On Tendonitis

Table of Contents
I. How tendonitis develops
II. Corrective measures
III. Planning rehabilitative sessions

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 subequently 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 tendonoris’ 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.

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. May be a good idea to start eating the cartilage and tendons off your meat too to get the basic building blocks for your cartilage/joints that are universal in animals. 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.

The anti-inflammatory agent I would recommend is fish oil (plus fish oil is good for a lot of other things too such as the brain, cholesterol, heart health, etc.). Fish oil acts helps decrease inflammatory cytokines which are prevalent because of our pro-inflammatory diets. Systemic inflammation can hinder recovery because of poor blood flow to the tissue leading to poor tissue quality and slow healing. Thus, it is important to overall limit inflammation from dietary sources (too many carbohydrates), as well as take healthy systemic anti-inflammatories like omega-3s from fish oil.

I would recommend AGAINST NSAIDs because of the specific method of action that they work. They work on COX2 inhibition which prostaglandin type inflammation which is critical for muscle and connective tissue healing. Obviously, this may interfere with the natural inflammation that has to occur within the muscles and tendons which are going to negatively affect muscle gains and tissue health. You can read more about this on Kelly Starrett’s blog.

Pain relievers tend to be a mixed bag depending on what they are. Some tend to interfere with similar processes like NSAIDs. In general, I think the best rule of thumb is try not to take too much of anything unless absolutely necessary. There is simply no medicine that humans have invented that doesn’t have some adverse side effects.

The reduction of inflammation from fish oil is overall systemic and does not interfere with the specific inflammation stimulated from the self massage and eccentric exercises that is needed to help heal your tendonitis. This is why fish oil is much superior, and I recommend that you take it.

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.

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.