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This is What CAUSES and WORSENS Tendonitis

Everyone thinks their tendons hurt because of inflammation. But they’re all wrong. Here’s the truth. A lot of painful conditions like achilles tendonitis, patellar tendonitis, lateral epicondylitis, and rotator cuff tendonitis actually have very little to no inflammation. They’re actually caused by chronic repetitive microtrauma and tendon degeneration. I’m going to tell you how to treat your tendons to remove pain, restore function, and allow you to take back control of your life.

The better name for all of these common tendon disorders is tendinopathy. And the reason for this is because when we look at these tendon problems under a microscope, we don’t see an inflammatory process.

This review article writes that histological examination of tendinopathy shows disordered, haphazard healing with an absence of inflammatory cells, a poor healing response, noninflammatory intratendinous collagen degeneration, fiber disorientation and thinning. Frank inflammatory lesions and granulation tissue are infrequent.

So what we are learning from tendon disorders is that the pain comes from mechanical and structural problems, NOT inflammation. And this makes sense. When you have a chronically degenerated tendon, it doesn’t transmit forces well. And this abnormal transfer of force leads to pain.

And so now we need to ask the question, how did it get degenerated? For a lot of people, the reason is obvious. Athletes, weekend warriors, painters, construction workers, cleaners. All of these people do something that requires significant physical effort and this puts them at risk for repetitive stress injuries.

But what about everyone else? Why do some people who don’t do any repetitive motions, who don’t play any sports, who don’t put a lot of stress through their bodies – how do they get chronically degenerated tendons?

Clinical studies such as this one are finding that people with metabolic syndrome are at incredibly high risk of tendon problems. Metabolic syndrome is defined as having three of the following: 1) excessive abdominal fat 2) insulin resistance or impaired glucose tolerance 3) high blood pressure 4) abnormal lipid or fat levels and 5) elevated fasting blood sugar.

The authors report that those with metabolic syndrome had about 2.5 times higher risk of tendon problems. Those with elevated hemoglobin a1c, which is a marker for prediabetes and diabetes, had a 3 times higher risk. And those with high cholesterol had a 1.5 times higher risk.

In fact, poor metabolic health also affects how we recover from tendon disorders. This study compared the clinical outcomes of an exercise program for achilles tendinopathy in patients with or without metabolic syndrome. They found that people WITH metabolic syndrome had lower satisfaction ratings and needed MORE pain medications. They concluded that exercise programs were less effective in patients with metabolic syndrome and suggested that these patients need to be managed with a combination of other treatment modalities, specifically targeting their metabolic health.

We see this same effect in other tendon pathologies. This study compared the efficacy of corticosteroid injections in treating trigger finger in patients with and without metabolic syndrome. They found that those with metabolic syndrome had worse functional outcomes and higher treatment failure compared to those who did not.

Now, there are a few explanations for how and why metabolic syndrome affects tendon disorders. First, increased abdominal weight leads to an increase in force on load bearing tendons. This will then lead to increased wear and tear. This partially explains patellar tendon problems and achilles tendon problems, but it doesn’t provide a good explanation for non weight bearing tendons like the elbow or the shoulder.

So, how do we explain that? Well, systemic inflammatory markers caused by excess fat tissues and high blood sugar cause low grade whole body inflammation. Both of these amplify the negative effects of tendon overuse. In addition, deposit of fat and cholesterol byproducts into tendon tissues weaken the tendon leading to poor mechanical strength and impaired tendon healing. Combine all of this together and you have the makings of a chronically degenerated tendon.

So I hope it’s abundantly clear that tendon disorders are as much a metabolic problem as they are a repetitive overuse problem. And that’s why when we talk about treating tendon disorders and tendinopathies, there are two main arms of treatment. The first arm is rehabilitation. The second arm is nutrition and physical activity.

So let’s talk about rehabilitation first. The cornerstone of tendinopathy rehabilitation is centered around mechanotherapy. The theory is that by carefully applying controlled and progressive mechanical forces to a tendon, typically in the form of exercise, the body can initiate a cellular response that helps with tissue repair, tissue remodeling, and tissue adaptation. All of this with the goal of restoring the tendon’s structural and functional properties. This is why a lot of rehabilitation programs involve exercises such as isometric exercise, eccentric exercise, concentric exercise, heavy slow resistance training, and stretching and mobility work. You can find sample rehabilitation programs on my website which I will link in the descriptions.

Most rehabilitation programs should be done three to four times a week for anywhere between four to eight weeks. Make sure to allow for at least a day of rest in between sessions. It’s also important to note that the exercises may lead to some worsening of the pain initially. I usually tell my patients a pain level of around three or maybe four out of ten is acceptable. If the pain is severe or continues to increase, then you need to reduce the intensity or frequency of the exercises. And of course, if you have questions, you need to consult with your healthcare provider.

Ok, so how can you take back control of your metabolic health? First, focus on your diet. Minimize the consumption of processed and fried foods. These types of foods have been associated with triggering inflammation and increasing oxidative stress. These foods skyrocket your risk for metabolic disorders, insulin resistance, and cardiovascular disease. The same is true of refined carbohydrates and sugary foods. These too are notorious for contributing to overall inflammation and destroying your metabolic health.

Instead, focus on eating an anti-inflammatory diet. This means filling your plate with foods that have been shown to reduce inflammation and improve your metabolism. Fruits and vegetables are packed with antioxidants, vitamins, and minerals that can help combat inflammation and improve insulin sensitivity.

Lean proteins such as chicken and fish or plant based proteins such as nuts, seeds, legumes, and soy are excellent choices. Healthy fats such as those found in avocados, olive oil, and fatty fish are also beneficial. These contain omega-3 fatty acids which have anti-inflammatory properties and improve your metabolic health.

And don’t forget about exercise. Exercise comes in two flavors. The first is aerobic exercise such as daily walking. Walking has benefits to all cause mortality, cardiovascular disease, mental health, cognitive function, immune function, weight loss, and more. Other excellent forms of low impact aerobic exercise include cycling, swimming, elliptical training, and rowing. Aim for at least 30 minutes every day of aerobic exercise.

The second flavor of exercise is strength training. This helps increase muscle mass, improve insulin sensitivity, enhance resting energy expenditure, promote fat loss, and induce positive metabolic adaptations. Aim to do strength training at least three times a week and include both upper and lower body training. Just be sure to modify your workouts so you don’t aggravate the tendon that is being rehabilitated.

The key thing to understand here is that tendon disorders are as much a metabolic disease as they are a chronic repetitive stress injury. To truly recover from this, we need to address both the tendon structure through rehabilitation exercises as well as the metabolic component through nutrition and exercise.


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