Abstract Operation and maintenance (O&M) costs can account for 10%–20% of the total costs of electricity for a wind project. Structural health monitoring method is a form of preventive maintenance consisting of regular monitoring of the wind turbine components to detect potential faults. The strain measurements on the blades are typically used for load monitoring and damage detection, but only obtain a small amount of concentrated load information. In this work, a strain distribution monitoring method was proposed and validated based on aerodynamic measurements in the field. Then the contribution and evolution of the strain distribution from the aerodynamic load, gravity load, inertial load, and centrifugal load in the complex start-up process of the wind turbine were analyzed. The results shows that the mean value of the synthetic strain is mainly determined by the aerodynamic load and the centrifugal load, while the fluctuation amplitude is mainly determined by the gravity and the aerodynamic load. Furthermore, the fatigue damage of the blade root was evaluated based on strain extrapolation, rainflow cycle-counting algorithm, Goodman diagram and Miner’s linear superposition principle. It is found that the fatigue damage is generally greatest near the pressure side and suction side, and least near the leading edge and trailing edge. The strain distribution monitoring method can capture the location of maximum stress and the most severe fatigue damage on the blade, which are helpful for damage detection and load control, and further reduces O&M costs.