How Tendonitis Develops / To the top
Tendonitis is an overuse injury. This condition arises when the volume of the workouts exceed your body’s ability to recover. Since our muscles have better blood supplies than our connective tissue (tendons, ligaments, cartilage) and bones, they often are able to adapt to the stressors of exercise placed on them faster. This leaves our connective tissues and bones vulnerable to overuse since they cannot heal as fast. If excessive stress is placed on them, they start to break down and subsequently become inflamed and painful.
There are some alternative applications of how tendonitis develops. For example, for tendonitis of the lateral and medial epicondyles of the elbows there are a lot of muscles that have a common origin (or insertion for other muscles). If the muscles become inflexible and tight then that puts additional stress on the tendon which may not let it heal correctly after exercise. Similarly, our individual muscles have sheaths they slide in against other muscles when they contract. If they are are not moving and sliding correctly it can often recruit multiple muscles that do not need to contract to put additional stress on the tendons as well. This also may not let the tendons heal correctly. The application of prehabilitative and rehabilitative protocols will address all of the above reasons including plain overuse in the next two sections.
Tendonitis starts out as an inflammation injury (-itis is the suffix for any inflammation). If a person continues to work through the injury and pain, it will lead to chronic degeneration. Thus, tendonitis may lead to tendonosis which is characterized by (1) a lack of inflammation, (2) continued degeneration of the tendon, and (3) pain that usually worsens and intensifies.
Once an overuse injury starts to develop, if rest and ice is prescribed right away the body will heal itself because the natural inflammatory processes that arise promote healing. However, if this process is aggravated into a chronic state over weeks and months, then the inflammatory process goes away leading to the chronic degeneration. In these cases, rest and ice may not promote full healing of the injured body part because of the lack of inflammatory healing processes.
There is more details about tendinosis’ etiology and physiology located here.
Common places where tendonitis is easily developed are located at:
- Medial epicondylitis (inner elbow – Golfer’s elbow) which arisea from excessive pulling exercises.
- Lateral epicondylitis (outer elbow – Tennis elbow) which arise excessive hyperextension of the wrist.
- Triceps tendonitis (elbow) which arise from excessive pushing exercises.
- Biceps tendonitis (elbow) which arise from excessive pulling exercises.
- Wrist tendonitis (wrist) which arise from overuse at the computer or in excess flexion/extension of the wrist.
- Patellar tendontis (patella/knee) which arise from overuse in running, plyometrics, or weightlifting.
- Hamstring tendonitis (knee) from overuse in running, plyometrics, or weightlifting.
- Achilles tendonitis (ankle) which arise from overuse in running, plyometrics, or weightlifting.
If you have sore joints or tendons that are starting to become sore, this is your body letting you know that you should back off from exercise. This indicates that those body parts are under excessive volume or repetitive strain that you cannot recover from. Continuing to train through this will lead to chronic overuse which is very difficult to correctly rehabilitate and may be only fixed through surgery. This will also hinder your training significantly, so it is not advisable ever to push through any type of pain.
Corrective Measures / To the top
The goal of this section is to provide you the correct rehabilitative protocol to promote healing for the conditions of mild tendonitis to chronic tendonitis. It is my hope that this protocol can help you, and that you have not aggravated your condition to the point that it requires surgery.
I am going to be writing each rehabilitative procotol in order of importance on what you should be doing including explanations for why each is prescribed.
A. Stay away from painful exercises.
Pain is your body telling you that something is wrong. Listen to your body. Continual aggravation of the injury will make it worse and significantly hinder your training.
Step 1: 1-2 weeks of total rest should clear up mild forms of tendonitis because the initial inflammation will promote healing. Realize that this does not mean you have to cease workouts altogether but just the exercises of the injured body part.
If the rest is successful, work your way back into exercise slowly starting with 20% volume and adding 10% more each week as it’s very easy to aggravate again. If you feel any twinges of pain or aggravation, immediately back off for the day. It is better to be conservative than to have a chronic condition.
Unfortunately, chronic tendonosis may not respond favorably to pure rest. If your tendonitis does not clear up after 2 weeks of total rest then you probably have the chronic condition. This is to be treated different than just mild tendonitis with rehabilitation exercises to stimulate the inflammatory process (along with massage) to promote healing. The overall elimination of exercises that use this affected area should be followed religious if this is the case.
A. Self massage.
Step 1: Concentrate cross friction massage and myofascial release to first and foremost the tendon, and secondly to immediate local area within 1 inch of affected location.
Step 2: To ensure the surrounding musculature is operating correctly and not causing excess strain at the affected area, continue apply cross friction and myofascial release to the whole area inbetween both joints that surround it. For example, massage all of the muscles between the shoulder to wrist for medial epicondylitis at the elbow; massage all of the muscles between the ankle and hip for patellar tendonitis. Alternative manual massage techniques that may help are ART, graston technique, foam rolling, using a golf/tennis ball to roll the area, etc.
- Aim for 20-30 minutes a day of massage, with most of it in to the tendon and local area. If you find tight muscles with adhesions in the surrounding musculature, focus on those areas as well.
- Time of day does not matter, and it can be broken up into as many session as you desire. I often hit up my soft tissue while I am driving to and from work it is basically “dead” time for anything else.
- For structuring massage according to type it really does not matter. All that matters if that you’re getting into the tissue and helping it reorganize through mobilization plus breaking up any scar tissue or adhesions.
Explanation: The purpose behind massage is to promote blood flow to the area for healing as all tissues need nutrients and waste products carried to and from the area respectively. Also, massage helps improve tissue quality through helping to release and reorganize the tissue through the body’s natural inflammatory processes plus break up any scar tissues or adhesions that may be limiting proper movement of the affected and surrounding area.
Note: If you have tried physical therapy and your therapist did not use significant amounts of manual massage therapy, then they are not good therapists in my opinion. Besides rest and ice (which we will talk about shortly) which most doctors and PTs recommend, the #1 thing that will help you the most is massage and/or self massage.
B. Ice after any use & when sore.
Step 1: Ice 10-15 mins per session for 2-5 times a day. Alternatively, ice can be used every other hour on the hour. Direct ice massage on the skin tends to work the best, but be careful of giving yourself frostbite.
Explanation: Like massage, icing helps limit some pain and excessive inflammation (characterized by edema/swelling) especially immediately after exercise or prehabilitation work. Additionally, icing will promote good blood flow to the area afterwards as the body tries to warm up the area.
Alternatively, heat can be beneficial sometimes. For non-acute overuse injuries it tends to be a bit better a week or two out as your body has had some time to heal. If ice is leaving you stiff and not helping much, you may want to try heat instead.
3a. Light stretching.
Step 1: Light stretching for the agonist muscles connected to the tendon, and strengthening for the antagonistic muscles on the opposite side. For example, for medial epicondylitis at the elbow, you will want to stretch the forearm flexors, and do strengthening work for the forearm extensors. For patellar tendonitis, you want to stretch your quads, and strengthen your hamstrings.
Explanation: The reasoning behind this is twofold. The stretching is aimed at the agonist muscles because they are usually tight and short from overuse which may contribute to excessive strain on the tendon. Also, in many cases there are existing muscle imbalances if there is overuse on one side, so it is important to bring up the strength of the antagonistic muscles. Both of these tend to put more stress on the joints and supporting structures such as the tendons and ligaments, so loosening and correcting the imbalance should help get the tissue to function properly. Also, eccentric nature of stretching creates small microtears which will stimulate the body’s natural inflammatory process for healing.
3b. Light eccentric exercises
Step 1: Start with a very light weight, and work on the eccentric portion of the lift slowly. The eccentric movement should take 5-7 seconds.
Step 2: After it starts improving significantly you can add in concentric work. Be careful not to overdo it as it is very easy to reaggravate. For something like medial epicondylitis you should strengthen everything in the forearm. For example, rice bucket exercises.
- This protocol is mostly for chronic tendonosis cases that are not alleviated with solely rest.
- It is probably best to start with very light weights which is best with open chain exercises such as eccentric flexion wrist curls (medial epicondylitis) or eccentric leg extensions (patellar tendonitis). You can use the other arm/leg to help the other arm/leg up for the concentric phase. The reason for this is because it’s easy to microload with light dumbells or ankle weights or other small incremental weights.
- As you progress, you can move on to more closed chain exercises such as the eccentric of walking down stairs slowly or negative pullups. Close chain exercises tend to use a larger portion of bodyweight, so progressing to them too soon may be detrimental to the healing process if they are too difficult and aggravate the injury.
- Eccentric exercises that are anymore than slightly painful (preferably not painful) will probably be detrimental.
Explanation: Eccentric exercises are important because they help induce small amounts of microtearing which is part of the inflammatory process to promote healing. Additionally, in many cases, the musculature at that joint will become unable to properly execute the movement because of compensation for the pain. Thus, it is important especially if the muscles are shaking trying to eccentrically lower the weight to reeducate them to fire correctly.
4. Other methods
Cortisone may be a helpful option as it has shown improvement in conditions such as lateral epicondylitis. Repeated use of corticosteroids may lead to detrimental effects, so make sure if you go in and get a cortisone shot that you are also doing proper rehabilitation work in combination to get the best out of your healing.
Next, many of these other modalities are highly dependent on the person to whether they will help or not. If you have exhausted the options above (as well as physical therapy) then it may be a good idea to try some of the moadlities below in conjunction with the above protocols if you want to avoid surgery.
Joint/tendon/cartilage health supplements:Basically, there’s a lot of stuff that works but your mileage may vary depending on the person. Glucosamine & chondrotin sulfate (together 3:2 ratio), Methylsulfonylmethane (MSM), cissus, S-adenosylmethionine (SAMe), shark fin, etc. are all very good. Have also heard good things about Universal’s Animal Flex. Fish oil (which I will talk about later) is very good too.
Other modalities: Low level laser therapy, platelet rich plasma (PRP), prolotherapy, ultrasound, electric stimulation, autologous blood injection, dry needling, etc.
I’ve seen some good testimonials with the LLLT, PRP, prolotherapy because they’re supposed to help with natural inflammatory healing process, so I would recommend checking out those options first.
Similarly, surgery is the last ditch option because of the potential for infections and the often sub-par ability of humans to do what the body should naturally do itself.
5. NSAIDs/anti-inflammatories/pain relievers.
This is my new stance on this subject, which can be found in the new foot article as well.
NSAIDs while great for pain relief often help slow the healing rates of issues that you are trying to fix with rehab. For example, typical NSAIDs prescribed for pain and inflammation are over the counter such as aspirin and ibuprofen. Things you may typically get with a prescription are stronger such as naproxen.
Image from altair.chonnam.ac.kr
The mechanism of typical NSAIDs is to inhibit the cyclooxygenase pathway of inflammation as seen above (aspirin, indomethacin). This is great because it eliminates the pain by inhibiting the PGE substrates that aggravate the delta and C sensory fibers within the area like we talked about before. However, this is bad because it also inhibits the prostacylins and HHTs which are responsible for drawing in white blood cells and platlets that help clean up the damaged tissues, and release growth factors to move on to the more proliferative phase of healing. Here’s a few studies showing this.
Now, I’m sure we tend to all think of Tylenol/Acetominophen the same as the other NSAIDs, but it is in fact actually not and anti-inflammatory agent. Thus, if you’re having pain with this, it would be recommended to take this over any of the NSAIDs because of healing rates.
This also applies in reverse though. If you suffer a traumatic injury to the ankle such as a sprain and it’s inflammed and swelling up then avoid acetominophen in this case. It’s not going to help with what we need which is the anti-inflammatory factors. We would want to do the RICE protocol, NSAIDs, massage, mobility work, etc. in these cases.
I would try to avoid using NSAIDs for anything related to pain where tissues need to heal. The cyclooxygenase pathway is a critical step of that inflammatory phase that is needed for any sort of tissue regeneration whether it be muscle, tendons, ligaments, bones, etc. If it hurts bad then use different anti-pain medications like tylenol. It’s only when the inflammation gets so out of control such as with lots of swelling or fever where NSAIDs start to become more useful.
Warmness of the skin area is a good indicator of acceptable levels of inflammation (as prostagladins of the cyclooxygenase are fever inducing), but when there starts to be a lot of redness and swelling symptoms it may be time to help cut down on excessive inflammation with NSAIDs. For example, a couple days after workout the muscles are usually warmer because of the inflammation and healing process that is occur; it is unlikely unless there is severe DOMS or rhabdomyolysis that any NSAIDs may be needed for this.
Fish oil is also a good anti-inflammatory if needed, and of course eating right is going to help the most.
These are things are probably not told to you by your doctor or any other healthcare professional (heck, I didn’t even know about NSAIDs vs tylenol until I was taught that in class a few weeks ago). Keep this type of stuff in mind.
Planning Rehabilitative sessions / To the top
Integration with regular workouts is the same. Do your workouts, then the structure suggested above. If the workouts require use of the injured limb and does not aggravate it, then make sure the tissue is sufficiently warmed up before doing anything.
Proper structuring of the modalities listed above is important. Here’s the combination of things that I’ve found work the best.
For massage to the tendon itself:
- Light eccentric exercise (1-2 exercises, 1-2 sets of 15-20 reps)
- Self massage (5-15 minutes)
- Ice if it helps (10-15 minutes)
So for example with something like medial epicondylitis I would do:
1. Negative wrist curls
2. Massage to the wrist flexors and tendons
3. Ice if it helps.
For the muscles:
- Strengthening of the antagonist muscles of the tendon (1-2 exercises, 1-2 sets of 15-20 reps)
- Heat to the muscles to the affected tendon (10-15 minutes)
- Massage to those muscles (10-15 minutes)
- Light stretching focusing on improving range of motion without pain (5-10 minutes)
So for example with something like medial epicondylitis I would do:
1. Extensor wrist curls
2. Heat to the wrist flexors
3. Massage to the wrist flexors
4. Stretching of the flexors with wrist hyperextension
Remember, having an injury or something you need to add in prehabilitative work doesn’t mean that you should rest everything and neglect other training. If you have medial epicondylitis (elbow tendonitis) for example you can still do legs and core work as well as do other skill work for your sport and corrective nature things such as flexibility/mobility.
One of the big things with tendonitis at “stability” joints such as the elbows is that there tends to be a loss of mobility in the wrists and shoulders thus putting more stress on the elbows. The same thing occurs with tendonitis at the knees and losses of mobility at the ankles and hips. Thus, if you have tendonitis at the elbows or knees you should work on improving the flexibility and mobility of the two joints surrounding it.
Here’s a general rule to distinguish chronic tendonosis from tendonitis:
1. If total rest for 1-2 weeks does not improve pain levels, and
2. If the tendon is stiff and achy after periods of inactivity, or
3. You tried to work through the tendon pain for a period of about 3-4 weeks or more
All of these types of symptoms can indicate that the condition has progressed from tendonitis to tendonosis so be wary of what you were doing.
As we discussed a bit before chronic tendonitis (tendonosis in reality) tends to persist even with rest. With this in mind we need to make alterations to rehabilitative processes.
Since there is no inflammation present in chronic tendonosis we need to create some. Thus, eccentric exercise becomes the most important part of our rehab routine. In addition, ice tends to not help as much for chronic cases; thus, we want to use heat instead.
In tendonosis there is chronic degeneration of the tendon. Thus, we don’t want to massage the tendon itself so much (you can but it needs to be lightly), but we want to focus moreso on releasing the tension on the tendon by hitting trigger points or tight areas in the surrounding musculature, especially the musculature of the affected tendon. ART, myofascial or cross friction techniques work well for this.
Additionally, mobility to get blood flowing and any fairly non-painful movement is good.
Thus, a rehab program for a chronic case would look more like this:
2-3x a week, once per day
- eccentric exercise with the affected muscle/tendon complex 1-3 sets of 20-30 reps
5-6x a week, 1-3 times per day
- 15 minutes heat to both the muscle and tendon
- 5-15 minutes massage or specific soft tissue work to muscle to loosen it up (NOT the tendon)
- Light mobility work focusing on pain free movement
- Another 5-10 minutes of heat to the muscle and tendon if you have time
Ice can also be substituted in if it helps more than the heat, but like I said heat tends to be better for those chronic cases that aren't healing with rest.
As the condition improves, we want to start to work slowly from the isolationalist high repetition exercises into lighter compound movements. From there, you can slowly work back into heavy exercise. The general rule for how fast to go with a chronic case is to take a week for each month you've had that problem. So if you've had this problem for longer than a year expect that it may take upwards of 10-12 weeks to completely rehabilitate yourself back into the heavy weights or high volume that you were used to.
fish oil specifics
Lastly, regarding fish oil – Here’s a list compiled by Jae on one of the sites I visit for cost comparison. Unfortunately, Kirkland brand recently changed their products some so I don’t know if they can be trusted or not.
This is the one that I have been using; however the price recently went up $3. (“LOW052” coupon at checkout will get you $5 off plus save me some money on my purchases if you want to go that route). Comes out to be around ~9.5 cents per 1g EPA+DHA if you want to try it.
This is a decent combo of glucosamine, chondroitin and MSM.
Thanks for reading. Hope this helps you.
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