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“But my pain goes away when I exercise?” All About Tendinosis

“But my pain goes away when I exercise?” All About Tendinosis Barefoot Rehabilitation Clinic
Tendinosis

13 Oct “But my pain goes away when I exercise?” All About Tendinosis

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The worst kind of problem is the one that doesn’t look like a problem (like tendinosis).

It makes you pause, observe for a second, before moving on.

Kind of like the tip of an iceberg.

problem-underneath-the-surface

Example #1: If the staff on the Titanic knew that those iceberg tips meant a massive icecube was underneath the surface, we wouldn’t have this…https://www.today.com/popculture/leonardo-dicaprio-kate-winslet-quote-titanic-each-other-we-can-t115526

Example #2: I was miserable in college, so I drank vodka straight by the cup. During a few semesters, I blacked out or peed on my computer as much as three times per week.  When I sobered up, the torment came back, so I drank more. Until it occurred to me that I couldn’t drink beer 24/7 and my emotional pain was only getting worse. Then, when it was really bad, I decided to change my thoughts.

Example #3: There’s a reason why home inspectors inspect your home. It’s to tell you where there’s a risk of problems happening. When our fire inspector told me that our grill was too close to the house, I remember thinking:

The grill has a top for a reason and looks comfortable where it is.

Until our little, rambunctious, Sweet Pea decided to lick the grease tray under the grill while I was grilling. When she burnt her nose and knocked over the tray, the whole BBQ went up in flames.

This is Sweet Pea diving through the mud.

sweet-pea

Luckily, we had a fire extinguisher nearby and our home still stands.

When the fire is in your body, it’s way more dangerous.

“But my pain goes away when I exercise?”

This conversation happens way too often in our office at Barefoot Rehab or even outside of the office.

Either because you:

  • Run into me at a dinner party and want to tell me about your minor, weird ache you hardly feel, like sitting or getting up from bed in the morning.
  • Are a patient in my office and I have to tell you to stop exercising because your pain is getting worse.

Talking about this so often made me wonder, why do so many people let the pain grow until the problem is much harder to fix?

I’ve realized two things:

  1. You don’t realize you’re doing more harm. Because the pain goes away during exercise, you don’t realize you’re increasing the pain after exercise and increasing the size of the problem.
  2. You really like working out. In fact, exercise is your only form of stress management.

The purpose of this post is to help you understand why it’s so dangerous to continue working out, especially when you have pain in one of the specific locations we’ll discuss below.

There’s one word you need to learn about: Tendinosis.

Not tendinitis.  Tendinosis.

Tendinitis is an:

  • acute (happened between 1 hour to 14 days ago) form of …
  • overload (doing too much) …
  • that resulted in inflammation (usually in the form of pain, swelling, or redness).

If there are no other problems and you take stress off of your injury, tendinitis can go away on it’s own.

Tendinosis is a:

  • chronic (has been happening over years) form of …
  • overload (doing too much) …
  • that is resulting in degeneration of the tendon.

A healthy tendon looks like the window in a box of spaghetti. Notice all of the fibers are going straight up and down.

spaghetti-healthy-tendon

A tendon with tendinosis looks like you poured the spaghetti out on the ground. “Degenerated fascia” is another word for tendinosis.

spaghetti-tendinosis

If your pain is in a tendon AND goes away when you exercise, you know, with 100% certainty, that you have tendinosis.

Is Your Pain Here?

The hallmark symptoms of having tendinosis are the:

  • pain that goes away during exercise in the early Phases of Pain, combined with …
  • the location of your pain.

If your pain is in any of the following locations, then you have tendinosis.

Tendinosis

Keep reading to see which tendon is located at these locations.

Then, you’ll see flexibility tests to determine how damaged the muscles around the tendon are.

Why is Tendinosis So Bad?

There’s a famous surgeon named Robert Nirschl who came up with the Phases of Pain for tendinosis.  His specialty was operating on elbow tendons.

Nirschl’s Pain Phases tells you how bad the tendon is based on when you feel the pain, letting you know how far your tendon has been damaged.

Below are Nirschl’s Pain Phases for Tendinosis:

  • Phase 1: Mild pain after exercise, resolves within 24 hours.
  • Phase 2: Pain after exercise, exceeds 48 hours, resolves with warm-up.
  • Phase 3: Pain with exercise that does not alter activity.

Notice, the first three phases above allow you to continue exercising.

Continuing to exercise (or use) a degenerated tendon only moves the Pain Phases in one, obvious direction.

How Tendinosis Gets Worse

Another 100% certainty, besides knowing  tendinosis is the problem you have, is that continuing to use a degenerated tendon will make it worse.

Hopefully, it’s obvious to you that a degenerated tendon that has been present for months to years won’t get better on its own.

The last four phases of Nirschl’s Pain Phases are:

  • Phase 4: Pain with exercise that does alter activity.
  • Phase 5: Pain caused by heavy activities of daily living.
  • Phase 6: Intermittent pain at rest that does not disturb sleep, and pain caused by light activities of daily living.
  • Phase 7: Constant rest pain and pain that disturbs sleep.
  • Pain phases 5, 6, and 7 indicate increasing percentages of permanent tendon damage.

Typically, surgery happens at Phases 5-7.

The cool part of these phases is that as your pain worsens after exercise, when you see me at that dinner party and we talk about tendinosis, I can give you a really healthy dose of perspective.

A doctor like me can say, objectively:

You were at Phase 1-2 of tendinosis.  Now, you can see you’re at Phase 3-4.  If you continue exercising, you’ll enter Phases 5-7 where the only potential solution is surgery with all of its risk.  You’re on a path towards greater damage.  How far do you want to take this?

Since tendinosis is such an easy diagnosis to make when you understand what it looks like, you’ll believe me and respect your body more than you’ve been doing in the fast.

Hopefully, you’ll want to fix your tendinosis.

How to Fix Tendinosis

Fixing tendinosis does not mean getting a treatment so you’re pain-free for a few days, then having the pain come back again.

If you don’t take all of the necessary steps, you’ll never be able to do what you want to do with that tendon again.

Fixing tendinosis means doing everything you need to do to get better, removing all of the problems contributing to your diagnosis. It means becoming pain-free, for the rest of your life.

Think of your diagnosis like a puzzle. In order to win the game, you need all of the pieces to your puzzle. Miss a piece and you can never win.

Here are the most common pieces of the Tendinosis puzzle:

  1. Overload – You have been doing more than this tendon can handle for a long time now.
  2. Adhesion – If your range of motion is restricted, you have relevant adhesion.
  3. Degenerated (and Granulation) Tissue – “Granulation” is a fancy word for “not-healing.”
  4. Weakness – If you were strong enough in the first place, your tendon wouldn’t have weakened.

You need to know right now that the healing path is not going to be as short as other patients.  It can take months, or even years, depending on how far you’ve damaged the area.  However, you really have no choice.  The other option you’d be choosing is an inevitable tear and surgery.  And no surgery is 100% effective.

To speeden your healing as much as possible, you need to pay particular attention to one puzzle piece.

By far, the puzzle piece that prevents someone with tendinosis from healing as quickly as he/she would like is Puzzle Piece #1 – Overload.

You must rest.

With all of pieces in front of us, we can look at all of the locations where tendinosis occurs.

Does the pain in your Achilles tendon or plantar fascia go away when you exercise?

Easily, the two most evil locations to have tendinosis are in the Achilles tendon and plantar fascia.

achilles-tendinosis

97% of Achilles tendon ruptures occur to tendons with tendinosis first (Source). Isn’t that an amazing statistic?

achilles-tendon-ruptures

 

plantar-fasciosis

They’re both really evil because as a human being, when you’re not sitting or lying down, you’re on your feet.

And when you’re on your feet, you’re putting more stress (remember when load exceeds capacity, you don’t heal) on these body parts.

I wrote about why your pain isn’t achilles tendinitis or plantar fasciitis and why conventional treatments often fail both of those problems.

You can see how bad your achilles tendon or plantar fascia are with the Knee to Wall Test. You need 6″ of flexibility. The more restricted both of these tests are, the more relevant adhesion is to your tendinosis.knee-to-wall-test You should also be able to kneel with your butt on your heels. If you can’t there could be adhesion in your knee or the front of your shin/ankle.  There could also be arthritis in your knee or ankle. A reputable pain doctor can help you figure out which one is your problem. kneeling-heel-to-butt-test

Does the pain in your patellar tendon go away when you exercise?

The patellar tendon is right underneath your knee cap.

Your knee joint is deep to the patellar tendon. This is one location where you need to be really picky about how superficial or deep your pain is.

If your pain is between my fingers below, it’s safe to say you have tendinosis. Degenerated tendons that are overused will be tender to the touch.

patellar-tendinosis

But if the patellar tendon is not tender and your pain feels deeper, then you probably have osteoarthritis. This is more common in people over 50 years of age. Osteoarthritis is a type of pain that will also go away with exercise.

If you do have tendinosis, see how bad your patellar tendon is with the Face-Up Heel-to-Butt Test. Your heel should touch your butt. The more restricted it is, the more relevant adhesion is to your tendinosis. Or, if you’ve ever damaged your knee and you have pain behind your knee or in your calf, then you may have Wallet-in-Door Syndrome. The greater the restriction in this test and the older you are, the more likely your pain is caused by osteoarthritis.

face-up-laying-heel-to-buttIf you pass the Face-Up version of the Heel-to-Butt-Test, then you can continue testing and find out of your quads have adhesion in them, contributing to your patellar tendinosis.

Do the Face-Down Heel-to-Butt Test. This test will be more sensitive for the patellar tendon and quads, assuming you’re younger and/or don’t have osteoarthritis. You’ll need a friend to help you keep your heel on your butt (see the right hand below) while lifting your knee 3″ off the table (see the left hand below).

face-down-heel-to-butt-test-pass-with-hip-extension

Does the pain in your elbow go away when you exercise?

Elbow pain is common with people who work with their hands or who type all day.

Conventionally, pain on the inside of the elbow is called “Golfer’s Elbow.” This is diagnosis is not specific enough to get out of pain.

elbow-flexor-tendinosis

Conventionally, pain on the outside of the elbow is called “Tennis Elbow.” This diagnosis is also not specific enough to get out of pain.

extensor-tendinosis

See how bad your elbow pain is Wrist and Finger Extension Test. Your fingers need to get to 7:00 to pass.

passing-wrist-extension-wrist

Unfortunately, the human body was made in a way that there is no way to test flexibility for the muscles attaching to the extensor tendon. You’ll need a reputable pain doctor to feel the muscles to see if there is adhesion present in the back of your forearm.

Does the pain in your shoulder go away when you exercise?

Pain in the shoulder can pop up anywhere.

If it’s in the back of the shoulder and it goes away during exercise, it’s probably the infraspinatus tendon.  A doctor like me would confirm this by feeling the tendon and asking you:

Is this where your pain is?

Is it tender right now?

infraspinatus-tendinosis

The shoulder muscle most likely to tear is the supraspinatus tendon, seen below.

If you guessed that tears usually happen to degenerated tendons, you’d be correct. : )

supraspinatus-tendinosis

See how bad your shoulder flexibility is by bringing your arms as close to your ears as possible.  The more restricted this test is, the more relevant adhesion is to your tendinosis.  Watch the below video to see how a patient of ours, who had 10 years of frozen shoulder and had surgery 3 times, had 90% less pain in 7 treatments as her shoulder flexibility increased.

So Stop Exercising and Get Fixed

You are welcome to continue exercising.

Just don’t expect this problem to feel better over time.

Putting stress on damaged tendons is guaranteed to make it worse.

I highly recommend that you get it fixed as soon as possible.

If you want to get your tendinosis fixed, then consider finding an Integrative Diagnosis Provider.  Or if you live in Northern New Jersey, call us at Barefoot Rehab.

What has your experience been with tendinosis? How long were you in pain before you sought help? How long did it take to fix your pain?

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Dr. Chris Stepien, DC, Full-Body ID Certified, ART Certified, CSCS, and CrossFit Level 1 Certified, is a Sports Therapy & Chronic Pain Resolution Specialist with Barefoot Rehab in Parsippany, NJ.  When you're in pain that hasn't gone away and you've been to at least 3 other doctors, Dr. Chris wants to help you. And when you're sad, depressed, or not enjoying life, Dr. Chris wants to hug you. He invites you to reach out, no matter what your concern is. Barefoot Rehab is here to serve you.
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