Table of Contents
I. How tendonitis develops
II. Corrective measures
III. Planning rehabilitative sessions
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.
Section 1
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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.
B. Rest.
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.
Section 2
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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.
Section 3
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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.
Section 4
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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.
Section 5
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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.
Chronic tendonitis
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.
Disclaimer: Any information contained herein is not professional medical or physical therapy advice. Always consult your doctor or physical therapist before using such information. For more details see our full site terms and conditions.
Steve,
I have right elbow pain on the inside for a couple months now. I have had 3 neck surgeries the last one approx 1 yr ago. I am not sure if the neck has anything to do with my elbow pain as I am on a computer for many hours a day and think that may have something to do with it? I am not one who likes going to dr.s and would like to know what I can do at home to relieve the pain withoug having to go thru phys therapy.
Hi Kim,
If you are having neck issues I would suggest going to physical therapy regardless. The neck isn’t really a simple thing that most common people can attempt to rehab themselves.
Regardless, your elbow problems may or may not be related to your neck. Sometimes issues in the neck can cause compensations which may manifest themselves down the arm. Or it could be a separate issue. A good physical therapist should be able to determine that.
Although in the meantime if you are a computer worker then working on your posture is almost always a good thing you can do that will help out with neck and upper extremity issues.
Steve –
Thanks for your detailed an thorough article. A lot of it is very familiar to me as I have been in the process of trying to get my left knee to heal. Long story short, I am a tennis pro who played at a division 1 university and also professionally. In late 2010, I did a split step (hop) and pushed off my left knee and felt something click. At the time it was not that bad but boy, the next 3 weeks were very painful.
Had an MRI at Hospital for Special Surgery in NYC which did not show much (which is a good thing I take it). Ligaments looked fine, but the doctor said I have some tendinosis in the patella area. Also very, very minor meniscus issue but I have never had pain on the inside of my knee so the doctor ruled that out. I have dealt with patella tendonitis in the knee for nearly my entire tennis career, but nothing this painful. Ever since that day I tweaked the knee I have had a constant dull ache that gets worse as the day progresses.
After rest, physical therapy, and pretty much everything you named in your article to no avail, recently I have had two PRP injections into the tendon. The first PRP injection was not that painful. The doctor at HSS said he only did eight needling in two place with a thinner gauge needle. After about six weeks i noticed some improvement but not where I need to be as a tennis pro. So we scheduled a second PRP injection and this time he used a bigger gauge needle and did twice as much needling as the first. Now that was painful! The first couple of weeks were pretty brutal. Now I am at about seven weeks post PRP injection #2 and I am better than I was after the first week but I still have soreness and that constant ache.
I am wondering if this ache is ever going to go away. After a month of rest of PRP injection #2, I have been going to the gym and doing 15-20 minutes of elliptical at a medium level and stretching afterwards for 30 minutes. The doctor said no weights or squatting for 3 months. I can do the elliptical ok and I have pretty good range of motion when stretching the tendon (pulling heel up to my rear end).
If the PRP is going to work, how long will it be in your opinion before I start feeling better and this ache I have had for the past several years goes away? Patience is key I know. It has just been so long since I have been able to move on the tennis court the way I need to. Is there anything else I should be doing in the gym? I have tried physical therapy to no avail, maybe get some electric stim or ultrasound? I have been taking fish oil. What has been your experiences with PRP and am I on the right path to recovery? Any suggestion are welcomed.
Thank you so much!
Eric
Hey Eric,
What exactly did your physical therapy try in terms of reps/sets of exercises, massage, etc.?
Eccentrics have been proven in the studies from at least what I’ve seen to be the most potent way of overcoming tendinosis, but they generally have to be programmed correctly.
Additionally, this resource may be able to help if the tendinosis is being aggravated by improper joint function:
http://glennpendlay.wordpress.com/2012/02/17/got-tendonitis/
As far as PRP goes, it really depends on how much damage and how long the tendinosis has been there. I can’t really give you a timeline on that. It shouldn’t take more than a few months though, if it’s on the correct path.
I’m more interested in the exercise aspect of it though because in my experience doing the correct things with exercise significantly improves the majority of cases even chronic.
Steve
Thank you for posting this it is very thorough. I have been suffering from tendonitis of the hip. The hardest part is trying to rest. I notice a huge improvement with backing off from the pain though, and it does seem to be improving. I am hopeful for a complete recovery. I also hope for the willpower to totally rest.
Yep, the legs can be hard because you have to walk around everyday. Keep up the rehab!
Hi Steven:
I enjoy reading your insightful posts.
I am a 39-year old exercise science instructor and strength coach, who has been active my entire life, training functionally for everything from triathlons to Crossfit. Unfortunately, I have been more or less sidelined recently with what I believe to be medial epicondylitis. The first signs of pain began about 10 weeks ago, and I have spent the last 8 weeks avoiding any movements that cause any discomfort whatsoever (such as pull-ups, chin-ups, rowing actions, and any Olympic lifting). The pain is localized around my ME and happens when I grip anything forcefully, flex my elbow against resistance, or pronate my forearm. There has never been any tingling sensations or numbness. I am very conservative with injuries, so I immediately began cross-friction massage, and RICE for 3-4 weeks. I have followed your protocols (posted above), and I have received even treatment (ultrasound, iontophoresis ) from the athletic trainer and sports physician, here at our university, but I have seen little or no improvement. The doc is thinking about a cortisone shot, at this point. Can it be something other than Medial Epicondylitis, with the same signs and symptoms?
Thanks a million for any thoughts that you might have.
Pat
If it’s chronic, literally the best rehab option that I’ve seen so far is utilizing correctly implemented eccentrics.
Follow the eccentric protocol in this article.
If the issue is more along the inner side of the medial epicondyle (the pronator teres) then this will help:
I would alternate the supinator/pronator + forearm extensor work. Reason behind this is that it turns on/off agonist and antagonists which help a bit with the soft tissue relaxation as both sides may generally be fairly tight.
Also, instead of pure supinator/pronater I like the full range of motion with flex wrist + pronated forearm —-> supinated forearm + extended wrist.
That way you hit the full range of motion of the pronator teres, which is the the likely culprit, and you also get in some of the flexors in the negative.
Thanks, Steven. Sounds like it makes sense. I will give this a shot for a couple of weeks. Does that sound right? I appreciate your thought always!
Pat
Yep, sounds good… 3-4x a week is ok.
With tendonitis going through pain for rehab is OK as long as the pain doesn’t get worse. But don’t overdo it. You want a very light weight where you can do about 30-50 reps for about 2-4 sets comfortably. Don’t go all out at once with the volume but build up to it.
Excellent! Thanks again, Steven.
So, in keeping with your point (that some pain is OK during rehab, as long as it doesn’t get worse), should I wait until I am relatively pain-free before I begin the eccentric protocol, or can I begin right away? The last two days have been better, pain-wise (I rested completely), but I still have some mild aching when I pronate maximally, and when I grasp maximally. As a test this afternoon, I hung from a pull-up bar for 2-3 seconds and could still feel the pain, somewhat.
Sorry to bother you with more questions. I really do appreciate it.
Hi Steven
I have had a history of patellar tendonitis in my left knee due to excessive basketball. I have not run or played any sport in the past year and a half. About 5-6 months back my knee was in a very bad state with pain in everyday activity.
After doing progressive physiotherapy since the past 4-5 months I was able to 40+ half squats without any pain. Also there was no occurrence of pain in normal day to day activities. I was even climbing and descending stairs taking 2 at a time.
About 4 days ago, I joined a gym and started running. I started with 500m brisk walk + 1Km running trying to add 100m everyday. Unfortunately since that time a sense of discomfort and irritation has returned to my knee. I am still able to bend and squat without any pain, but the discomfort remains continuously throughout the day. Their is no pain or discomfort during the activity, but it increases after my body cools down, and reduces by the next day. It also reduces if I cover my knee and keep it warm. The weather is chilly where I live currently.
I am 23 years old and was planning on joining the military and am scheduled to join after 15 days. There will be a lot of running involved after I join. Fortunately the training is at a coastal place where the weather is quite hot and would promote less discomfort. I have considered forgoing this opportunity and trying again after 5 months. I wanted your opinion on this.
This is definitely something you will want to talk to an orthopedic doc about and potentially get an X-ray for prior to going into the military.
Accumulative injuries is one of the biggest predictors of degenerative changes such as arthritis.
What happens when you run is that the articular cartilage swells up which helps pad the joint and promote good movement. However, once you stop exercising it decreases in size. That really sounds to be me like once the articular cartilage decreases in size there may be some arthritic changes there that are making the pain increase.
That’s why I suggest you talk to an ortho and potentially get an X-ray to see if there’s anything structurally wrong.
Now, it could also be potential patellofemoral tracking issues (correctable by physical therapy) which are not degenerative changes which is why you would want the ortho to rule out certain possibilities so you can figure out what you need to do to be active for hopefully your new career.
Thanks for the advice Steven. One of my MRI’s taken last year in December showed Grade 1 Chondromalacia and a tear in the patellar tendon.
I started consulting a phsiotherapist regularly since July. He was of the opinion that there are no mobility issues but a slight misalignment of the patella in my left knee which has improved since I started increasing half squats, and other rehab exercises.
Anyway, I suppose I’ll follow your advice and consult an ortho also to ask for a scan.
Ah, if you already know what you have from the MRI then you probably don’t need another scan.
You will likely have to keep on doing rehab though, and fix the function/biomechanics of your knee.
From what I have understood I have a little bit of both – catilage damage and patella tracking issue.
). I am aware that half squats are among the best exercise for this condition. But due to the nature of my condition, proper squats are necessary. I also would like your advise on whether the squats should be done with a larger leg base or smaller. Which would be more helpful for correction of the outer muscles around the left knee?
The patella on my left knee seems a little depressed on the outer side of the leg. I also know that I have slightly lax ligaments in my body and will always require to keep exercising to avoid further injuries. And I sometimes also feel that the muscles in my left leg are more elastic than the right (maybe bcoz of playing too much basketball
Hi Steve
I have been seeing a sports medicine specialist since the last couple of weeks who put me on primus training. Since that my muscles have improved a lot and I am having very little trouble in daily activities. I have still not gotten back to sports or running.
Still throughout the day there is a certain nagging sensation in my knee, as is something is floating inside. But there has been no pain. The nagging sensation sometimes turns into a stiffness or a small ache, but it remains with me throughout the day. The only time when it dissapears is when I wake up in the morning and am in bed. As soon as I get up it starts building up.
Can you advise, whether this is harmful in any way or should I just learn to live with it.
Never had much problems in the past, 39 year old exercise enthusiast. Both knees and elbows have been very sore for the last few months. Knees actually had some slight soreness for the last year. I stopped the heavy strength training about 1 month ago and did very little. Some light ski machine and regular yoga/pilates were recently re-started. Also just added back in some light at home strength training. Not really getting much better–have iced the areas on and off and even tried some heat. Doctor just said I was getting older and tried 1 physical therapy session which was also not helpful–gave me a few home stretches. Help please. Any suggestions are appreciated. Complete rest did not seem to help and is hard for me anyhow.
If you have been diagnosied with tendonitis and it’s been there for a couple months you definitely want to be doing the eccentrics.
See the article for programming details.
Steven,
Need some help and advice. I’m 54 years old. I had a hip labral tear repaired when I was 52. After the 6 month recupirative period, I kept getting better and better. I started to go back to the gym about 3 months ago and everything was fine. I think I overdit it in my last session about 10 days ago and got horrible pain in the hip that I had surgery on, mostly to the outside tronchanter down the IT band and up in the hip flexor. I think I developed tendonitis from ramping up the excersices at the gym and doing a difficult program on a elliptical machine on top of the leg and hip weight training I did that day. I also think I strained my hamstring with the leg curls. I started with Aleve and ice, and I think it has definitely gotten better, but I still see some visible swelling in the area and its difficult for me to sit or lay on that side. I recently tried some light stretching and all it did was bring on the pain abit more. How long will this take? What else should I be doing other than resting and icing? At what point do I apply heat?
You need to talk with your doctor and/or physical therapist about this.
This is not something I can make any accurate predictions over the Internet with because there are multiple issues going on, and it is after a surgery. Depending on the phases of recovery it could be heat or ice or maybe none. So definitely ask your healthcare providers these questions.
Thank you for such great infomration, I will make sure my trainor sees your work
I have an ache in the anterior part of my knee, I think that its tendonitis, however it only hurts when I have been sitting for a long time or when walking uphill carrying a heavy load. I have had relief from using the short foot position whenever I sit. My question is do I need to rest my knees for a few weeks, or can I carry on with training the short foot position and stretching/massage. Thank you for any advice you could give me, and I think that your article is very useful.
Well, typical tendonitis tends to clear up with 3-4 days maybe a week at most of rest and good non-painful mobility work + massage/stretching.
If it’s chronic then rest won’t help, so you’ll know your answer if you rest and it doesn’t really go away.
Thanks Steven for such a comprehensive article. Very nice work and very helpful.
For the eccentric exercises, I’m surprised to see you recommending 2-3x per week. The studies I’ve seen, including the original work on achilles tendonitis and the nice followup on patellar tendonitis, indicate two times per day, five days per week. They also use a steady increase of resistance weight, and performing the exercise so that it generates a small amount of pain.
Any thoughts on the differences and which is now the preferred protocol? Does your method come from research you’ve seen?
Generally speaking, most people tend to still overdo it, so my recommendations on the lesser side of things.
I would agree with your assessment though. This article hasn’t been updated in some time and I need to do that hopefully soon!
Thanks.
I went on an intense workout program five months ago. I managed to hurt my right hip flexor, calf area mostly. I rested the area for five months and did some deep tissue massage (helped alot because I limped around). I am trying to return to workout but cardio aggravates it and leg workout flared me up again? Can I continue to do my five or six leg workouts (leg extension, leg press, calf raise, hamstring curl) with an emphasis on eccentric (low weight) and only do bike for cardio? Would this help?
Thanks, this is make me feel nuts. I want to heal it up.
Hi Melanie,
Have you gotten this checked out by an orthopedic doc or physical therapist?
Generally speaking, the hip is a complex area so any type of imbalance or poor biomechanics may have set things in motion. It may be tendonitis (but they should confirm), and also it may not be the tendonitis that is the actual problem. The problem may be some type of imbalance or biomechanical issue that I alluded to before, which can then cause the tendonitis. Even if you address the tendonitis, it won’t go away until you have solved the other issue.
That’s why any type of hip problems I recommend getting checked out by a professional because it’s usually multifactorial and trying to fix the problem on the Internet or by yourself typically doesn’t work out too well.
Hi Steven, in reply to a previous comment you wrote “This is why negative biceps curls work for tendonitis of the biceps tendon at the shoulder joint (not the distal portion connecting to the radial tuberosity)”.
I have distal biceps tendonosis – I want to check my understanding – are you saying that eccentrics do not work (or should not be used) for this condition?
Many thanks in advance.
No, they work for both.
I’m not sure why I would write that unless there was a specific context of say shoulder flexion component.
Hi Steve,
I injuired my left shoulder back in Septemeber I dont remember the moment it happened but fei feel it ever since.. I dont have insurance so from looking online of the shoulder anatomy i guess its my Rotator cuff tendons..I stayed off working out the arms for a month or so it became silly that am loosing my muscles and strength so i got back to working out but not heavy weights or anything close to the weights i used to before so..i dont feel the pain in all excersies .. i feel it mostly when i do curls, and pull ups, not so much doing push ups, or pull downs, benching (which i still use light weights) do u have any idea what to do to make it it heal or take away the pain? its not sharp pain but it is pain and its been a long time. whats frustrating is i dont remember how it happened where a person whould feel sharp pain the moement it does.. Thank You
Answer the questions in the quote and I can make a guess:
http://eatmoveimprove.com/forum/viewtopic.php?f=11&t=10
hey Steve! long story short, both my wrists (upper/top) randomly started aching at the same time around Jan 20th 2013. They progressively got worse and by now, the 9th of Feb, it is up to my elbows. i’ve been using splints for a couple weeks now, and ice for about a week, with the occasional ibuprofen. I’ve been to the family doc several times and a neurologist who diagnosed me with tendonitis (ra has been eliminated by blood test). from all i’ve read, it should be getting better, not worse! i have a 1.5 yr old toddler who needs mommy in tip top shape and instead i’m going the opposite. my hubby has been doing most of the heavy lifting, etc to help me out. i am seeing a physio next week to see if that helps, but i’m really worried about my arms because nothing is healing!! and i need to be there for my kid! thought i’d send you a message to get your take on the situation. thanks very much in advance
Answer the questions in the quote and I can make a guess (ignore the shoulder articulations and do wrist instead):
http://eatmoveimprove.com/forum/viewtopic.php?f=11&t=10
Hi Steven, first off thank you for this GREAT article on tendonitis! I myself have chronic (about 4 months) medial epicondylitis in both arms, caused from straight arm exercises that I was not yet prepared for. I am following your protocol in the article (heat, massage, eccentrics for forearm flexors), yet my progress is slow. Since exercises with a supinated grip are painful, would eccentrics starting with dumbell in a supinated curl position and slowly lowering into an extended pronated position (opposite of a dumbell curl) help? Sorry to belabor the wording, but I would appreciate any additional advice you would have for eccentric exercises dealing with medial epicondylitis.
Thanks
Start with elbow flexed and wrist pronated — then move into an elbow extended and write supinated position.
If the pain is more on the inside of the common flexor tendon it may be due to the pronator teres especially and the above position moves the pronated teres throughout the full range of motion.
You can also train them separately though with eccentrics of the wrist and pronation/supination. However, I typically get good results with the above movement.
Very light weight (1-2 lbs at most ot start) with high reps… 30-50+ in 2-3 sets. 4-6 times per week. Keep up with the heat, and make sure you are strengthening the extensors. The heat for both the tendon and muscles, and massage directly into the muscles (not the tendon).
Hi, My daughter is 10. Healthy, active, wonderful. A few years ago we noticed overpronation in her feet, a bit of turned in knees and turned in hips that kind of cause rear to protrude and more lower back curvature. Have been keeping her in stability shoes and all has been great. Until 7 weeks ago when she was playing in a travel softball game and when running came to us and said the back of her heel hurt. Several days later brought her to ortho who said achilles tendonitis so rest, light stretches and should be back to normal in 2 weeks. Three weeks later still hurting. Brought to different ortho who said enough rest take naproxyn and play through the pain. Get orthotics and should help. Got her fitted for orthotics but still don’t come in for over a week. She has been playing in pain. Two weeks ago when pitching she said something just hurt in her back and now has lower back pain. Two days ago brought her to different orth who said she has miserable malalignment of ankles, knees, hips. Nothing we can do about it. Orthotics will help. Kids usually don’t get back pain, but her back is tight. Ankle xray is fine. Back xray is fine. Dr. said go to physical therapy for ankle and back. Will start that tomorrow. My normally happy, active child is now so depressed and just wants to feel better and be able to walk and run and play like all the other kids. We are at a loss why we can’t get her better or help her. Not sure if we should be seeing a different type of doctor or someone in egoscue. Just read a book on that the other day. Just want to help her get back to normal and do whatever we can to elminate any future problems. Thank you for any help you can provide.
You need to fix her biomechanics… read through this entire 5 part article.
http://www.eatmoveimprove.com/2009/11/shoes-sitting-and-lower-body-dysfunctions/
Also, find a very good physical therapist. Orthotics may help the problem, but generally don’t fix the biomechanical issues.
Also, pretty bad orthos there… you should never play through pain. Very bad idea.
Hey, great read.
I too have heard that NSAIDs should be avoided although the doctor is saw (diagnosed be with Bicep Tendonitis) said I should be using them everyday. I originally managed to shake the pain off after 1 weeks rest. 5 days later I did some Chinnups and now regret it. 6 weeks on and heat/tennis ball massage (compression against wall) seems the only pain relieved. Ice leaves it stiff plus i’ve heard Ice is quite outdated method and heat should be used once swelling has dissipated.
I digress. My arms swells when I do band dislocates. It is fairly light swelling, is this a good thing? Should I do these more often and accept the swelling to be a good sign? Thank you.
Generally, swelling is not a good sign and typical generally aggravating the area.
I would definitely recommend seeing a physical therapist to evaluate your situation.
When I say “arm” I meant my shoulder area. Front of the shoulder, where the Bicep connects.
Hi Steve, thanks for the informative writeup!
I’ve been battling jumpers knee for about 2 years now, both with intermittent PT and strengthening exercises. It seems like each time I try, eventually the pain seeps in and I’m starting over from scratch. I can actually feel it at times by just sitting down in a chair (with a bent knee) and resting my arm on my thigh, sometimes even without the arm.
My question for you is: Do you have any accounts of someone making a full recovery? After much googling I’ve come across many who suffer but not many (if any) who’ve made a full recovery, so it’s a bit discouraging at times. Thanks again
Yes, but you have to think about rehab as a long time project. If you’ve had something for longer than a year it’s likely going to take at least a couple months if not more to do a complete rehab without aggravating it.
Mainly, you need to get it moving without aggravating it… if you have access to a pool or cycling where you can get a lot more activity and blood flow to the area that doesn’t aggravate it that would be good.
Additionally, a good program focused on eccentrics, stretching, and all of the other things I listed above would be good.
Rehab isn’t something you can half-ass… it’s really a full time thing to get better and your training goals need to be on the side.
Hey Low
What about this workout;
http://www.youtube.com/watch?v=dhNDPD4gxpc
Please reply
Also I have chronic tendinitis in both arms
My plan is for the next month:
REST, No typing or mobile use (makes it tight)
Correct posture, relax, breathing exercises for circulation and break scar tissue etc. 10 min breathing in the morning and at night
Some dynamic meditation to relax, I got pretty tight of this injury and now its time to fix the problem
Use contrast therapy hot for 2-3 mins and then 1 min (ice)cold .. twice a day or once? help me with this..
Nutrition wise: avoid for 1 month or as much as possible :
- processed foods (less processed foods are ok to?)
- grains,bread etc.
- deep fried foods etc.
And eat anti-inflammatory foods
- minimum 2x a week 150 gr fish (tuna,salmon,sardines etc)
- have 500 gr of vegetables a day; brocolli/carrots/ dark leafy greens/peppers etc… any tips?
- lots of fruits like orange,apples,kiwis,bananas
- get around 50gr of protein a day
Some spices that will help I think
- Turmeric powder with ginger powder tea + honey + cayenne pepper
Supplements
- 900mg of fish oil a day ( got enough for 2 months)
- 500mg of magnesium (for 3 weeks, Just to try if it helps relaxing)
- Vitamin D 2x a week 50000IU.. Im low on vit D
- I got magnesium oil aswell,
Im 16 years old , and have had this for nearly 1 year
Now Im going to do something besides only ”rest” to really heal it because I want to beable to train again, do bodyweight stuff damn I MISS it! Makes me want to cry, really hard especially mental:(
Would really appreciate it if you could say something/add to my ”plan”
Tolunay
Forgot to add that I have it on both sides, inside + outside and on both arms… on top of the forearm the tendons are very tender to touch and my bone and insides is tender too and hurts.
Its slightly better the last months, I can type again without too much pain actually. Only thing that makes it hurt are ; I cant go into a pushup position, basicly put any weight on it. Heck it even hurts when I touch it.. sometimes it hurts directly(at the moment when Im doing something) and sometimes it hurts afterwards pretty bad that it lasts for almost 1 week to go back to ”berable” pain
Last time, forgot to add ”rice bucket exercises” to promote strenthening of the tendons + blood flow
Any tips on this? How many times a week etc?
In my opinion you need to get this checked out by a physical therapist. There are multiple issues going on if you have pain on both of the sides of your forearms and need to be evaluated for other potential wrist and shoulder issues that may be contributing to your pain.
Most of the stuff you are stated here looks fine, but again a complex case needs to be assessed professionally because there’s usually a lot of things that are missed.
The point is, I went already to a physical therapist in the first 4-5 months..but it didnt really help I was frustated because I wasnt getting progress and the therapist said it wasnt really a ”hard problem” … we corrected my posture exercises etc. posture was getting better.. but now Im doing that on my own…
I was recommendend to ”build up” again thru pushups (knee) but even that would hurt.. and he said that that is normal.
Then I want again to a new therapist… and they press like a …. it freaking hurts they press so hard on the tendon that I couldnt move it for 4-5 days without pain.
I dont know how to found a good therapist… these days its hard to find people that actually understand injuries and imbalances…
Thats why I asked u for help but I understand via internet without seeing it its hard to say what to do…
But Im just going to try my way and see if it helps..
This article will help for finding a good PT:
http://www.eatmoveimprove.com/2010/02/healthcare-professionals-for-athletic-complications/
Otherwise, what you wrote down looks to be OK from a general perspective, but I can’t really say anymore than that to be honest. It may or may not be OK for your particular situation.
I simply do not have enough details.
Hi Steve,
I’m a 36 year old male who had distal biceps rupture approximately 5 years ago in non-dominant arm. Surgery, PT, etc… It has never been 100% but was good enough for activity that I enjoy. I aggravated the biceps again in January 2012 shoveling snow. It gave me fits all spring and summer when rowing raft down rivers. Every time it flared up I would ice, massage and minor exercise (flared up approximately half-dozen times in 7-month period).
I finally took 3 full months off (September – November) followed by 3 months of consistent weight lifting/strengthening (little eccentric exercise). The biceps responded well and I thought I was on my way to a full recovery. Fast forward to the end of February (2013), the biceps flared up again after an aggressive day of training at the gym. The pain and discomfort from the most recent episode was 10x worse than anything I experienced last summer.
I went back to my orthopedic surgeon who diagnosed it as tendonitis. He recommended PT and Dexamethasone treatment. PT has me focusing on eccentric loading, ice, stretching, ASTYM treatment, and corticosteroid treatment. All of which seems to be helping but at a snails pace. PT is saying a minimum of 3 -4 months of before I can get aggressive with it and get on the river again.
Do you have any history with ASTYM treatment? Is this tendenosis? In your opinion, can I come back from this? I spend 50 – 60 days a year on the river rowing a raft/fly fishing so I’m anxious to get back to full strength. Will I be able to continue this level of activity? Any other thoughts are greatly appreciated.
Hi Steve,
I have been having pain in my right knee just below the patella for almost the last 4 months. At first I didn’t worry to much about it and just thought it would get better on its own. At first it would seem to get better, but then I would do something that would aggravate it such as hoping off the tailgate of a truck and the pain would be back. I would then do as little walking or other activities as possible til the pain went away again. Well about 2 months ago the pain came back with a vengeance after me and a friend spent a lot of the day walking around town shopping. This time it has stayed with me. At that point I went home and scheduled an appointment with an orthopedic. He diagnosed my pain as patellar tendonitis (which I’m starting to think is actually tendinOSIS after reading your article and others where it is said tendonitis should clear up in 2 weeks). I have not been able to get back to work for 7 weeks now(I am a firefighter, so daily tasks on the job will most definitely aggravate this condition). Even simple things such as taking a short walk down the driveway make it hurt. I have been doing stretches for my hamstrings and calves as my PT prescribed and this has helped some but I’m wondering if I should be doing more since in my opinion this seems to be tendinosis? Would you think that eccentric exercises are appropriate for my condition? Also, if I do attempt eccentric exercises should I expect to feel any pain in the patellar tendon? If there is pain should I stop? I’m worried about going too far, I really don’t want to do anything to delay recovery but I am willing to do anything to get where I need to be.
Any advice you can give is much appreciated!
Thanks in advance!
-Daniel
Talk to your PT…
And yes, if your case fits the chronic symptoms I described then sure it’s probably somewhat of a chronic condition and likely would benefit from eccentrics.
Hopefully, you can do them without pain, but if you can’t then as long as the pain doesn’t get worse and will get progressively better then that’s what matters.
You really need to keep up the convo with your PT though not me.
Okay I go in the morning so I will mention it to him.
Thank you.
Hi Steven,
Thank you sooooo much for this post. I am truly grateful. I was diagnosed with posterior tibial tendonitis about 6 months ago. I have only seen slight improvement since I stopped my running. A few questions for you:
- Is there any chance you can tell me exactly what eccentric exercises I should be doing? I’m having trouble finding anything for this condition and my old PT had no idea.
- Is it normal to feel pain during the eccentric exercises or is that a sign to stop?
- How will I know if its helping vs harming?
My MRI showed nothing, but we have ruled out a whole host of other conditions so my ortho insists on tendonitis. I found a great chiro / ART guy who thinks he can help me, but i’d like to try to eccentric loading if I can just figure out what to do! THANK YOU!!! You are a wonderful human being helping us all out
-jen VR
1. Eccentric is basically shortening the muscle to lengthening it.
Since the posterior tibialis inverts and plantar flexes the foot, that is the starting position. The ending position is everted and dorsiflexed.
2. Yes, for bad cases of tendinosis you may have pain during the eccentric. This means you should back off of the weight as much as possible (even starting with no weight). Generally speaking, if no weight hurts with the exercise then as long as the pain does not get worse during the exercise it tends to be OK,… but I would consult with your PT first.
3. At most, any type of rehab you should start to see results in at least 4-5 session or 2 weeks or so.
Ok, thank you so much. Then does using resistance bands and making that motion seem reasonable? Sounds like my foot would be pointed down and inwards, then I should move it up and outwards, possibly with some resistance? Doesn’t seem like a motion I would do on the stairs then as that would not give me the movement from inward to outward.
Let me know if this sounds right…
Thanks!
Yes, resistance bands can work as can ankle weights put on the foot.
Yes, down and in and then move up and outwards. You can manually resist it with your arms if you’re comfortable sitting in a ball.
The basic gist of it is to regain the control there and get the muscles working.
I would also suggest deep tissue massage to the PTT muscle (not the tendon), as well as some very light non-painful stretching, and dorsiflexion strengthening.
I am a 65 year-old male and have been fighting patella tendenosis or PFS for years. The last two therapists I went to both suggested procedures that were not appropriate given what I have been reading. One suggested doing leg extensions, the other lunges. Neither indicated massage or heat was needed. I know that I have to find another therapist, but would like your suggestions. The pain is bilateral, generally below my kneecap running into my shin. I was diagnosed by a doctor with PFS but am beginning to think it is patella tendenosis. What should I expect a therapist to do? At this point I have no idea.
PFPS you’d typically feel underneath of the patella… whereas patellar tendinosis would be directly on the patellar tendon. ALso, there could be some intrapatellar fat pad involvement as well.
If you are unsure I’d suggest getting a 2nd opinion from another doctor (preferably an orthopedic) though.
Lunges and leg extensions can be useful in a rehab program but that’s not all you should be doing for that.
You need to ask your rehab professionals more questions on why certain exercises or treatments are used. If they can’t explain why they are doing certain things then they are not good and you should ask for someone else.
Hi Steven,
Thanks so much for this website, so nice to know someone cares! I have been told I have either posterior tibial tendonitis or tarsal tunnel syndrome. I’d like to know what type of eccentric exercises I should be doing for PTT. I can’t really find much on the internet on what this motion looks like. Can you help?
Also, how will I know if its helping or hurting? Should I expect to have some pain during the exercise or after? Or is that an indication that its making it worse? THANK YOU!!!
-jen
Oh, sorry i posted twice – i did not see your earlier reply.
Hi Steve,
I really need your help here. I’ve had some sort of wrist tendonitis (right worse than left) for a year now. It has had its ups and downs but overall I have not been able to do any of my favorite activities for a year (tennis, computer games, weightlifting). I hurt it playing computer games April 2012. It irritates it to click a mouse and type – especially hard keyboards. The pain is in my wrist area but feels like it is irritated by gripping/finger curling activities. I tried physical therapy, but they made it way worse somehow, and had to stop working (chemist) for months afterwards. Now I can work again (3 months), but it just won’t heal! I’m icing this thing a few times a day normally. My pain level is generally low (3/10) but prevents activity nonetheless. What do I do?
Thanks for any help here,
-Everett
P.S.
When I read your tendonosis definition, it seems like I don’t have it. I mean, mine normally feels better after resting/in the morning. Anti inflammatory and ice make pain go away. It feels just as bad and behaves similar to when I first hurt it!
-Everett
Hi Steve, let me reformat my original post:
1.) Pain is on and around prominent wrist tendons (palm side), although thumb tendon sometimes hurts as well (in wrist area). Both wrists. Right significantly worse. I hurt them playing computer games.
2.) Type and mouse click hurts. Gripping squeezing hurts.
3.) Pain type often sharp then ache afterwards.
4.) Normally 3-5/10, depending on how bad I push it on accident.
5.) Chronic (1 year)
6.) Only working around injury, not using it (no pull ups, bicep curls, etc.)
7.) At my job I do have to use hands (chemist), which irritates it.
8.) Rest, Ice helps temporarily, and hot shower.
Do dishes, open door, wash hair, anything can essentially bother it.
9.) No swelling
10.) Early day best, late day worst.
11.) Never injured wrist before.
12.) Typical posture in my workplace.
13.) I don’t workout the bodypart, becuase if I do it hurts more.
I have to be able to do my job.
14.) Tried physical therapy – massage, wrist curling etc.
Seemed to maek it much worse. Missed 3 month work after quitting
my physical therapy, then got better enough to work.
-Everett
What did they have you do in physical therapy? I need to know all of what you’ve tried.
What is your orthopedic doctor’s diagnosis? Did they even diagnose this as tendonitis?
Did they use any joint mobilizations?
Hi Steve,
Thanks for the reply. They had me do “tendon glides” by making different fists repetitively. They advised me that I could resume working out with moderate weights as long as I do not grip the bar tightly and let it hand a bit in my fingers, since they thought my wrist was the problem. Turns out, I think my fingers are the problem, but the tendon goes through my wrist. So, taking their advice about dead-lifting and doing pullups backfired pretty bad. My doctor had diagnosed this as bilateral wrist tendonitis. I guess he was wrong and so the physical therapist recommendations did some serious damage – in my opinion. They tried putting wrist braces on me, all it did was irritate the tendon via rubbing. I don’t think any of them realized its my fingers that are the source of the problem. Hurts a little to type this for example. May hurt more later.
-Everett
They also heated messaged the tendon. (September-Nov). Made me do wrist curls (all 3 directions) with bands. Didnt seem to help much. They made me squeeze a gripper. Seemed to hurt it.
No wrist joint mobilizations?
And where do the tendons hurt? In the fingers, at the wrist, or what? What specific tendons?
I still don’t have enough information to make a guess… and it’s really not sounding a lot like tendonitis to me honestly. Double onset of tendonitis in both wrists is a bit weird.
Did they screen you for neck issues as well? Might be a decent idea to get a second opinion on that.
Hi Steve. What are wrist joint mobilizations? The tendons hurt at my wrist always, although like I said it seems to activated by finger not wrist movement. I am not sure what specific tendons – the finger/index tendon mostly but other areas of the wrist start to hurt if I over use the other fingers (more rare).
I am going to see a hand therapist early May. Should I ask or tell him anything other than what I’ve told you? Thanks for trying to understand this. I’ll look into your point about neck issues.
-Everett
Hi Steve-yrs ago I got tendinitis-piano/keyboard player.-it was music gig so I didnt stop,until I knew i was in trouble.15 yrs later it finally leaves my forearm (the constant aggravation)then goes to my upper arm and shoulder-more like burning and involuntary contracting muscles–needless to say I backed way off my profession.Now-Feeling that my forearm is better- today I went to practice playing a difficult Chopin piece-relaxing as I play–but the forearm cant take it.I used to be very strong for a female-even so-I became inflicted with this discomfort-no matter how I hold my arm while playing.is it just that some people are prone?I have some arthritis in my shoulder now–age 53
There sounds like multiple things going on. I would definitely suggest getting looked at by a physical therapist who can tailor a plan of care towards the specific things going on in your case.
Hi Steven,
Just bought your book and am loving it – thanks for writing it!
My question is about quad tendoitis or tendonosis (probably have the chronic) . I was diagnosed with quad and patellar tendonitis a little over a month ago in the left knee. 7 years ago I had IT band issues after a marathon in the same leg.
I have spent the last few weeks stretching, resting and foam rolling the leg. I have done some eccentrics, but am worried they irritate too much. There is a little pain and tightness around the top of the knee, and a tightness that almost aches on the top outside (lateral side) of the knee. I feel the tightness all the time, and the ache when i massage and foam roll. I wonder if this tight achiness is IT and not the quad tendon?
I did 150 air squats last night for the first time in several weeks, focusing on activating the glutes. The tightness seems a little worse,but there was no pain, so is this ok? My fear is doing too much, too soon.
If it helps, I am 36 and started crossfit in December 2012. Onset was feb 2013, shortly after I decided I needed to push myself harder
Thank you!
So you’re having concurrent ITB and patellar/quad tendon issues at the same time?
The main point with the eccentrics is to regain control of the muscles that are offending the muscle in particular. The stretching, foam rolling the quad and ITB are good but I would also hit the calf/front of the leg area as well as potentially the glutes. The big thing is to focus mostly into getting the glutes and hip control active as well.
If you need to do the eccentrics with assist because it’s too much weight on the leg that works, and eventually you want to work from squats up to a single leg squat to your butt on one of the jump boxes (18 or 24″ one depending on how tall you are) but that might be a ways off with chronic tendinosis.
Tightness is probably OK as long as it doesn’t get worse, if there’s no pain. Aim for a slower eccentric if you can between 4-5 seconds and make it as smooth as you can. Use your hands to assist the concentric if it’s too much.
Definitely cut back on the intensity of any CF so you can rehab properly though. If you’re seeing a PT definitely listen to him/her rather than me because it’s better to listen to the person who actually evaluated though. But you can bring this stuff up with him/her.
Hey Steven,
As I mentioned earlier on, today I tried the rice bucket exercises for a few mins and my arms barely hurt but my forearms felt an immense pump, didnt had such a pump in a year. This will promote blood flow I guess and aid in healing? Im also doing foam rolling+crossfiction and sometimes trigger point release. Any good wrist mobilizations to add?
Sounds good. Just general wrist stretching is fine as long as it helps.
hey steven its me again
Im thinking of starting with eccentric exercises; wrist pronation and supination since I have pain in both areas
do you do the eccentrics in one session and how much rest between sets? is pain good?
also isnt fishoil counterproductive when you try to create inflammation?
thanks
Yes, IT and quad are affected. I hadn’t been rolling the calf, so will start doing so. Thanks for your thoughts about eccentrics, too. I did a set of ten yesterday, and my leg felt good today, so I ‘ll keep up with those. Seems like everything I read points to pistol squats, too, so I ‘ve started working towards that. The PT recommended cutting crossfit to 2 weekly for a month, with very light weights, then adding a day, then slowly adding weights. I ‘m going to focus on getting the glutes active since I have a desk job.
I am glad that at least I can work the upper body in the meantime, and will be using your book as a guide.
Thank you for your thoughts
Sounds like a plan. Fitness is a journey… not a rush. Don’t do too much too soon lest you get overuse injuries..
Let me know if you have anymore questions, and don’t forget to submit an Amazon review.
Left a review and just ordered the fish oil using your code!
So after performing eccentric exercises for tendonosis, should I apply ice? I realize that in chronic cases there is no inflammation but am confused because the exercises are supposed to create inflammation?
@ Nicole
Some inflammation is needed in the healing process. So no.
You can go with heat if you want if it makes it feel better.
On April 1st (funny joke) I noticed some pain located at the inside of my arm when doing weighted chin ups on a fixed bar. Like any other avid boneheaded lifter I pushed through the pain for about 2 weeks. At the point I decided to take a break and read up on whats bothering me. For the first week I was performing strengthening exercises which included wrist curls, tennis ball squeezes, protation and supination with a pipe wrench and putting a rubber band around my fingers to work the extensor muscles then ice it after. This would aggravate my elbow but I also made progress in strength and my pain when gripping seemed to go away. The following week I dropped all exercises once I read your article thinking I had a chronic case and focused on heating and massage, which made a huge difference, The only pain I would get would be squeezing my ring finger to my thumb. Just yesterday I tried some eccentric work while holding a pipe and suppinating my wrist, doing so I feel a tiny twinge at the medial epicondyle which after resulted in some minor discomfort making it again painful to make a fist. Where before with just the heat and massage I was getting better daily. Now that I preformed the eccentric exercises I seem to be worse and feels like I lost a week of healing. Do I continue with the heat and massage and not worry about the suppination exercise? Am I going about this all wrong? Do I have tendonitis or tendonosis?
@ Ryan
It’s not a chronic case because you haven’t had it more than 3-6 months.
You should mainly be doing rest, massage to the muscle, extensor work, etc. Basically the non-tendonosis component.
If you can’t do it yourself get yourself to a PT before making anything worse.
Should I start following the acute protocol you have listed above? How many reps for the eccentric wrist curls 20-50? Also how many days a week should I preform this? Thank you for the reply.
@ Ryan,
I added for who the posts were for.
Your case is not chronic. I believe the article above says 3 months if I remember correctly. Typically, a chronic case may take even a bit longer to develop than that. If it hurts to do eccentrics and doesn’t improve then it’s clearly not chronic. Don’t do them.
Do the non-tendonosis components if you want to attempt to self rehab.
You say once it gets better start with low volume (20%) and slowly add 10% week by week. My question is how should we progress with intensity? Im assuming it isnt safe to jump right into heavy weights again, so how should one go about adding intensity back into the mix?
@ Ryan
Well, most of the rehab work should be done with 30% 1 RM. So if it’s a truly chronic case you’d be adding volume to the 30% 1 RM case, and then after you progress up to about 150 total reps 5-6 times per week and about 2x per day then you want to start adding to the 1 RM and start reducing volume.
Can you give me an example of that please? I was mainly talking about deadlifts and pull ups
Just start with 30% 1 RM DLs. If it’s 300 lbs then use 90 lbs for 15-30 reps. Then increase intensity from there.
If the exercise is for tendonitis you shouldn’t be starting with compound exercises…
Steven, I appreciate your help and im sorry for the questions, but I have one more. The culprit of my elbow pain is stemmed from my ring finger, any pulling or squeezing with that finger will cause pain at the medial epicondyle, all other fingers are fine.
Steve,
I was a very active person (running 12-15 miles a week, hikes, basketball) but I injured my ankles stand-up paddle boarding in June of 2012, (first and only time I did SUP). I cut running out of my life for four months, but continued to lead a somewhat active lifestyle (went on walks, did ZUMBA once a week). I started to run late October last year at a slowish pace, but in early November, after picking up the pace on a treadmill, I developed a nodule one the lower right side of my Achilles tendon. It went away after a few days, and then I went on what I now call the carousel of different orthopedists and PTs. I tried to find someone to help me, as I think my ankle injuries are chronic.
The pain is in both of my achilles. One doctor want to jump right into surgery for my peroneals (I had some pain there because I had changed my walk to compensate for my achilles problems). I sought another doctor who was less aggressive and sent me to a PT. But, the PT was obsessed with getting knots out of my gastroc and soleus. I developed plantar fasciitis from the hard massages and stretches (ballet/pull toes back) I was told to do. One day this PT crippled me after pulling on my foot back then forth in forced holds. Both of my achilles got puffy and stiff.
I never saw this PT again. (This latest even happened three weeks ago.) I’m sorry this is turning out to be so long, but I don’t know what to do anymore. The latest doctor I went to said, stay away from PT and try taking 1800 mg of Advil for about 3 weeks. I’ve been fighting my bilateral Achilles issues since June 2012 to the present. Seeing the first doctor and PT only made me worse, as I do not drive anymore and can only walk for 15 minutes before the achilles get aggravated. I don’t know how I can try to heal myself, or when I should start. The plantar fasciitis has tamed down, but the achilles pain is present. Neither achilles is swollen, maybe just a tad at the bottom parts, but the aches are always there. Please help/advise.
@ Noreen,
Have you tried night splints? Those have some decent success rates for plantar fasciitis.
If you truly have achilles tendinosis then you need to absolutely be working with eccentrics though. If you have a theraband you can get started with those seated or you may have to modify them standing up. As long as the pain doesn’t worsen you want to work on them with control (about 3-7s per eccentric depending on how poor your control is) and start with 3×15 and then progressively work up to 3×30-50 about twice per day for 4-6x a week.
Thanks for your post it is very insperational to know that one can overcome chronic tendonitus! I have had tendonitis in my shoulder and bicep and the whole of my right side of body is week as a result. This has been going on for two years and only in the last year have i seeked help. An MRI on the shoulder did not show very much. The first physio i saw had me doing excersises with a theraband for my shoulder. These did not help much. I then saw another physio and she said that the pain stemmed from my neck and not originaly from my shoulder and to treat that area first. She also said the whole of my right side was week and that the excersises i had been doing where counter productive. I am at a lost point and in pain. I work offshore so i only have small periods of time to see spedcialists often resulting in me getting half way to the root of the problem and treatment and then having to go away again. Can you recomend me some excersises and also any renowned specialists that i should go and see? Than you so much! Joe
@ Joe
I can’t recommend anything because I don’t know your specific case.
I only know some people, so I don’t know if I can recommend you to anyone. Depends if I know anyone in that specific area.
And would also like to ask that if you can do rice exercises and eccentric exc. at the same time?Ive read that several people spread their eccentric sets through out the day and do 15-20reps, less than you recommend?
Any specific warmup/massage before/after eccentrics?
Whats your opinion on hot-cold therapy for my case?
a lot of questions, sorry but I just ‘feel’ better when asking someone that knows his stuff and shows that you can heal from it. Now Im going to make and start a serious rehab plan
Its a very mental thing, after suffering fo a year now its time to take actio…
@ Job
OK, you’re asking too much detail and I can’t answer it because I haven’t examined you specifically.
“General” recommendations for chronic cases are described in the article so you don’t need to keep asking about them — heat, massage to the muscles to release tension on the tendon, eccentrics. Contrast baths can be fine too.
30-50 reps per set controlled… but if you can’t do that many to start then lighten the weight and/or start with 15 and work your way up. Multiple times per day, most days of the week as long as it doesn’t aggravate it more.
This is general stuff, so it may or not may not work. See a physical therapist if you have more specific questions…
Hi Steve
When starting with ricce bucket exercises, would doing rotations, up-down side-side enough, with about 2 sets of 30sec each movement?
My flexor muscles(forearm) respond well to foam roll but my extensor muscles, I need to be very carefull on that side because the tendons there get easy irritated.. should I avoid massaging extensors because it irritates it?
Massage and heat work very well so far, doesnt make it worse atleast.
Adding some stretching&mobility for wrists and rice b. strengthening.
Great article and Overcoming Gravity was a great read!
Will you make a smaller version, because its a hard read.. a lot of INFO!
@ Elliot
It depends on every individual case… you can try and see with the rice bucket. Avoid aggravating it definitely.
Trying to get OG2 out so hopefully it’s more newbie friendly… Don’t forget to submit an Amazon review.
Hello steve,
Thanks for this informative article. Lots of good info here.
I had an mri done ~45 days ago.
The findings were (left shoulder):
bicep tendonitis (long head),
degeneration of the supraspinatus tendon (7mm from its insertion),
no sign of rotator cuff tendon tear,
no excess fluid in the shoulder joint and
no problems with the bones at the shoulder.
Doctor’s advice was to abstain from any exercise that caused pain and start doing the following exercises 2 times a day(1x morning, 1x night), 30 reps each with 1 lbs dumbbell.
external rotation
bicep curl
lateral raise
I do these and nothing else.
I ‘ve been following his advice since the diagnosis but have little to no results. Its fine when i dont stress it, but when i do any pushing or pulling it gets irritated.
Should i continue doing the same exercise regimen, the 3 exercises he prescribed and nothing else, or should i change something?
Heating the area feels ok, so does ice (~10mins on) after exercise.
Bear in mind that i have the pain since Dec 2012 so i guess its tendinosis and not tendonitis.
Thanks in advance!
@Kanenas
Have you been to physical therapy?
I would suggest going to physical therapy if at all possible since they would be able to look at your specific case and anatomy and figure out the details of what needs to be done.
Thanks for the reply
I havent been in physical therapy.
The orthopaedic surgeon said it is just tendonitis and didnt refer me to physical therapy.
@ Kanenas
If you haven’t improved ~45 days then I would definitely suggest trying to get a referral to physical therapy. Honestly, the exercises if they were going to help you should start helping in about 1-2 weeks. If there’s no improvement that tends to mean there’s something else going on that needs to be looked at or solved. Physical therapist would be your best bet to try to figure out if there’s any other compensations or issues going on that may been some specific work.
If PT doesn’t work then come on back and we’ll see what happens.
Hi Steve, Dont know if you can help me but here goes, I had a Total Knee Replacement in January 2013 everything was going ok with PT until 6 weeks after my op when I started with pain in the back of my knee, the PT has told me its tendonitis and he massages my Hamstring and Calf everytime I go to see him. I have now finished having PT and I am still having pain, are there any excercises that I can do to help. I am trying to massage my knee myself and also applying ice packs, but nothing seems to help. I am also due to return to work and I am worried that as I have a job where I am sitting down all day that this will also aggrevate my knee.
Thanks
Sue
@ Sue
Problems after surgery don’t really crop up unless there’s excessive stress on it.
If it hurts during walking, there’s probably something in your new gait that’s aggravating it. If you waited a long time before having the TKR and your arthritis was very bad or you had severe knock knees then that can potentially alter your walking pattern since you have gotten the replacement.
Did your PT take a look at how you were walking and make changes to your gait pattern?
I would generally avoid pain, but a little bit is ok if you can’t avoid it completely with the eccentrics.
Don’t do things that aggravate it… just the rehab.
You need to ask that to your physical therapist. I don’t know the exact orientation of your body so I can’t make that recommendation.
Hi Steven:
I have a general question. In the diagnosis of an injury such as mine (elbow pain on the antero-medial aspect of elbow), is it safe to say that if I can perform certain movements without pain, that it is “this” injury or “that”? For example, I have been battling with what I have assumed is chronic medial epicondylitis (tendinosis?) for a few months, now. I have no numbness or ROM restrictions. I have pain in that location especially during pullups (strict or kipping), but not during movements such as handstand pushups, burpees, pushups, kettlebell swings, thrusters, or even some Olympic lifts… is it possible that it is not medial epicondylitis but perhaps something else in that area. If so, I am wondering what else it could possibly be? Would it be medial epicondylitis if I am able to do all of those other movements which use my elbow, painlessly?
Interestingly, I notice my elbow ache when I do “very light” things like shake hands, shampoo my head, wash my face, or push down a door handle or toilet handle.
I have been performing the eccentric protocol for a few weeks, which doesn’t hurt, but unfortunately has not improved my symptoms.
Thanks for any insights.
No, each case of medial epicondylitis can present differently than another depending on mechanism of injury and your particular anthropometry and physiology.
If it’s more along the anteromedial aspect of the forearm rather than strictly moreso on the medial aspect I would suspect that it is tendonitis of the pronator teres specifically. In that case, I would use high rep eccentrics with the elbow in a curl position with your hand facing you supinated, and slowly move into elbow extension with the hand pronated. That does the eccentric of the pronator teres specifically and should help start to get the healing process going.
Thanks, Steven. On the last two lines of your reply, did you mean to say “with the elbow in a curl position with your hand facing you supinated, and slowly move into elbow extension with the hand GOING INTO INCREASED SUPINATION”? It would seem that that would make the movement eccentric for pronator teres… maybe I’m mistaken. Just wanted to confirm.
Thanks a million!
Pat
Is it reasonable to expect that within a week, I should notice a slight reduction in pain, or might it be several weeks before I notice any improvement at all. I’m not in any rush to get better per se; I’m just curious.
Sorry, you’re right. Mixed up my anatomy, good catch.
It should be curled with the hand pronated, moving into straight arm with the hand supinated.
Couple of times a day, very light weight, 30-50 reps.
Should start to notice some improvement in a week or two. Depends how long you’ve had it. Can’t really make a good estimate since I don’t know.
Hi Steven:
Do you have any choice mobility exercises to compliment the eccentric exercise? I am worried about doing something that will aggravate my elbow tendonosis.
Also, what are your thoughts on using a VooDoo floss band for compression while I perform my eccentrics, or while doing mobility exercises?
Thanks always!
Pat
Anything that gets the joint moving non-painfully is ok.
If you’re going to do the band compression do it before or after you do the eccentrics not during. Otherwise, it will interfere with the stress put on the tendon which is the primary role of the eccentrics to facilitate the healing process.
Thanks, Steven. Maybe I will refrain from using it for the time being. I have not been using it, but wondered if I should be.
I woke up this morning will a tingling/numb forearm and hand (mainly my palm, my little finger, and the finger right next to it) and a few hours later it is still numb. I didn’t sleep any differently last night, and usually if I sleep on that arm, the numbness goes away after I get up, within seconds. I’m guessing that the tingling is some sort of ulnar nerve compression (?), but I don’t know for sure. Could it be that the eccentric protocol has strengthened/tightened my pronator teres and made it impinge the nerve? I have followed the protocol recommendations very closely and have kept the volume low and the self-massage regular.
If you’re having neurological issues along with your tendonitis I would get that checked out by a physical therapist/orthopedic doctor.
Hi Steve:
I have been experiencing some pain on both my forearms from overdoing pulling exercises with overhand grip for a long period of time (mainly pull ups and barbell rows) and never alternating grips.
The pain is not constant though.
It is only noticeable when I extend my arms in a straight line and try to squeeze my palms or if I relax my arms and try to apply force as if I was trying to push my hands against my thighs.
Does this sounds like forearm tendonosis?
Would the protocol from your book (which I bought) work that is described on page 159?
Thanks for your help,
Roberto
If it’s not all of the time and only hurts during exercise it is most likely acute — rest, massage to the forearms, stretching, etc — should work well to alleviate it. Chronic cases where you may need the eccentrics probably aren’t needed.
If you need to get blood flowing to the area I would suggest contrast baths (hot/cold 1 minute each) or rice bucket rehab if it doesn’t aggravate you.
Hi Steve:
Thanks for your response.
I forgot to mention that I have had this condition for over two months so I believe it could be classified as a chronic condition.
What are y.our thoutghts?
Thanks,
Roberto
Typically chronic cases often do not hurt during exercise (they may hurt while warming up, but after they get warm they don’t hurt) and often feel stiff and achy in the morning. If it’s chronic, then follow the chronic protocol.
I don’t know because I haven’t examined you personally. Your sports medicine specialist would be a better person to ask.
If I randomly make a guess it might be meniscus related, or it could just be chondromalacia patellae, or just tight muscles that need to be stretched. There’s lots of things that COULD cause that which is why you need to ask people who have seen you in person, not me over the Internet.
You can youtube wrist joint mobilizations and you’ll get videos. Unfortunately, you can’t really do them on yourself…
Definitely tell the therapist all you’ve done before with PT and everything you can think of that may potentially help.
@ tolunay
If it’s chronic…. ~3 sets of 30-50 reps for each movement, with a very controlled eccentric usually 3-5s. Maybe 3-5 minutes rest between sets.
Pain is ok, not preferable, as long as it doesn’t get worse.
4-6 times a week. Add in heat, etc.
Honestly, I don’t remember your case… see a PT if at all possible.
Who was this directed at? My time stamp is not right.
@ jennifer
Thanks! Hope everything resolves in a timely manner.
With eccentrics, a little bit pain is the main poin of it , isnt it?
So little bit pain is ok? But it should hurt..?
@ Tolunay
As long as it doesn’t get worse.
Hey Steven
If you have the chronic chase, what is better to start with for rehab
rice bucket exercises for a couple weeks and then eccentric exercises?
wrist rotations are enough? how many times a week?
and for eccentrics;tennis elbow so how many exercise?
I think about negative pronation first and couple wks later add in negative wrist curl?
and what about reps for this , 15-20 or 30-50…I cant imagine doing 30+
didnt try but I dont think it will make it better that many reps..gotta try it
2-3 times a wk to 4-6?
@ Ryan
Odd.. may want to do some rehab work with that finger then too.