   Tendon healing relies on a complex interplay of collagen synthesis, cellular activity, and vascular supply. Estrogen plays a key role in these processes.
Estrogen supports blood flow to connective tissues. Lower estrogen means reduced vascularisation and ultimately reduced nutrient and oxygen delivery, which delays healing. Micro-tears are tiny disruptions in tendon fibers caused by repetitive stress or overload. Normally, these heal quickly through collagen remodeling. However during menopause:

§  Slower Repair → Micro-tears accumulate instead of resolving.

§  Weaker Collagen Matrix → Tendons become less resilient to daily loads.

§  Higher Risk of Tendinopathy → Chronic pain and degeneration develop over time.

·      Inflammatory processes rise, contributing to chronic pain.

o   Estrogen helps regulate inflammation. Without it, inflammatory markers can remain elevated longer, impairing tissue repair and increasing pain. Without enough estrogen, the body produces more inflammatory chemicals, which can break down tendon tissue and keep pain signals active. As a result, tendons heal more slowly. Over time, this makes tendons weaker and more likely to get injured again. Because inflammation lingers, pain often lasts longer and can become chronic, leading to conditions like tendinopathy.

Studies confirm that estrogen receptors exist in tendon tissue, and their reduced activation correlates with increased stiffness and higher risk of tendinopathy. This explains why many women experience tendon pain through menopause.

Common Tendon Conditions in Menopausal Women

Achilles Tendinopathy

The Achilles tendon is particularly vulnerable due to its weight-bearing role. Reduced elasticity and calf muscle weakness increase strain, leading to pain and stiffness.

Rotator Cuff Tendinopathy

Shoulder tendons often suffer during menopause, especially in women who engage in repetitive arm movements or strength training without proper conditioning.

Gluteal Tendinopathy

A leading cause of lateral hip pain in postmenopausal women, often linked to muscle imbalances and altered biomechanics.

Risk Factors

·      Sedentary lifestyle or sudden increase in activity

·      Weight gain and metabolic changes

·      Previous tendon injuries

·      Poor muscle strength and flexibility

Evidence-Based Physiotherapy Strategies to limit the chance of a tendon injury.

1. Progressive Loading

Tendons respond best to controlled, progressive loading. Eccentric and heavy-slow resistance exercises are proven to improve tendon structure and reduce pain.

2. Holistic Rehabilitation

Address posture, biomechanics, and muscle imbalances. Incorporate core stability and balance training to reduce strain on tendons.

3. Education & Lifestyle

Understanding the role of hormonal changes in tendon health. It is encouraged to ensure:

·      Regular physical activity

·      Adequate protein intake

·      Weight management strategies

4. Adjunct Therapies

Manual therapy can provide short-term pain relief, but exercise-based interventions offer superior long-term outcomes.

Hormone Replacement Therapy (HRT) and Tendon Health

Emerging evidence suggests HRT may improve tendon health by restoring estrogen levels, enhancing collagen synthesis, and reducing inflammation. While not a physiotherapy intervention, awareness of HRT’s benefits allows for informed multidisciplinary care. Always consult a healthcare provider before considering HRT.

Practical Tips for Women

·      Warm up before exercise and cool down afterward.

·      Avoid sudden increases in training intensity.

·      Wear supportive footwear for weight-bearing activities.

·      Schedule regular physiotherapy check-ups for early intervention.

Key Takeaways

·      Menopause impacts tendon health through hormonal and structural changes.

·      Physiotherapy interventions like progressive loading are essential.

·      Collaboration with medical professionals enhances outcomes.

·      Early intervention prevents chronic pain and functional decline.

References

Espírito Santo, J., Moita, J., & Nunes, A. (2024). The efficacy of manual therapy on musculoskeletal pain in menopause: A systematic review. Healthcare, 12(18), 1838. https://doi.org/10.3390/healthcare12181838

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 and Neuronal Interactions, 16(2), 1–8.

Grimaldi, A., et al. (2024). Advances in practice: Tendinopathies of the hip. Rheumatology Advances in Practice.

Hobson, S. (2025, November 7). Menopause, physiotherapy and tendinopathies. The Menopause Consortium. Retrieved from https://themenopauseconsortium.com

McMillan, R., Cowan, S., et al. (2025, June). Menopausal hormone therapy for managing tendon conditions in the postmenopausal population. Institute for Mental and Physical Health and Clinical Translation. Retrieved from https://impact.deakin.edu.au

Williams, C. (2024, June 11). Menopause and its implications on tendon and bone health. Elora Physiotherapy Blog. Retrieved from https://eloraphysiotherapy.com

Wright, V. J., Schwartzman, J. D., Itinochea, R., & Wittstein, J. (2024). The musculoskeletal syndrome of menopause. Climacteric, 27(5), 466–472. https://doi.org/10.1080/13697137.2024.2380363

Goom, T. (2022, January 21). Is menopausal hormone therapy effective for tendinopathy? RunningPhysio. Retrieved from https://www.running-physio.com