Podcast Summary: "The Lifting Heavy Trap: Strong Muscles but Weak Tendons & Why You Get Injured"

Podcast: BETTER! Muscle, Mobility, Metabolism & (Peri) Menopause with Dr. Stephanie
Host: Dr. Stephanie Estima
Episode Date: February 23, 2026

Overview

In this solo episode, Dr. Stephanie Estima dives into a misunderstood and underappreciated topic: tendon health and adaptation. She elucidates why tendons – the critical connectors between muscle and bone – often lag behind in strength gains, setting the stage for injury, especially in women over 40. Drawing on her clinical experience, research insights, and personal reflections, Dr. Stephanie offers a comprehensive "tendon operating manual" for training, injury prevention, and rehabilitation.

Key Discussion Points & Insights

1. Why Tendons Deserve Attention

• Tendons vs. Muscles: Muscles adapt quickly; tendons adapt slowly due to lower blood supply and metabolic activity. This can result in strong muscles but relatively weak tendons when training ramps up, creating an "adaptation mismatch."
  • "If muscle is the engine, tendons are the drivetrain... They transmit force from the muscle to the bone so that you can move." (11:09)
• Tendons’ Dual Role: Tendons tether muscle to bone and also act like springs, storing and releasing energy for efficient movement, particularly during athletic activities.

2. Tendon Biology: Structure and Adaptation

• Composition: Tendons are ropes made of many smaller ropes of collagen (primarily type I), structured to withstand tensile forces.
• Remodeling Mechanism: Adaptation occurs via mechanotransduction – tendon cells (tenocytes) sense mechanical strain and trigger collagen growth and reorganization.
• Bradytrophy: Tendons have "low metabolic activity," translating to slow healing and remodeling, especially compared to muscles.
  • "Tendons are bradytrophic... they have low metabolic activity." (16:28)
• Stiffness: Contrary to the common negative connotation, tendon stiffness (within a healthy range) is essential for performance.

3. The Trap of Quick Muscle Gains ("Six-Week Trap")

• Timeline Mismatch: Muscles react to new training within days, but tendons need 12–15 weeks for significant adaptation.
  • "Your muscle and your nervous system... improved faster than your tendon’s capacity." (38:25)
• Classic Injury Pattern: People starting strength/sprint training often feel great at first, but by 6–10 weeks, tendon pain creeps in because tendons haven’t kept up adaptively.

4. What Tendons Love and Hate

• Love: Heavy, progressive, consistent load (not spikes); slow, steady increases (“progressive overload”), and energy storage/release training – all applied gradually.
• Hate: Sudden, high-intensity spikes in activity, large volume jumps, novel unprepared activities, and inactivity after injury.
• "Tendons don't hate intensity... they just hate surprise." (41:12)

5. Common Tendon Injuries in Women Over 40

• Frequent Problems:
  • Achilles Tendinopathy: Poor blood supply zone makes the mid-Achilles particularly susceptible, slow to heal.
  • Patellar Tendinopathy ("Jumper's Knee")
  • Tennis Elbow (Lateral Epicondylitis)
  • Rotator Cuff Injuries
  • Gluteal (Lateral Hip) Tendinopathy: Especially common in midlife women.
  • Proximal Hamstring Tendinopathy
• Imaging vs Pain: Pain and imaging don’t always align; clinical evaluation trumps scans.
  • "You can have structural changes without pain and you can have pain without any dramatic imaging findings." (1:01:16)

6. Tendon Injury & Healing: Phases and Psychology

• Healing Phases: Inflammatory (~1 week), proliferative (weeks–months), remodeling (months).
• Psychology: Extended healing time can challenge driven individuals; patience and strategic load management are crucial.

7. Four-Step Tendon Rehab & Training Framework

1. Load Management:
   • Reduce, don’t eliminate load. Remove pain-provoking spikes, but keep some stimulus to avoid deconditioning.
   • Eg. Lower weights to avoid next-day pain.
2. Isometrics:
   • Heavy holds reduce pain and help reintroduce stimuli.
   • Eg. 3–5 sets of 30-second holds (leg extension for knee, calf raise for Achilles).
   • "Isometrics are a really important tool... it's not the entire rehab plan, but literally step two." (1:06:17)
3. Heavy Slow Resistance (HSR):
   • Gold standard for long-term tendon remodeling; slow tempo, progressively increased weights.
   • "If you want real remodeling, it has to come under heavy, slow resistance." (1:08:57)
4. Eccentrics & Energy Storage/Release:
   • Eccentric training improves tendon resilience, and elastic recoil exercises help prepare for return to sport.

8. Special Considerations for Women Over 40

• Estrogen & Tendons: Tendons have estrogen receptors; hormone changes in perimenopause/menopause impact tendon strength, stiffness, and healing.
  • "Hormones can meaningfully change connective tissue behavior across the lifespan." (1:28:36)
• Typical Injuries: Lateral hip (gluteal) and shoulder (rotator cuff) tendinopathies are especially common.
• Auto-Prevention Notes: Recovery needs go up; sharp activity changes become riskier.

9. Practical Prevention Checklist

• Progressive Overload: Heavy, slow strength training (especially lower body) 2x/week minimum.
• Gradual Progression: Add sprints, plyos, or new activities slowly; track footwear/surface changes.
• Pain as Feedback: Stable, non-worsening pain can be worked through; escalating pain = throttle back.
• Consistency:
  • "F your feelings, follow the plan." (Referencing Leila Hormozi and emphasizing discipline.)

Notable Quotes & Memorable Moments

• On Tendon Surprises:
  • "Tendons are very much like me – they don't like surprises. They like progression that's steady." (24:21)
• On Remodeling:
  • "Quick symptom suppression is not the same as remodeling. If you want a strong tendon, you must remodel it." (1:09:11)
• On Women’s Unique Risks:
  • "For women over 40, if I had to choose one signature tendon problem, it’s lateral hip pain – greater trochanteric pain syndrome." (1:31:10)
• On Loading Plan:
  • "Train [tendons] like architecture... the infrastructure to your body, not like decoration." (1:36:21)
• On Psychology:
  • "There’s nothing more devastating than not being able to do what you love to do... We want to give ourselves a really long runway for healing." (1:02:13)

Important Timestamps

| Timestamp | Topic/Quote | |---------------|----------------------------------------------------------------------------------------------------------------| | 00:00 | Introduction; why tendons are "the most underappreciated tissue in the body" | | 11:09 | Role of tendons in movement; analogy: "Drivetrain" | | 16:28 | "Tendons are bradytrophic" – slow to remodel | | 24:21 | "Tendons... don't like surprises. They like progression that's steady." | | 38:25 | The "six-week trap": Strong muscles, lagging tendons | | 41:12 | "Tendons don't hate intensity... they hate surprise." | | 1:01:16 | Pain vs. imaging; unreliable correlation | | 1:06:17 | Step 2, Isometrics in rehab | | 1:08:57 | Heavy slow resistance as the "gold standard" for tendon remodeling | | 1:09:11 | “Quick symptom suppression is not the same as remodeling.” | | 1:28:36 | On hormonal changes: "Hormones can meaningfully change connective tissue behavior across the lifespan." | | 1:31:10 | Lateral hip pain/Greater Trochanteric Pain Syndrome: "Signature tendon problem for women" | | 1:36:21 | "Train them like architecture... not like decoration." |

Actionable Takeaways

• Tendons adapt to strength training far slower than muscles, making steady, progressive overload and patience vital—especially in high-impact or heavier-load activities.
• Rehab and prevention must focus on load management, isometrics, heavy slow resistance, and later, eccentric work and elastic recoil training.
• For women over 40, hormonal shifts heighten the importance of careful training progression and prioritizing tendon health in the lower body and shoulders.
• Pain should be seen as feedback, not something to fear—but sharp or worsening pain is a clear sign to reduce load and proceed with strategic, consistent training.

Conclusion

Dr. Stephanie’s episode is a must-listen (or must-read!) for women aiming for longevity and performance in fitness. By respecting the slow and steady nature of tendon adaptation, and applying an evidence-based, strategic approach, you can prevent injuries and train for life—staying "better," not just "perfect."