How the menopause can cause Achilles tendinopathy

The menopause may contribute to someone getting Achilles tendinopathy or tendonitis. Our female patients who are in the perimenopause and menopause often also take a bit longer to recover, and it can be a bit trickier to increase their exercise regimes without flaring their injured Achilles tendons up. In this article, we look at how the menopause affects tendons and whether taking hormone replacement therapy can be useful. Remember, if you need more help with an Achilles injury, you're welcome to consult one of our team via video call.

The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in most of our articles.

In this article:

1. What makes the Achilles tendon so strong?

2. Perimenopause, menopause, and postmenopause

3. Why can the menopause cause tendon injuries and/or prolong healing?

4. Top tips for tendon health during/after the menopause

5. What about hormone replacement therapy (HRT)?

6. How we can help

I've also explained it in this video:

What makes the Achilles tendon so strong?

Tendons are mainly made up of lots of collagen fibres that are tightly packed next to each other. In healthy tendons, these collagen fibres are organised in parallel, and this is one of the reasons why tendons are so strong. A single thread is easy to snap, but if you bunch a few pieces of thread together in parallel, they become an extremely strong rope.

Perimenopause, menopause, and postmenopause

Perimenopause: This is the period during which a woman is making the transition to the menopause. It can start around 10 years before the menopause and is basically the period during which your oestrogen levels start to drop. This is when you start observing symptoms like changes to your periods, sleep, mood, weight, hot flushes, decreased sex drive, painful joints, etc.

Menopause: You are in the menopause when you’ve not menstruated for a full 12-month cycle. The symptoms are very similar to those of the perimenopause but usually more severe.

Postmenopause: This refers to the years after the menopause. Most women’s bodies will get used to the new lower levels of oestrogen, and you may find that the menopause symptoms gradually decrease.

Image from The Cleveland Clinic https://my.clevelandclinic.org

Why can the menopause cause tendon injuries and/or prolong healing?

Your oestrogen level drops dramatically during the perimenopause/menopause and then remains low afterwards. Oestrogen plays an important role in the production of new collagen fibres and, as mentioned above, your tendons are mainly made up of collagen.

Exercise of any form causes micro-trauma in our muscles, bones, ligaments, and tendons. This micro-trauma is normal and acts as the signal to the brain to rebuild our bodies stronger.

If your oestrogen levels are low, your tendons will take longer to recover from a bout of exercise than when your hormone levels were normal, because they're not as effective with producing new collagen fibres. This makes it much easier to over-train, causing the micro-trauma to accumulate and cause a tendon injury.

Top tips for tendon health during/after the menopause

The good news is that the menopause does not have to cause you injuries. Your body has changed, and there’s nothing you can do about that. But now that you know how it affects your tendons, you can make adjustments to your training and lifestyle to accommodate this.

1. Take more notice of your body and how well you recover after training sessions. You may need longer rest periods after hard sessions like hills, speed workouts, or very long runs.

2. Strength training is extremely important. Heavy, slow resistance training stimulates tendon growth. Furthermore, oestrogen also affects the collagen in your muscles. So you will also help reduce your risk of muscle strains by adding this to your regular routine.

What about hormone replacement therapy (HRT)?

This section of the article is based on a video that my colleague Alison made:

One of the most common symptoms of Achilles tendinopathy is a thickening of the tendon. Patients often describe this as having a lump in their Achilles tendon.

Injured Achilles tendons indeed have a larger diameter on ultrasound scans than uninjured ones.

A research study, using scans, that compared the tendon thickness of two groups of active postmenopausal women with Achilles tendinopathy – one group getting HRT and the other group not – found that the thickening in the injured tendons of the HRT group was not as severe as in the group who did not have HRT.

However, let’s not jump to conclusions. People can have changes on a scan and have no Achilles tendinopathy symptoms. Other people can have changes on the scan that are very minimal and have severe symptoms.

What the research doesn't show us is the correlation between those that are doing rehab exercises and getting HRT and whether that's improving, as well as people with symptoms and getting HRT and whether that's improving. The only thing it's telling us is, that the diameter is getting less; it's making that a bit better.

It is tempting to extrapolate that information and say, “Well, maybe that means then my symptoms would improve, and I can do more,” but the research to support this isn’t out there yet.

There has been some research on gluteal tendinopathy, where they applied HRT to that area with a gel or a patch and put the patients through a strength training programme. Unfortunately, the research was somewhat flawed, because they only analysed people for about 12 weeks; it should have been for much longer. Also, the rehab exercises were not the type that I would prescribe.

So, the jury is still out on whether HRT can help, but the indications are really positive and it may be something to test if you're struggling to make progress in your rehab. Your doctor will be best placed to advise on whether this is safe and appropriate for you.

How we can help

Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author:

Maryke Louw is a chartered physiotherapist and holds an MSc in Sports Injury Management. You can follow her on LinkedIn, Facebook, Twitter, and Instagram.

References:

1. Leblanc D, Schneider M, Angele P, et al. The effect of estrogen on tendon and ligament metabolism and function. The Journal of Steroid Biochemistry and Molecular Biology 2017;172:106-16.

2. Oliva F, Piccirilli E, Berardi AC, et al. Hormones and tendinopathies: the current evidence. British Medical Bulletin 2016;117(1):39-58.

3. Peters, J.A., Zwerver, J., Diercks, R.L., Elferink-Gemser, M.T. and van den Akker-Scheek, I., 2016. Preventive interventions for tendinopathy: A systematic review. Journal of Science and Medicine in Sport, 19(3), pp.205-211.

4. Cook, J.L., Bass, S.L. and Black, J.E., 2007. Hormone therapy is associated with smaller Achilles tendon diameter in active post‐menopausal women. Scandinavian Journal of Medicine & Science in Sports, 17(2), pp.128-132.

5. Cowan, R.M., Ganderton, C.L., Cook, J., Semciw, A.I., Long, D.M. and Pizzari, T., 2022. Does menopausal hormone therapy, exercise, or both improve pain and function in postmenopausal women with greater trochanteric pain syndrome? A 2 × 2 factorial randomized clinical trial. The American Journal of Sports Medicine, 50(2), pp.515-525.