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.
This is a great article.
How would you apply this to tendon issues in the wrists from typing all day? Taking a two-week vacation is pretty infeasible for me.
The wrist tends to get irritated a lot because it’s stuck in the same position for long periods of time (and the tendons keep rubbing on everything over and over again).
Basically, hit up the stretching and other prehab work as much as you can (along with the ice and massage). And make sure your wrist isn’t in any awkward positions when you’re typing..
Very well written Steven. Easy to read and not too long-winded.
I like your style of writing. You don’t know me, but you have answered my questions on the CF and CA forums before.
This blog looks very neat. Keep the content coming
Probably the best article about Tendinitis what I read in last …
Thanks for sharing Steve
Gonna come to this site more often
The thing is that the most doubts come from beginners. They just haven’t had time to feel all the different exercises. For example, you need a certain mass of muscle just to be able to feel a “pump” or a strain – so that you need time before your body can speak to you.
This is true. Although tendon or joint pain is generally clear cut overworking (or underrecovery) which is why I am not concerned about it too much.
thanks for posting your informative guide; if you are not too busy, could you advise me on my injury? i was struck by a peice of partical board shelf that flew off my table saw directly into my patellar tendon…..it swelled up, and is still swollen after 9 months; i initially continued moderate weight lifting exercise, but have stopped for the last 3 months; pain went away gradually, and now i have slight pain in the area, but still moderate swelling; is there any special difference in treatment for a direct blow to a healthy tendon vs. injury through strain such as jumpers knee?….thanks a million; i have started to massage already
This is unlikely tendonitis.
Traumatic injuries are 99.99% of the time a different breed than overuse injuries such as tendonitis/osis.
I would advise you to see a doc for that.
Hello, just needed you to know I have added your site to my Google bookmarks because of your great blog layout. But earnestly, I think your site has one of the cleverest theme I’ve came across. It really helps make reading your blog a lot simpler.
I really enjoyed reading this and I am wondering if there is any extension to medial tibial stress syndrome. My reading on MTSS comes up with such a mixed bag, but at this point I feel it is an overuse injury of the attachment of the flexor digitorum longus muscle. So it seems like I might be able to logically extend your advice to this problem. Any thoughts?
Shin splints are a mixed bag. It depends on how they form… usually from poor running technique or too much stress. Heel-toe running is improper and from what I’ve seen tends to cause this a lot. Similarly, it may not be just this and may actually be stress on the tibia from too much plyometric or jumping activity. In both cases, you’re going to do nearly the same thing anyway.
In general you can use this protocol for it — focus on rest, ice massage (if it helps, otherwise heat), self massage and stretching out both the anterior muscles with plantar flexion and the posterior muscles with dorsiflexion work.
Take your vitamin D and calcium if it’s a bone issue. Take your fish oil for anti-inflammatory if you’re having problems with the muscle/tendon complex as well.
Let it heal then begin working back into stuff focusing on improving range of motion and strength at the ankle joint. And fix whatever technique was off or avoid overusing it.
Wow, thanks for the quick reply! I really have tried everything for the problem but maybe your methodical approach will help. I’ve seen multiple specialists and tried their many hundred dollar orthotics. A bone density scan came back normal. I take fish oil. I have taken up yoga and am generally pretty flexible. I have stayed off it for several months and tried starting again at 5 minutes of jogging/walking every other day with a 10% increase per week at slow speeds. I was a half miler in high school then ran in the Big Ten for a couple years but after about 4 stress fractures per leg I gave it up. I have been trying different things for literally 10 years at this point. I’ll try your advice and see how it goes. Thanks again!
Steve
Thanks for this article, it was just what I was looking for! I’ve had tendonitis in my knee for maybe four months now, and I’m still waiting for my appointment at the sports clinic…
I have a question about fish oil: what dose do you use? Is there any limit on how much you should take?
Also, I suppose that with all these treatments, including the fish oil, you really are treating the condition, not just suppressing the pain? So when the pain goes away, you know you are ready to work out again? Or is it not quite that simple?
Thanks in advance for any further illumination!
Peter
If you’re having bad problems then at least .5g of EPA+DHA per 10 lbs of body mass. For serious inflammation issues (and especially if you’re overweight) then you can go up to .75-1g EPA+DHA. Make sure you’re getting enough vitamin K (K2 specifically) in your diet to counter the anti-coagulent effects of the EPA though.
Fish oil is reducing inflammation, which in general if there’s too much will help improving healing rates significantly. Also, fish oil has lots of other health benefits as well as you know.
If you’ve had some chronic stuff it may not be an inflammation issue (but it’s worth trying IMO). Like I said in the article the stuff that is going to benefit you the most is the rest, massage, likely some light stretching and eccentric exercise.
When the pain leaves you NEED to work back into it very slowly. I would even go as far to say 1-2 weeks after you have no pain you should start back with <30-40% of your previous routine and see how it feels. Then add maybe 10-15% per week until you're full go again.
Any injuries are easy to reaggravate so playing it safe ensures you will hopefully have a big chance of avoiding reaggravating yourself to where you have to take more months off from exercise.
Thank You Steven for your articles and your CF Forum posts…I am day 3 subcromial decompression surgery. Doing some ROM, still very sore. Started back with fishoil yesterday, ice, rest. Have a post op appointment on the Feb 23rd. Will use your advice in search of a good PT. Any other suggestions or comments would be greatly appreciated….Again Thanks!
What a great article! Difficult stuff easy to understand. And I finally understand what problem I have with my wrist, it’s probably tendonosis as is it chronic ~ 4 months already. It is my right wrist it get a lot of use with writing, computer use, hand greets, picking and carrying things. I just hope it isn’t that bad it will heal ..
Now as I understood in tendonosis there’s no inflammatory process so I will try to induce it with massaging and maybe later with eccentric exercise. What about ice then? Maybe heat would promote inflamation more?
I’m gonna to reduce the wrist work as much as you can. Gonna massage with tennis ball.
Steve thank you very much, and if you know some specifics about wrist please answer.
See how much ice helps. If it doesn’t then use heat.
If you have carpal tunnel or something similar add in the stretching, and nerve glides (first google link).
Steven, I have had knee issues most of my life, it is definately the limiting factor in my training. The knee pain is on the insides, tops, and bottoms of my knees; basically everything hurts except the outsides. I will be looking into some of these supplements.
One thing that concerns me with all supplements is the purity of them. I notice that everything comes in capsule form has extra ingredients such as : Gelatin (capsule) and Magnesium Stearate. On the other hand you can take the tablets but those typically have even more crap added to them such as: cellulose, cellulose & glycerin coating, stearic acid, silica, vegetable glaze.
What are you thoughts on these extra ingredients? Adding all the pills together; BCAA’s, L-Glutamin, Glucosamine, Fish Oil and who knows what else I will end up trying out, means putting a lot of added ingredients into my body.
Should I try to find liquid forms or powder forms of the supplements that are more pure? Or are these added ingredients not something to concern myself with?
Hey Johnny,
It may be tendonitis.. but it probably stems from other sources. I would definitely look into a lot of the soft tissue work here:
http://www.eatmoveimprove.com/2009/11/shoes-sitting-and-lower-body-dysfunctions/
As for supplements, the additives are in general fine. However, if you’re concerned you can get powder forms of them. That works as well.
You can always google the ingredients of things and see if they have any harmful human side effects. Most of the types of pills and pill fillers are commonly used by most supplement companies so you should be able to easily find information on them.
Hello Steve,
Thank you for your very informative article. I have struggled with tricep tendinitis for the past few months that was aggravated after I broke my elbow doing rock climbing. I was wondering whether you had any specific excercises\massage techniques for tricep tendinitis? I have been taking fish oil and swimming as this does not seem to put too much strain on the muscle but I know that there is no way I can get back to climbing anytime soon and my patience is running out as it seems my recovery is incredibly slow paced… I would be grateful for any advice on this specific tendonitis!
Cross friction massage directly to the triceps tendon.
You can also loosen up the triceps muscle itself with some cross friction and myofascial work. Also, heat for the muscle itself too before you massage to loosen it up (although maybe not heat for the tendon just yet unless it helps significantly).
Moreover, strengthen your biceps if there’s a strength imabalance and your biceps are much weaker than your triceps.
I enjoyed reading your article (my friend posted it on her facebook page because she really liked it). I am also currently in school getting my DPT from Regis University. I agreed with your article except for the part about cross friction massage. I know that it has been used for a long time in PT, but the evidence really isn’t there supporting it:
Brosseau L, Casimiro L, Milne S, Welch V, Shea B, Tugwell P, Wells GA. Deep transverse friction massage for treating tendinitis. Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD003528. DOI: 10.1002/14651858.CD003528.
A systematic review and meta-analysis of clinical trials on
physical interventions for lateral epicondylalgia
L Bisset, A Paungmali, B Vicenzino, E Beller
I guess it kind of makes sense- why beat up tissue that is already partially destroyed? If you have ever seen a cadaver with tendonosis, you will think twice about really digging in on your patient and furthering the trauma. I like the idea about it bringing blood flow to the aread that will help heal it, but until there is more evidence, I think PTs should use other manual therapy techniques.
Hmmm, I could see that.
I also read the section in the study on manual therapy techniques. In I think all cases there wasn’t enough evidence to significantly support massage to the tendon; however, the majority of the patients reported improvement.
Maybe not a significant enough improvement to say this works all the time (because it doesn’t depending on the severity), but I do still think it works given what I’ve seen in the clinic and in theory.
I’ll have to do a bit more research on this though.. study was in ‘02. I also have to do some rewriting on a lot of material in this article as well. Half of my articles need rewrites. :\
So it’s more than a month I was massaging my wrist (I use tennis ball), and I think it got better, I have no pain in everyday activities, although I am very careful not to aggrevate it. But there is additional issue with it, recently I started to notice that during sleep I sometimes get my injured wrist little finger numb or tingling. What it might be? Maybe I little bit hard with massageing, and should lay off it temporary? Is this some nerve thing?
Also I’m gonna incorporate some exercises for wrist just wondering how. I’m gonna do wrist curls and reverse curls only eccentric phase, that’s ok right? I also think about doing negative part of pushup, first maybe eleveted.
I guess I should have done these exercises earlier but I’m very caucious as I had so many times aggrevated my injuries doing this rehabilitative stuff, I promised myself this is the last time I did stupid things while injured.
Use your hands for massage… more accurate.
Do nerve glides (google first link).
See how eccentrics feel with some negatives. If they aggravate it, then hold. If it’s medial epicondylitis start with the reverse curls (those are the ones you want). If it lateral then opposite.
Stretch if it helps.
Hi Steven,
In first place very good articles&web.
My cuestion, proper structuring for chronic tendinitis rehab (my case: repetitive injuries in finger flexor tendon, small nodule in the tendon). I read various sequences and I´m confused.
What is the corrective measures correct sequence in a sesion for better results?
Cross Friction Massage, Eccentric Exercise, Stretching agonist and Strength antagonist, What should go in first place, second…?
Eccentric Exercise > CFM > Stretching agonist > Strength antagonist??
CFM > Eccentric Exercise > Stretching agonist > Strength antagonist??
……
can you help me?
cheers
Each of those are fine.
Figure out what works better for you.
thanks for fast reply and I hope no annoy,
my principal confusion is about Cross Friction Massage, I have read:
1_after, NO physical therapy, only ice, because CFM is hard for tendon and he is weak.
2_after, DO physical therapy (strength antagonist and stretch agonist), because, CFM breaks adhesions and the physical therapy is more effective.
what is the correct?, I would like to know your opinion, I don´t want worsen my lesion (rock climbing; repetitive injuries in finger flexor tendon, small nodule in the tendon)
thanks
Depends on how intense the massage is.
#1 may be the case if you’re going at it pretty hard.
#2 is usually the case for muscles. For degenerative tendonosis you tend to want to be a bit less rough on it and focus on just loosening everything up. Then with the stretching/eccentrics that’ll be your inflammation stimulus.
If massage isn’t helping at all then don’t do it. For some people it doesn’t so if that’s you then feel free to ditch it.
I’d try both and see how you feel.
Steven,
Wondering about your thoughts on this: I am a 41 yr old woman and have been doing scaled Crossfit workouts. I developed some shoulder discomfort when I started CF about a year ago. but it resolved with rest, a trip to the doctor (who didn’t find anything significant), and some sessions with a PT who basically gave me home exercise for strengthening.
Recently, the discomfort returned after I did a WOD with many sumo deadlift high-pull reps. It’s a general discomfort. I hesitate to call it “pain”. I have full ROM. No decrease in strength. It feels like a mild burning/achy sensation, sometime along the top of my shoulder, sometimes in patches on my arm, sometimes around the scapular area.
Does this sound like a tendonitis issue? Any thoughts or advice would be helpful…I’d like to prevent a more serious issue in the making.
I first found your posts on the CF discussion board. Thanks for taking the time to help so many!
Sounds more like impingement to me although I can’t so anything one way or the other because it’s a bit vague doing this stuff over the Internet.
Have you gotten it checked out by your doc? If so, what is/was the diagnosis? Were you at the PT for tendonitis?
There’s lots more information that would be useful but yeah… Internet is pretty vague.
Thank you for your reply, Steven. I understand it’s difficult to get/give an accurate picture over the internet. Truth be told, I was sort of discouraged by my last doctor’s experience regarding this issue so I’m guess I’m trying to figure as much out as I can first. When I saw and ortho about 6 months ago, I was getting this general burning. There were a few incidents…OHS, SDHP, kettlebell swings that made my right shoulder feel slightly achy intially. But after a night of playing on the floor with my son (propped up on my right elbow for a long amount of time) I woke up with pretty intense burning down the right side on my neck, shoulder, and upper arm. That day there was pain. This calmed down after a day but during a kickboxing class later that week, when my partner struck a pad in my right hand during a drill, I felt a “zap” like a laser throughout the same area. There was no real pain, no limitations after that split second though.
My GP sent me to the ortho after I told her this on during my annual exam. The ortho basically made me feel I was wasting his time when i said that I wasn’t experiencing any “pain” just “discomfort”. He found nothing with manual testing, I don’t even know if he looked at my xray. That’s when I saw the PT. No-one suggested any diagnosis other than inflammation.
This hasn’t bothered me for 5 months of CF workouts after seeing the PT. Except for one time trying a heavy (for me) kB swing, and now after doing the SDHP WOD. My arm doesn’t seem to be settling down. The burning comes on with activity or even if I am sitting in the car. The SDHP/protraction movement REALLY aggravates it. It is general but now I’m feeling it a little more in the front top of my right shoulder, upper bicep area. It is not a constant sensation though. But it’s nagging.
I was hoping seeking out massage/ART/ would be first but I suppose I should return to the ortho. I really want to continue working out as I was. It’s been the best I’ve felt in years.
Thank you so much for any input you’re willing to offer…your time and knowledge are appreciated.
Hello! I have chronic tibial tendinitis due in my right foot due to several congenital bone deformities. The ankle flairs when I am on my feet for more than several hours at a time. I recently started a job where I need to be on my feet. Do you have any strengthening exercises you could suggest to support the ankle? I wear custom orthotics, but I think I could really benefit from some strengthening. I really like to be active and hate to think my swollen foot might mean I can’t keep my new job!
Yup, we do. Check out this article, more specifically page 4 (but if you haven’t read the whole thing you should):
http://www.eatmoveimprove.com/2009/11/shoes-sitting-and-lower-body-dysfunctions/
If there’s significant swelling with walking you might want to get that checked out though.
Steven,
I am a runner who began experiencing Knee Pain below the kneecap a little on the outside and the inside. It got to where I would feel pain a few minutes into a run and then I would stop. As the day wore on, the knee would get stiff and not want to extend very well. I assumed this was tendonitis.
I have essentially taken off a full month and just started up again with walking only. (Which even that would produce pain a month ago) I am not experiencing real pain, just a general soreness on an around the kneecap.
Would going barefoot help this, do I need to take more time off, or is this just normal after starting up again after a month off?
Thanks!
Generally, tendonitis tends to be localized to the tissues (the tendons themselves).
The fact that you had some pain on both sides of the tendon (and presumably possibly under it?) SEEMS to me like it could be a patellofemoral syndrome where the patella rides up pretty high on the femur and kind of wears on the cartilage a bit. This would also tend to agree with the general joint soreness/stiffness.
What kind of shoes are you wearing? Barefoot may help.
Do you sit a lot? Are you quad dominant?
I would definitely suggest checked out the shoes, sitting, lower body dysfunctions article as that may have more useful information pending figuring out what exactly you have.
Fantastic article. I do have a question though.
I have a chronic Golfer’s Elbow(since last 2 yrs) and I have already tried cortisone shots, physiotherapy, ARTS sessions, flexbars and nothing seemed to have worked.
I dont think I can go for surgery as it is too expensive. Can you suggest some options for me?
Greatly appreciated.
platlet rich plasma, autologous blood injection, prolotherapy is probably the best bet.
However, I’m curious… what did the physio/ART/flexbars entail? What was your current rehab at the time?
Have you tried eccentrics?
Steven,
I’ve developed supraspinatus tendonitis. This is the third week with symptoms. The pain went away almost immediately; currently I’m having problems supporting myself on my elbow (when in bed for example), my tendon locks itself in the wrong position all the time and I’m a bit numb.
My rehab routine has consisted of naprapath treatment (3 times), NSAID’s, ice and rehab exercises like dislocates and the Diesel Crew’s circuits (4/week).
I don’t intend to start pressing before I’m free of symptoms for at least a week or two, and then with low weights ramping up very slowly.
Should I do something differently?
Um, if it goes numb in the arm I’d look into doing some nerve glides for your arms and maybe getting other neck/shoulder muscles loosened up as well.
Keep the shoulder girdle active when you support yourself on your arm so it doesn’t impinge the structure there, but in general avoid this type of stuff for now if it causes pain. Same with any of the other exercises.
Work on your posture and mobility. The pressing plan sounds fine.
Thanks for your input!
Rehab’s easy to follow, the thing I tend to forget is working on my posture.
Just one question though. Perhaps you have made creating this blog as your career or do you do this within your extra time? Merely curious..
Free time and because helping people is good.
Steven,
I began having pain on the lower forearm about one month ago. I play ice hockey and believe that the pain was caused from handling my (too long and too heavy stick) with one arm. About one day or so after the stiffness/pain began the arm blew up and I had quite a big bump on my lower forearm, just below my thumb. I tried to ice it but still played hockey over the next two weeks and believed I worsened it significantly to the point where the arm was making a ‘grinding’ noise when I flexed my wrist. Two weeks since (and after a good deal of disciplined icing and stretching) I have barely touched my stick and have sat out from games. The grinding stopped and the wrist/arm are pain free, but there is still a slight swelling. I have just as good mobility with my other arm, but what would you suggest? More rest or can I return to hockey and other sports? I also play squash but use my other (right hand). Any help would be greatly appreciated.
Best regards.
May be a good idea to get that checked out.
If it’s pain free that’s generally a good sign to ease back into activity. I wouldn’t play a full game or go aggressively on it though.
Use massage to loosen stuff up and help eliminate the swelling.
Hi, thanks for the great writeup.
I’ve been suffering from tendonitis for the past 3 months but only saw a doctor a month ago about it. There’s no pain just a lot of stiffness and a feeling of weakness when I try and write and draw too much. The only thing is I won’t be able to properly rest my wrists for another 4 weeks (until I get winter holidays). I’m just afraid I’ll cause permanent damage if I keep using my wrists and my course is a really intensive art course. They were getting better since I started the exercises but earlier this week they’ve gone back to the way they were because I have so much work to do. But is the fact that there’s no pain a good sign? I’m just worried I’ll have to drop out.
Thanks
No pain is a good sign. As long as it is not getting worse that’s a good sign as well.
Try to get through it with no pain and not make it worse, then deal with it the best you can afterwards.
Hi Steve,
I’m a PT with what I think is a poorly managed hamstring origin tendinitis. Began in April 2010 mtn biking w/ tight shoe clip ( didn’t losen the tension and had to fling my leg out over and over for about 8 wks.Then I amped up my running. I rested and had 2 coritisone injections in June and July. I was able to return to running and increased too quickly in order to do Marine Corps marathon 2 wks ago. No pain at all during race. Now I must have flared it up. Pain at rest, deep buttocks ache and pelvic rim pain. I have a hard time finding a practioner to get to the spot and my pelvis keeps rotating. Any suggestions? At this point I will do anything, or nothing. Also, please give me a time line. This is very frustrating. I’m trying to be a good patient but its really hard.
Thanks.
Tendonitis of the hamstring would be more superficial and on the ischial tuberosities… but you may get something deeper.
Based on your description it seems to be a deep gluteal thing.. maybe piriformis or sciatic nerve.
Are you working with a physical therapist? If not, I would get to one to figure out what you actually have.
At this point trying to self diagnose is not a good idea since it’s been around for months.
Hi Steven,
This is one of the most comprehensive articles I have found on tendonosis/tendonitis and appreciate the time you have taken to write it.
I have had issues in both shoulders for over a year and have been to many consultants which have prescribed treatments which have not cured it to this date.
I believe the cause is my job, sitting at a desk and as I am quite tall I have been leaning forward the whole time putting a strain on my shoulder.
I have tendosis in both shoulders and in the last month believe I have possible tendonitis in my left wrist as I keep spraining it with very little pressure.
Over the last two months I have been working in the gym on movements which do not cause pain like deadlifts, rows and elevated push ups however in the last week I have been unable to do these without pain.
In your article above you write:
5-15 minutes massage or specific soft tissue work to muscle to loosen it up (NOT the tendon)
So this would be massage to the bicep and forearm flexors, would this be also to the pecs or any other connecting muscles of the shoulder?
and also in terms of bicep tendonosis in the shoulder as opposed to elbow what eccentric exercises do you recommend?
Been massaging it while I sit at my desk for the last 30 minutes and already am finding less discomfort
Thanks, Tristan
Where exactly is the tendonosis in both shoulders? Did they indicate what specific muscles/tendons are involved? Same with the wrist.
You can’t tailor anything specifically unless you know what is actually causing the problem.
The massage for the muscles is for the muscles of the affected tendons. So yes, that may be the forearm flexors if the tendons of the flexors of the forearm are overused. You see now that this is why you need specific diagnosis of what muscles/tendons are affected so you can target them.
For biceps tendonosis you would want to do light biceps curl eccentrics with the long head biased (if that’s the tendon in the shoulder that is hurting).
Hi Steven,
Thank you for writing this article, and for taking the time to reply to questions!
I would just like to clarify what you mean by starting back with 20% volume after the rest periode – does that mean 20% of the intensity, the number of repetitions, or both?
To take my own case as an example, I have developed tendon pain in my elbows from working too aggressively on one-armed chin ups. When the pain started, I backed of and waited 2 weeks, until the pain went away. Then I began doing pulling exercices again, but evidently with too much enthusiasm, as the pain has returned. I plan to wait another couple of weeks until the pain clears up, at which point I plan to resume pulling exercices, but much more progressively this time.
How should I begin to resume my exercices? For arguments sake, let’s say that before the tendon was strained, I could comfortably do 3 sets of 10 chin ups. Should I then start back with 20% of that number of repetitions – eg. 3 sets of 2 chin ups? Or should I start with 20% of the resistance eg. 3 sets of 10 bicep curls with a dumbbell equivalent to 10% of my body weight?
Your help is much appreciated.
Thank you,
Ben
Repetitions tend to be higher than they were when coming back from an injury. 20% intensity, but be wary of the volume. You’re likely only going to be doing max 3-5 sets or less for the injured body part when coming back since overloading is an issue.
For OAC work you’re going to go back to a less intense version of pulling whether it be regular pullups with some slower eccentrics, or rowing variations, etc. and then work back up to OAC over the course of maybe next month or two. Biceps curls are fine too if pullups are too intense.
And with OAC it’s not a 100% biceps curl so you’ll have to modulate accordingly. OAC if you’re 150 lbs, for example, means you’ll probably be able to curl maybe half of that. So 20% = 15 lbs so you’re looking at 10-15 lbs with concentrics or eccentrics to start.
Hi,
I’ve not had golfers elbow for 13 months. I’ve had physio and steroid injections from my doctor (three now) and still no let up. I’ve been icing (which makes it worse), heating and stretching the muscles. I massage every day using heat rather than anti inflammatries. The physio has told me to do all of this to try and clean out the tendon using the heat source.
My forearm has been like a steel pipe, it’s so tight. The stretching has helped ease the muscles.
Physio hasn’t helped much at all and has cost me over £300 so far.
I use to do lots of weight lifting, which caused the problem but haven’t done this now for 8 months. I do no lifting or strenuous activities on my arms any longer.
Have you got any advice? I’m only 26 and not being able to use my right arm is getting silly. I can’t even pass a newspaper over the desk at work without being in pain. I have given up weight lifting which I enjoyed massively, and which kept me in good condition.
Could it be diet or something I’m lacking? I’m not overweight (probably under weight now) and have a good diet. I’m fit in general but have had injuries which limit my exercises and movement slightly.
Any help or advice would be amazing
Finding an ART, graston, or rolfer would be a good idea. Graston is pretty intense, but it should help get in there very quick (albeit can be painful) if you want faster results.
Your current problem seems to be the fact that the muscles are perpetually super tight. When this happens it keeps a lot of strain on the tendon and doesn’t allow it to get any rest (which is where the nutrients help go in). This would be akin to making you exercise and leaving you without food… of course you would collapse and be hungry all the time.
If ice doesn’t help then forget that. The major thing you want to do is focus on loosening up the muscle… don’t bother with the tendon at this point. Use your heat on the tendon (as that will feel good), but the other majority of the heat should be going onto the tight forearm muscles.
Likewise, the massage and stretching should be aimed at lengthening the muscle. If it’s super tight then maybe 20s is not enough if you’re not getting noticable length changes to the muscle. Likewise, same with the massage… if it’s the muscles are not loosening up maybe you’re going too soft or too hard. Very difficult to tell which is why I suggest you see an ART/graston/rolfer because they tend to have much more experience with soft tissue work than common people.
Eccentrics would likely help, but it’s pretty hard if the muscles are pretty tight at this point. You can try them though.
The first thing is to get the tension off the tissues otherwise they will never be able to heal.
Thanks for your advice, that’s really helpful and something I will look into further.
I had physio again yesterday and he said the muscles aren’t as tight as in previous weeks so there seems to be some progression. HOWEVER, still no let up at all. I have the elbow taped up at the moment but nothing is giving in. I still have pain and discomfort throughout the day.
I’m worried this is going to be a long term issue, or even something that will bother me for the rest of my life (I am 26yrs as I mentioned).
If the muscles seem to be easing somewhat, why the pain still? I’ve had tendonitis in my knees since I was 17 and never been able to heal this. Could it be that my body is lacking in protein or some vitamin?
Thanks again for your help……it’s great to know people are out there to chat with.
Well, generally, if it is a chronic tendonitis which it sounds like it will tend to feel a bit better during exercise, but outside of exercise especially periods of inactivity it will hurt and feel stiff.
If that’s the case then, yeah, you need to be rehabbing it religiously but it’s a fine line between that and not doing enough or too much rehab. Hopefully your PT is good with that. If you’ve had it for longer than a year the rehab is going to take likely at least 2-3 months at the minimum because there’s going to be multiple issues to sort out.
If you feel like PT is doing nothing then talk to some others. With chronic you need to be doing eccentric exercises or some of the other things I indicated in the above article that are for chronic tendonitis that research shows support that (nitric oxide patches, prolotherapy, ABI, PRP). If your PT isn’t emphasizing those then you may want to try something else.
Steve,
Thank you so much for this informative thread. I was diagnosed with Tennis elbow about 3 months ago, after 8 weeks of PT I was able to shake it. If I overuse the muscle I still have pain so I’m not using it much right now. I’m an office worker so I’m constantly at the keyboard. Unfortunately, I’ve developed severe pain on the underside of my arms. My doc says its from the lack of flexibility in my wrist flexors. I’ve started to develop GE.
Because I have to continue to work do you recommend the heat and stretching route? I’ve just steered to your chronic tendonisis treatment as a route to get better.
Heat 3 times a day, stretch 3 times a day and light weights.
Couple of questions for you.
1 – Can I get better while working? Or do you recommend time off?
2 – Can you briefly explain ART?
3 – Also my PT is a big believer in massage – would you recommend another visit for the wrist tendonits/GE?
4- How would I know when I’m completely stretched if I did recover?
Thanks much!
1. If you’re not aggravating it (e.g. painful) sure you can definitely rehab and work at the same time. If it’s aggravating it to work then well you have a problem…
2. ART is active release technique based on hitting trigger points and releasing them. You can google this for more information.
3. I am a big believer in massage as well. If the PT is helping then it would be a good idea to continue. If it’s not then tell your PT, and if he/she is good then they should be able to try other things.
4. I don’t understand this question? Are you tryin to equate stretching with recovery?
Keyboard posture irritated ulnar nerve, pronator teres and quadratus, and the rest of the flexors pretty easily. I would definitely do more mobility work in both pronation and supination. Especially in supination. You should see some good loosening of pronator teres or ulnar nerve irritation/impingement with that.
Nerve glides might help as well.
Unfortunately its quite painful when I work. Not good news.
Sorry if I wasn’t clear on part 4. Assume that my doctor is right and all I need is to loosen my wrist and forearm flexors. How would I know when I’ve accomplished that? I assume there is a different timetable for everyone…
Thanks again for your insights, they’ve been quite helpful.
Do you remember back to the Olympics when you saw the swimmers warming up for their events? They would shake their muscles and they would be loose and pretty pliable. That’s how your muscle tissue should be at all times when you’re not using it in a contraction.
If you palpate your muscle tissue and it’s tight, painful, and it doesn’t move well when you massage it then that is what you want to focus on correcting. Stretching will help in the fact that by lengthening the muscle it helps reduce the tension (which can be one of the causes of tendonitis), but you also need to loosen it up with massage and other types of work possibly to make it so that it is loose and pliable again.
When there’s (1) no pain through full range of motion and (2) you can exercise like you want to, and (3) your tissue is loose and pliable like I was talking about then you’re “fully healed.”
That make sense?
Hope that helps.
Steve,
This thread has been a life saver, I’ve started to do your recommended workout for chronic tendonitis and this is the most flexible my wrist flexors have felt in months. My routine is as follows.
Morning (pre-work)
-Heat
-Massage 5-10 mins
-Light stretching
Lunch
-Heat
-Massage 5-10 mins
-Light stretching
Home (post-work)
-1 set of 25-30 reps of wrist suppination (3lb weight)
-25 – 30 mins of cardio on a bike
-Medium pressure massage
-Light stretching
-Heat
-Light massage
Again this is the best my forearm flexors have felt in months.
I do have one concern though, my arm rest at work allows me to only put half my forearm on the rest. Therefore, it seems to be concentrating all the pressure onto a small area. I’m looking into getting an ergo chair with a flat arm rest. In the meantime I’m having a real hard time putting any weight on my forearm. Is this normal as I work thru the tendonitis? Or is this more of a nerve issue?
Thanks again! Things are lookin up for the first time in awhile!
Yes.
It wouldn’t be a bad idea to take some time off from massage or a couple rest days once in a while to let the muscles heal up.
Massage and stretching are like exercise — they can tear up the muscle.
So if you’re having some pressure issues by putting weight on the muscles it may not be a bad idea to take the rest days and see if it comes back better and healed more.
Remember, rest is when your muscles et al are actually recovering. Therapeutic stuff is important, but it’s still the same as working out… you recover when you rest.
Great information. Found your site through a thread about wrist injuries.
I’ve been doing research but I’d like to ask your opinion.
Been experiencing wrist pain from grappling/jiu jitsu. The pain is located on the dorsal surface of my wrist where the radiocarpal joint would be located. It is right in the bend of my wrist when it is in extension, as if making a hand signal to stop. It is most painful when I bend my wrist back in extension and apply pressure to my hand. Imagine the position your hands are in when doing push-up. Push-ups hurt! If I do them on my knuckles there is no pain. I can move my hands in any direction with no pain if there is no resistance. Recently there has been some pain associated with gripping things while carrying them.
I feel that with all the gripping that goes on in jiu jitsu that my flexors are tight and my extensors are weak which is aggravating the problem. That is my opinion and I have nothing to back this up and I am by no means qualified. Just a guy obsessively researching his ailments on the web. I’ll probably read your article 10 more times to try and figure out what strengthening exercise/stretches to do for my particular problem.
Any advice is appreciated. I feel I should be stretching my flexors and strengthening my extensors but not exactly sure about what exercise and stretches.
Thanks again for what you do. I found the info about NSAIDs really great. I’ve never been a fan of using them for these types of things. Now I know why. I am going to try to incorporate all the aspects you covered in the article.
Well, no pain when not weighted is good. That actually means it’s less likely to be tendonitis.
The fact that it hurts when it’s compressed may mean it’s tendonitis but I would probably think it’s more along the lines of tenosynovitis or just a general impingement issue there with a nerve or something. It’s possible it’s the extensor carpi radialis brevis or longus.. or something else given the area.
First off, has ice helped at all? What about resting?
I wouldn’t be against NSAIDs if it was some type of impingement or tenosynovitis because that is actually likely an area where there may be too much inflammation.
Stretching/massage/etc may help the muscles themselves if they’re tight — if the muscle tissue is fine then this may not be an issue.
It all depends how long it’s been there and how much you’ve aggravated it and/or if it’s gotten worse.
I don’t feel that icing has helped. I haven’t taken much time off since I’d like to compete for the first time in April.
My right wrist has been like this for about 6 months and the left has become the same way within the past month. I wouldn’t say the pain has gotten worse and worse over time, just hasn’t gotten any better.
Since it started I have avoided any activity which causes immediate pain, like push-ups on my palms. Just before my left wrist started to hurt I tested my right wrist by easing into a push-up position and there was no pain. I was surprised but kept off it so I wouldn’t re-aggravate it. A week later they both hurt.
You might wonder how I know they hurt if I avoid such activities. Usually it will be from pushing open a door without thinking about my wrist.
One thing I did differently in the past month is mixing in some boxing and heavy bag work. No immediate pain doing that but it could explain why the left one all of a sudden got bad. Think I’m going to at least cut that out for the time being.
I’m going to start documenting everything I do and if I see significant improvement I’ll post it here.
Ok.
Honestly at this point it would be a really good idea to hit up an orthopedic doc or physical therapist so at least you can get diagnosed with an issue.
I currently have a bunch of guesses as I told you, but if it can be narrowed down to a specific thing they there is specific rehab you can do for that.
Right now if you do the generalist method it may work but at what time commitment cost to your training and health?
Something to think about beyond the “do it yourself” method which can often fail.
Hi Steve,
Heard about this site on APK. Thanks for the great article! Really clear and informative.
I’m pretty sure (like, 99%) now that I have hamstring origin tendinosis. I was hoping I could ask a couple of questions:
1. I’ve looked around a bit for eccentric exercises that would help with treatment and I can only seem to find ones that work for the hamstring proper. Do you think these would be just as good for hamstring origin?
2. I haven’t been doing any exercises that directly aggravate my leg (squats, running, rowing machine, dynamic stretching etc.), but I was wondering if there are others I should be careful with. I’m thinking mostly of deadlifts here. It doesn’t HURT to deadlift, but what with how much it works the posterior chain I’m wondering if it would still be negatively affecting the injury…
Cheers!
– Nick
1. It’s fine to do the knee movement hamstring exercises because it works fine for tendonitis. 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)).
If it was a localized strain then it would be a different story, but it’s not so any type of hamstring eccentric should work fine.
2. You can be on the safer side if you want and thus cut them out. However, anything that doesn’t cause pain is generally a good indicator that it’s not causing much damage as long as you don’t excessively keep doing it.
Hope that helps.
Hi Steve,
I was diagnosed with wrist tendonosis after four months of struggling with it. I’ve been doing exercises and building back strength for the last three months and its been feeling a lot better (there was never any pain, just stiffness and weakness). I’m a young guy (21) and am just hoping this doesn’t end up being a permanent part of my life. At the moment my physiotherapist told me to focus on finger exercises as the wrist itself is back at full strength and this is whats causing the stiffness. How long am I looking at before a complete recovery?
Thanks!
-George
I don’t have enough information to give you an answer. You should probably ask your physical therapist to give you a rough estimate.
Hi, great article. I got an acute case of shoulder tendinitis doing wide-grip/behindtheback pullups about 2.5 weeks ago. I rested it for about 2 weeks, it was feeling ok. Then I stupidly went back into the gym and tried testing it out, and of course the next day it was sore as heck. It got better the next couple days but now I’m left with a dull ache in my shoulder that doesn’t seem to improve much. Additionally, certain movements will cause a “snapping or cracking” sound in my shoulder. I was wondering if this is a case of tendinitis turning into the chronic form? Would re-injuring an acute version of tendinitis be enough to lead to the chronic condition?
Well, your first mistake is BTN anything. I don’t like these types of movements because injury potential is high. Yes, some people can do them without injury, but why use these when there are perfectly other good movements. Anyway, side issue.
If the pain/ache is deep in the shoulder I would get it checked out by an orthopedic doc. It may be labral issues especially if you’re getting any painful snapping or crackling.
If it seems more soft tissue it’s possible it could be tendonitis, but chronic tendonitis if it sticks around that long tends to be be more on the sore-ish achy side and stiff after periods of inactivity. This does not sound like it is the case.
Hence, likely a good idea to get it checked out by an ortho or physical therapist.
Great info Steven, thanks. Unfortunately I don’t have access to an ortho right now so I’m scouring the net trying to find as much info as I can. Yes, going BTN was dumb, I’ve been lifting for 9 years and I know it’s dumb so I don’t know why I decided to do it. As for the cracking, popping, I do get some of that but none of it is too painful, but all the symptoms of all these shoulder injuries seem so similar.
Just a question I would like your opinion on, I know you’re not a doctor but I”m just curious. Would going too wide on straight bar pull-ups leave you more vulnerable to a Labrum tear or impingement of the acromion process?
Also wanted to add that after my injury I tried to do some light rows and felt no pain…but when i tried straight-arm pull downs I felt pain on the way up (as the shoulder raises against resistance), which is why I think it might be impingement.
Yes, going wide increases the propensity for impingement.
Since going “wide” pulls the humerus away from the scapula the rotator cuff is forced into double duty to help hold the humeral head in the socket AND because it normally helps keep the humerus from impacting up in the acromion. Thus, RC muscles fatigue faster = impingement risk increases as you fatigue overall.
Snapping/crackling if you didn’t have it before tends to indicate that muscle(s) are tight and possibly rubbing against the labrum. Is the snapping/cracking coming from the back/front/upper/lower part of the shoulder in particular? What about tightness of the muscles?
I kinda hesitate to say impingement because typically it just manifests as pain under the acromion and soreness/tightness/painfulness of the tissues directly there and it doesn’t seem to be the case for you although you haven’t actually said where the pain is directly.
You can always check some of the various tests to see if you may have it though:
http://www.fpnotebook.com/ortho/exam/ShldrImpngmntSgns.htm
The pain is actually right beneath the acromion, but it’s a vague pain which is similar to that described by labrum victims. Whether it’s impingement or labrum, I think it’s time to see a specialist, I’m just going to pay out of pocket. I know for a fact that the O’brien’s test hurts like heck though, which is not a good sign. Also, when I do shoulder dislocates with a band, I hear a clunk on the movement forward (like a throwing motion)…again not a good sign as it seems like labrum.
Oh yeah, it’s also directly in the front, no pain in the back, the pain is upper front…but again I can’t press down and feel pain, it seems to be deeper than that.
Okay, yeah, it seems like it could be either biceps tendon or superior labrum.
The main reasoning I see which I see which points to more labrum is that since wide BTN pullups fatigue RC muscles faster the “other” muscle which helps keep the humerus in the socket becomes the biceps tendons. Since the long head connects into the superior labrum that puts you at risk for a labral tear. Then again, impingement can be justified as well as stated above.
Upper front is biceps tendon area but deeper means it may be around that junction where it connects into superior labrum.
I hope you just have impingement though that would be a much better diagnosis since labral tears tend to require surgery. Good luck.
After doing some tests with a partner, i’m 90% sure it’s a labrum issue…yikes. Wow, one set of widegrip pulls and that’s it for me, no more heavy lifting every again. I’m not a bber so I can manage doing cardio and some light cable work the rest of my life, but I’m pretty disappointed. I’m still going to see a specialist, but I think the best thing for me to do right now is start strengthening my rotator cuff and scapula, these are gonna be key in preventing further injury…surgery is not an option and the day-to-day pain isn’t bad. Would you quite the shoulder dislocations even if they’ve stopped clicking or causing pain? If I can do this exercise I think it might be key in strengthening my RC and getting blood to flow into the labrum area.
Oh, and thanks again Steven, this article along with your posts on the crossfit forum have been a big help.
When you have one set doing something terrible to you it’s usually because you had something already wrong in the first place and it was just the straw that broke the camels back.
I would quit anything that’s pain. Labrum tears can be managed in some respects, but if you have day to day pain I mean that’s pretty bad enough that you may want to reconsider surgery if it is actually a labral issue.
Let me know how it goes.
Well I don’t currently have insurance so a surgery is out of the question regardless. Right now the pain is anywhere from a 0-2 on a 10 scale, so it’s quite manageable. Plus, I can still do some cable work with no pain as long as I don’t go back beyond the vertical plane. My back will probably shrink up, I can’t really do any exercises for it. I can basically do bis, tris, chest, legs with cables and dumbells, and that’s better than nothing.
Now if I get insurance and it turns out it’s a type 1 tear, then I’ll definitely consider surgery (no screws). I’ve heard that type 1 tears usually are present due to wear and tear, not acute injuries like mine. Have you heard the same? Im definitely hoping its a type 1 tear, the pain seems to indicate it is minor. I’m also thinking of trying PRP to experiment as well.
Well, yeah, those are the most common so it’s possible it can mostly result from that.
PRP/autologous blood injection/Prolo may be an alternative sure. A lot more research needs to be done, but from what I’ve seen it works for some people.
Hi Steve,
I am a Crossfitter and developed biceps tendonitis in January. After reading your article, I found a chiro who treated me for several weeks with ART. I performed eccentric curls daily and the biceps tendon seemed to heal. I still had lingering pain deep in my arm which the chiro believed was in my pronator. He tried getting to it with ART but admitted that he couldn’t really access the pronator. Even though I still had pain, it did improve quite a bit so I ceased treatment and went back to my normal excercise routine. The pain has continued and I have just dealt with it but now it seems my biceps tendon is once again injured. I guess I’ll try the ART again but I’m not sure what to do to finally get rid of the pain in my pronator. It’s very stiff and painful when I wake up in the morning. Pullups, presses, clean & jerks all cause arm pain (after the exercise not during). I have no idea how to finally make it heal.
I appreciate any advice you can offer.
Well, you probably went back to your exercise routine so fast which is why it’s flaring up again. Injuries you need to be more conservative with working back into more controlled movements at lower volumes and intensities first… and then working back into more explosive/high speed movements.
Which pronator is it? Teres?
I don’t know specific areas or times or during which movements what hurts so I can’t really help you out with this. I’d get yourself to a PT to see if there’s any compensations, movements, or anything else like that which is aggravating that specific area. That would be your best bet.
Tendonitis may be related or may not. Can’t tell.
You’re probably right that I went back to my workouts too fast. I received treatments for about 5 weeks but I went back to my workouts (at lower volumes) after about 2 weeks.
Yes, it is pronator teres that’s bothering me. I’ve assumed that’s also a tendonitis problem because I don’t know what other problems would arise there. The specific movements which cause me problems are pullups, power cleans, thrusters, presses. Pullups on rings for some reason don’t cause me pain. Pushups don’t hurt and the stretch actually seems to help.
I’ll look for a PT as you suggest. Thanks Steve.
Yeah, that’s probably too quick especially with the volumes CF is at.
You should try doing some eccentrics on the pronator or some light stretching if that doesn’t aggravated it. Have you tried ice or heat? Do whatever else more in the meantime.
You can still exercise with exercises that don’t aggravate your injuries.
I’m back to icing 3-5 times a day and doing eccentrics. I’m not sure whether the ice really helps or not. Have not tried heat but will give it a shot.
I’ve excluded arm exercises from my workouts lately. I’ll also try PT and see if that helps.
Thanks again.
No problem. Let me know how it goes.
People, PLEASE be careful about accepting advice as ‘truth’ from sites like this. Though some of the same information is available at other reputable sites, much of the information here is plain false. example of statement from this writer that (who has no scientific or medical credentials, despite dispensing such advice); should set of alarms for you is, “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.” Though laughable, eating cartilage from dead animals will no more strengthen, or give you building blocks for your own bodies connective tissues than eating a orange will cause you to grow a fruit tree from your elbow. The actual building blocks are collagen, and there are even various types of collagen that are “Building blocks” for the various tissues in your body.
Though well intended, this author is miss-guided on many points. Please, please be careful!
I agree no one should take any advice given on the Internet as truth. I always inform readers in my articles that they should consult with medical professionals. Hence why I put this statement in every article dealing with injuries:
“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.”
And actually I would agree with that statement as false having done further research. I will eliminate it. Although you gave a poor analogy; eating cartilage from other animals gives protein which is definitely the building blocks of collagen. Although protein from any source will do that for the most part.
However, given you said much of the information on this article is just plain false can you given any examples backed up with evidence? I am open to changing points if there is further scientific evidence.
Additionally, “(who has no scientific or medical credentials, despite dispensing such advice)” is not really valid. You should assess quality of information on its backings in science and not who is saying it.
I look forward to your further critiques if any.
I do a significant amount of hand balancing. recently I have upped the amount of wrists preparation to try and keep my wrists loose during my sometimes 2 to 3 hour sessions. however, recently I have also noticed that what usually works to get rid of soreness or acheness has not ha ha. so I am laying off any palm down balances and working my parallete training to give my wrist flexion and extension a rest. I was consdering doing forewarm balance as an alternative while my wrists recover do you feel this is a good idea or should I just avoid it all together for a while and work on hanging skills like levers for a bit. thanks for the great article “Francesco”
I would just give your wrists some time off and do mobility work on the side.
If it has really be intense they need a bit of time to recover probably.
Great article! So I have bicep tendonitis in the short head. Should I do eccentric curls or what do you recommend?
Yes, although the short head is relatively harder to isolate.
Hi, I wish to get some advice from you
I have had patellar tendonitis (left knee) for almost like 3 yrs now. It reflects as pain under the bottom lower part of the kneecap. I also feel uncomfortable if I keep my knees bent (like in a sitting posture). I used to play a lot of basketball, but now have not played since past 6-7 months. Within these 3 years i recovered twice and the problem reoccured again this year in April. Since then its troubling me a lot. Also when I straighten my knee there is some amout if friction under the patella. Right now I do most kinds of quad strenthening exercises twice a day. Should I opt for a surgery or trust the quad strengtheing.
Focus on squat eccentrics for control, but if that is too much for the knee you can do just bodyweight eccentric leg extensions (and increase with ankle weights). Aim for 50ish reps per set and 100-200 total repetitions.
Chronic tendinosis is typically characterized by poor strength and lack of control, so the eccentrics will help to remedy that.
Also, focus on improving your ankle and hip strength, especially the glutes and hamstrings to take off some of the pressure from your knees.
Thanks for the advice. I will start working on leg extensions more frequently.
I aim for about a set of 50 half squats. It doesn’t pain while doing the half squats, but the affected area feels tendor and pains on full leg extension after the half squats. Applying ice soothe it down. Should I keep up with the application of ice after half squats or leg extensions or does putting ice in any way hamper the healing process?
If it’s chronic you should use heat albeit it not immediately during or after rehabilitation sessions.
If ice doesn’t help (with the healing) then I wouldn’t use it. It can blunt inflammatory response, which you need for healing. If you need some analgesia then take a non-inflammatory pain medication instead (although you should check with your doctor about that).
Thanks Steven, the bodyweight eccentric leg extensions combined with stretching exercises 4 times a day seem to be helping. Just to be sure, by eccentric squat you imply going down should be slower and coming up?
Could you also comment on what should be the angle till which squats should be done, as was advised a year ago that full squats are bad for knees.
Also, when I attempt the leg extension the grinding sound in the knees is there if I bring up by leg to full extension. Is this by any way harmful? I try to do the leg extentions to maybe a degree or 2 less to prevent the grinding.
Could this be a result of misalignment of the patella?
I also had an MRI about 5 months back which showed about a 5mm tear in the tendon and grad 1 degradation in the cartilage below the patella, if that helps.
Yes, the eccentric should be slower and controlled. Concentric can be whatever you want.
Full squats are good for the knees, but for now you probably don’t need to be doing them because going deeper does indeed put more stress on the knees. Obviously, going deep puts more stress, but that is not necessarily bad if you have no pathology because being able to full squat is a fundamental human movement.
Grinding may or may not be bad. It may signify some chondromalacia or earlier onset potential arthritis. And it may be a result from misalignment or from other factors.
MRI pretty much confirms that. Nothing much you can do about it except sleep, eat well, and exercise well, and minimize your stress levels.
Steve,
So I’ve had patellar tendonitis in both of my knees before, I had hernia surgery and doing nothing for 6 months completely healed both of my knees. Before that though I had a sharp pain in my left tibial tuberosity and I wound up eventually having PRP done. This all happened approximately 2.5 years ago. I’ve been tendonitis free for over a year, up until about a month ago. Right now I am experiencing the same pain in my tibial tuberosity on my right knee. I play volleyball almost every other weekend and this issue only seems to be aggravated after playing volleyball, if I rest for 2 weeks, the pain goes away but comes back after I play again. I squat heavy during the week and the pain doesn’t seem to be there while I’m working out especially after a good warm-up. I’m trying to build up quad and hamstring strength to avoid issues like this, but the pain returns after I play volleyball and I can feel it even while just walking up stairs. I’m going to assume that RICE and perhaps massaging and stretching the muscles around my knee would help, but is there anything else that you would recommend that I do. Any help would be greatly appreciated. Thank you.
Focus on slow bodyweight squat eccentrics for control. Higher reps 30-50 for a couple sets. Concentric can be quick especially if you are squatting heavier weight.
Once you can control that effectively without shaking (you already may be able to), then next progression would be go to on you tip toes and pause for a second and into the half squat landing. You may see that you have poorer control from a position like that.
From there, start flat foot and go onto your tip toes quickly then into a half squat landing.
After that, focus on a small jump and controlled landing.
Practice near the end of your lifting sessions during the week. 2-3 maybe 4 times a week. Advance only when every repetition of every set is good. If it’s too much obviously back off the reps and or sets some.
Basically, we are focusing on building up your control of the landing so that your tendons aren’t being jerked around. The fact that you can still squat heavy seems to be fine, but the fact that volleyball is aggravating your injury seems to suggest that you are having some trouble controlling your landings properly. Hence, my suggestions above.
Hi Steve
Thanks for the useful article. There seems to be very little advise out there for tendinosis, as opposed to tendinitis.
I’ve had tricep tendinosis for 8months. I’m just 31years, and have basically hammered my body since day-dot. Have followed all the advise and backed off everything, but at this point whilst the agony has subsided I cant seem to get rid of what i can only describe as an irritation in the tendon (which makes me want to massage it vigourously (which i probably shouldnt do!) I’m starting to wonder if its actually the muscle wastage that is causing this feeling as I havent undergone a systematic programme of eccentric strengthening as yet, and feel as though all the rest should have reached its optimum by now. I do do yoga which helps flexibility.
can you offer any advice please?
thanks
So, what type of movements hurt and what portion of the movement?
Also, is it more of the middle of the triceps tendon, insertion, or muscle belly part?
Also, what is the quality if your triceps muscle? Does it have lots of muscle knots, or is it soft and pliable, or what? How is the total mobility?
Muscle wasting won’t cause tendinosis, but tendinosis can cause muscle wasting if that’s what you’re asking. Especially if there is significant pain.
Eccentrics, heat and mobility work would probably be a good place to start if rest isn’t helping.
Thanks so much for writing this article, its so well written.
I had a mountain bike crash a year ago which caused me sharp pain in the top of the right shoulder. I had full ROM, but a throwing action was very painful. The pain has been persistent, but becoming duller.
Last October I finished a 50km race and immediately felt an increase in pain and weakness in the bicep. Driving home was quite painful when raising the arm to the top of the steering wheel.
On getting home I noticed my bicep was very weak indeed and turning my arm palm up can be very painful. There is a lot of pain in the front of my shoulder. I’ve seen a couple of orthopedic surgeons who say its probably either impingement, RC injury of Labrum tear. From what I read, it seems to be more like bicep tendinosis.
I had one shot of cortisone to the front of the shoulder (not the tendon) 4 days ago which seems to have reduced the pain somewhat, but the pain and weakness are still there.
I do worry that if I have impingement, it may eventually wear the tendon and cause it to fail.
Are these typical tendonosis symptoms? What advice can you offer.
Many thanks in advance.
Well, any kind of chronic degeneration can eventually cause tendons to fail. So regardless of whether it’s say impingement, or tendinosis, or any type of chronic aggravation to the issues there is a potential risk for tearing as time goes on.
If the issue is more on the anterior of the shoulder and aggravating with pulling work that does sound like it could be tendinosis.
If, however, it’s underneath the acromion it could be both tendinosis and impingement (or one or the other — and yes, it can be both as inflammation there can cause tendonitis to compress structures and cause impingement).
Typically, if it’s more deep in the shoulder it could be a SLAP or labral issue.
That’s pretty odd that the orthos didn’t really figure it out though.. I guess it was an informal diagnosis?
If you have the money, I’d probably go the conversative route. Find a PT who works with athletes and get them to see if that can help you out (and it will if it’s a biceps tendon or impingement issue). SLAP/labral issues depending on what they are may need stronger intervention.