Persistent pain is a tricky thing.
I’ve personally experienced it at many points throughout my life. It started with pain in the front of my left shoulder, then both shoulders, then my knees, and then my back, my neck, and so on. Being a kid who’s main sports were martial arts and the gym, I never really had any major traumatic injuries, but I’ve had tons of overuse injuries, so I’m quite familiar with Tendonitis.
What even IS tendonitis? How is it different from Tendonopathy? What’s Tendonosis? Do I even have Tendonitis?
Let’s start by defining what a tendon is and how it’s different from a ligament.
A tendon is what attaches muscle to bone. Muscles help us move by pulling on our bones through our tendons.
A ligament is similar except there is no muscle involved–it attaches bone to bone. Today’s article won’t be talking about ligaments, but I wanted to get that out of the way so that we could all be on the same page.
When you exercise, you temporarily make yourself weaker.
How do you know this to be true? Try doing the workout again right after you finished it. Let me know how that goes.
After making yourself weaker, your body undergoes a process called Supercompensation where it makes itself slightly stronger than it was before.
This process takes about 24-72 hours depending on how hard you worked out. Keep working out and recovering regularly and this is how you get stronger!
Okay so what does this have to do with tendonitis Jordan?
I’m getting to it!
If the training stimulus is too strong too acutely and you weren’t adapted to it, or you don’t give yourself enough time/sleep/nutrition to recover, you can start “Undercompensating” causing your body to become weaker.
One place where your body can become weaker is the attachment between your muscles and your bones: The Tendon.
With too strong a stimulus (like a huge crossfit workout after not going to the gym for a year), or not enough time to heal (going to the gym 6 days in a row when you haven’t been in a while) your tendon may become irritated and inflamed which causes you pain (not to be confused with Delayed Onset Muscle Soreness–D.O.M.S.). If you manage this appropriately by:
Taking a couple (2-3) days off training and do light physical activity
Backing off on training volume/load/intensity for a couple weeks (start with ~50%)
Reloading your training appropriately (5-10% per week)
You can make the problem go away.
This… rarely happens. Why? Well because of something you and I both have: an Ego.
Because of this stupid sense of self importance, we decide “NO PAIN NO GAIN” and to push through because reducing our training means getting weaker and softer… and we can't be having that can we?
After this happens to you a few times, you may mature in your training and learn to back off for a bit when this happens so you don’t turn your Tendonitis into a Tendinopathy. But to be completely honest, it has to happen to you a few times before you learn to be smarter. It’s part of the process and it’s totally okay.
What is Tendinopathy/Tendinosis?
“Tendinopathy is a failed healing response of the tendon, with haphazard proliferation of tenocytes, intracellular abnormalities in tenocytes, disruption of collagen fibers, and a subsequent increase in noncollagenous matrix. The term tendinopathy is a generic descriptor of the clinical conditions ( both pain and pathological characteristics) associated with overuse in and around tendons.” 
Long, boring story short: Your collagen fibers don’t have time to heal properly so you just stuff them together like wet noodles (see above) and patch it up with glue and tape and hope it holds. Nerves and arteries start to grow and the area becomes chronically more sensitive.
How do we fix it?
Pretty much the same way as tendonitis but the process can take much longer. We need to stimulate the tendon to break down and rebuild itself. This can take many months, even up to a year or more.
Okay Jordan, but this article is titled “When Tendonitis isn’t Tendonitis”
So now that you understand what Tendonitis/Tendinopathy is, it makes it easier to understand what it isn’t.
Tendon(itis/opathy) is a condition of the Tendon. A contractile tissue that is only used when you flex your muscles.
So it should only be caused by high intensity exercise, overuse, and lack of rest. It should only hurt when you contract or stretch it. It should hurt in a specific spot and way you can point to and easily explain.It should respond to changes in training stimulus and go away in a couple weeks to months.
It shouldn’t be caused by office work or sedentarism. It shouldn’t be caused by seemingly “nothing”. It shouldn’t hurt more at night. It shouldn’t hurt more after you workout if it didn’t hurt while working out. It shouldn’t spread. It shouldn’t be hard to pinpoint. It shouldn’t move up and down or left and right. It shouldn’t hurt more cause you sat or stood for a while. It shouldn’t linger for months to years.
How do you know when your tendonitis isn’t tendonitis?
Here’s a checklist that may help you:
There wasn’t a clear cause
The pain is related to using the muscle, but also seems random
The pain is difficult to pinpoint and sometimes changes spots or sides
The pain is on both sides (both knees, both elbows for example)
The pain seems to have a mind of its own
The pain has persisted for a long time (over 2 months)
The pain feels better after a massage, but worse later
The pain did not respond to taking a few days off exercise and icing it
The pain seems to change based on what position you’re in
The pain is worse after being in the same position all day, even though you didn’t really use the muscle (office work, road trip, plane ride, etc.)
The pain is worse at night or when you’re not doing anything
This isn’t an exhaustive list, but if you are checking a few items on this list, chances are you are dealing with a sensitized nervous system, not a tendonitis.
Great, now I’m more confused. Do I have a neurological condition now?
I see Nerve Sensitivities very often in my clinic. There are many possible explanations and mechanisms that explain nerve sensitivities, but we don’t have any conclusive theories that have been proven yet.
The one that makes the most sense to me goes something like this:
Take your elbow and keep it bent.
Now do that for 8 hours a day every day for a week
Now try telling me your elbow doesn’t hurt.
It would, right?
Well you’re doing the same thing to your spine, the most mobile structure of your body. Keeping it in the same position all day is irritating. Remember the last very long car ride or plane ride you took? That feeling of just wanting to get up and move? Well your spine needs to move, but we distract ourselves with work and life.
The difference between the elbow and the spine, is the spine joints where a lot of the movement happens are right next to the Nerve Roots that exit your spinal cord to become nerves.
So if the joints are irritated from being in the same position all the time, it seems logical they could irritate the nerve roots. This causes an irritation of your “alarm system” and can make your alarms go off a lot easier (think fire alarm in the kitchen going off cause you’re steaming veggies when you only want it to go off when there’s an actual fire).
So are you saying my pain isn’t real?
Not at all! Pain is your body perceiving a threat. In this case your body is absolutely perceiving a threat. But it's because it's too sensitive.
So how to we fix it?
There are many ways to fix these “Tendindopathies that are actually nerve sensitivities”. But my favorite is through the use of Mechanical Diagnosis Therapy.
To keep things short, we try to find a repetitive often spinal–or sometimes another join–movement you can do that
Decreases your pain
Makes you stronger or more mobile
Centralizes your pain
Centralization of your pain means the pain moves up the limb towards the spine. So say your elbow was hurting, and now your shoulder hurts, that’s centralization. Or if your knee was hurting but now your butt hurts, that’s also centralization.
But before you do, I’m going to give you the most LIKELY repetitive movement that will help most people.
If this persistent “tendonitis” has been in your back, hip, butt, groin, leg or foot try Repetitive Cobras:
If this persistent “tendonitis” has been in your neck, shoulder, arm, elbow, or hand try Repetitive Neck Tuck & Extend:
Try 10 reps every couple hours for a week.
If you notice decreased pain, increased strength/mobility or centralization of your pain, awesome!
If nothing happened even though you were diligent, don’t be discouraged! This wasn’t a prescribed exercise for your condition, it’s just the most common one I end up prescribing. There are tons of others to choose from, so don’t hesitate to book an appointment with me to figure out yours!
If your pain got worse or even peripheralized (moved down your arm/leg) then great! That means your pain definitely responds to repetitive movements, but the one I gave you is irritating you more, and we need to give you a different one. Click here to find out how!
If you’ve been struggling with pain that has kept you from training and performing to your fullest, don’t hesitate to reach out. I spend my entire day, every day, getting people out of pain and back to the sports/hobbies they love!
Jordan Octeau is a Physical Therapist & Strength Coach located in the West Island of Montreal Quebec. He has almost a decade of experience in the strength and conditioning field and has helped countless barbell athletes get out of pain and back into the gym.