Why tendon injuries spike in perimenopause and what to do about it?
If you've developed hip pain, shoulder trouble, or Achilles issues in your forties or fifties and can't explain why, your tendons are worth understanding.
There's a pattern that comes up constantly in clinical practice. A woman in her mid-to-late forties, previously active without problems, starts developing tendon pain, often in the gluteal tendons on the outside of the hip, the rotator cuff in the shoulder, the Achilles, or the plantar fascia of the foot. She's not doing anything differently. Nothing changed, she says. But actually, quite a lot has changed: her oestrogen.
Oestrogen and collagen
Tendons are made primarily of collagen, dense, rope-like fibres that transmit force between muscle and bone. Oestrogen receptors are found in tenocytes, the cells responsible for maintaining tendon tissue. When oestrogen levels are stable, those cells support collagen synthesis (collagen building and repair) and help keep tendons elastic. When oestrogen drops, collagen production slows, tendons can become thinner, stiffer, and less able to absorb repetitive load.
Research published in the Journal of Applied Physiology found that postmenopausal women using oestrogen replacement therapy had significantly higher rates of tendon collagen synthesis than those not using it, suggesting a direct relationship between oestrogen and tendon maintenance. Separately, a review in the Journal of Musculoskeletal and Neuronal Interactions noted that as oestrogen declines, rates of tendon pathology and tendon rupture increase.
COMMON TENDON CONDITIONS IN PERIMENOPAUSE
Gluteal tendinopathy (often misdiagnosed as hip bursitis), frozen shoulder (adhesive capsulitis), plantar fasciopathy, Achilles tendinopathy, and rotator cuff tendinopathy all appear more frequently in women during the menopause transition. Women are twice as likely as men to develop frozen shoulder, and the withdrawal of oestrogen in perimenopause is emerging as a risk factor.
Stiffer tendons, the same training load
The injury risk isn't just about tissue quality. It's also about the mismatch between what a tendon can tolerate and what you're asking it to do. A tendon that was perfectly fine with your usual routine can start to protest when its capacity to absorb and adapt to load has quietly decreased. That's not weakness or age, it's biology, and it's manageable.
Tendons respond well to progressive loading, even in this lower-oestrogen environment. The evidence base for tendinopathy rehabilitation centres on gradual, progressively heavier resistance exercise, known as heavy slow resistance (HSR) training. This approach has been shown to reduce pain and improve function in conditions like Achilles and patellar tendinopathy by stimulating collagen remodelling. The principle of starting where you are, not where you were, matters here.
What about HRT?
The relationship between menopause hormone therapy (MHT) and tendons is still being studied. A 2021 study by Cowan et al. found some evidence that MHT may support tendon health in perimenopausal women, though the picture is not yet fully clear. What the evidence does suggest is that oestrogen has a direct role in tendon biology, which means managing the hormonal transition is relevant to your connective tissue, not just your bones and menopause symptoms.
If you're dealing with a tendon injury right now, getting the loading programme right is the priority. But it's also worth having a broader conversation with a menopause-aware clinician about where you are in the transition and what else might be supporting your musculoskeletal health.
Key references: Hansen et al. (2009), Journal of Applied Physiology; Thornton (2016), JMNI; Grimaldi (2025), dralison grimaldi.com; Cowan et al. (2021); Cook & Purdam (2009), British Journal of Sports Medicine.
These resources are for educational purposes only and do not constitute medical advice. Please consult your GP, physiotherapist, or menopause specialist before making changes to your exercise, nutrition, or medication.