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Managing recovery

I just received a completely unsolicited email from a 66-year-old quilter who purchased Target Tendonitis a few days ago:

Alex – I purchased your ebook yesterday and viewed the videos today and am excited to begin the exercises tomorrow. Your explanations re bicep tendons were so helpful. Your reference to pronation and supination absolutely explained to me why my pain is so much worse after doing simple things like knitting/quilting. But I now realize the motions used are exactly what you describe and could explain the bicep tendon pain I suffer after doing these activities. Also I kept thinking my pain occurred on extension and not flexion, but after your explanation I can see that actually the pain is occurring with pronation of my arm.

Thank you ever so much for the information not only in your book but the videos – doubt if I could have understood the exercises and gotten the above explanation just from the book. After recently becoming very discouraged with the issues I’ve been dealing with for 6 months and trying most of the therapies you described [as being ineffective], your videos have given me hope that maybe this condition/issue WILL get better and possibly go away.

thank you!

Take Care, Jean

First, I’d just like to say that it makes me very happy to receive this kind of feedback about the new TT video. Makes all the effort of putting it together worth it. So thank you, Jean!

Second, as a general comment I think that as we age it becomes more and more important to manage recovery in an effective manner. It just takes longer to reap the gains that comes from an increase in exercise intensity, or duration, or frequency, etc. In a subsequent email Jean said that she found that upping her yardage in swimming was the immediate precursor to her injury, which frankly doesn’t surprise me. I see this sort of thing over and over again in my business. And I personally spent the first part of my 40s trying to convince myself that I was still in the middle part of my 30s, hahaha.

If you are a regular exerciser, or if you perform any sort of motion on a repetitive basis, it makes sense to take a step back every few years and re-evaluate just how long it really takes to recover from a session. If you’re in the gym, be sure to keep a good workout log that includes the time between maximal weight attempts. (If you’re not getting stronger, the culprit is very likely insufficient time between such attempts.) And if you’re a knitter or quilter, like Jean, try cutting back about ten percent per decade after the age of 50. Doing so will still allow you to enjoy your hobby, but will go a long way toward keeping tendon issues from becoming a chronic problem.

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Pizza and Tendonitis

One thing that will help prevent getting tendonitis is a proper diet. And one of the basic components of good, anti-inflammation promoting nutrition is getting enough vegetables with every meal. Vegetables do a lot to push your body toward the alkaline side of the pH-scale, and can counteract (to a certain degree) the effects of eating too much acidic (and potentially inflammation-producing) red meat.

Of course, it’s helpful to know what is and isn’t a vegetable. Recently, the US Congress showed just how difficult making this determination can be by deciding that pizza is now legally to be considered a vegetable.

Apart from the blatant political self-serving–and the complete disconnect from reality that politicians apparently experience–no one should be fooled into believing that pizza will actually serve to replace a vegetable. But if you suffer from tendon inflammation, adding more (real) vegetables into your diet is a good step to take. Another would be adding a good supplement or two, which you can read about here.

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Pattern overload

Let’s talk about pattern overload.

Basically, pattern overload occurs when you perform too many repetitions of a particular movement. You don’t necessarily need to be using a lot of weight to have pattern overload occur; your own bodyweight is more than enough…as is a one-pound dumbbell if the number of repetitions is high enough. Typing can even become a problem if you never change your hand/wrist/chair/keyboard position.

Most of the time pattern overload isn’t too much of an issue, because even with high-rep activities like running or swimming, each time your foot strikes the ground or your hand cuts through the water, your body is going to use a slightly different “groove” to accomplish the movement. If you’re a highly trained athlete you might be performing in more or less exactly the same groove for a while, but eventually, as you begin to fatigue, your groove will start to become looser and while this means that your efficiency of movement will go down, it’s one way the body helps to prevent itself from getting injured.

But certain modes of exercise can be worse for pattern overload than others. One example is using gym machines too much. People who work out with free weights have a much lower incidence of pattern overload than those who work exclusively on machines. The reason is that when you’re using a barbell or dumbbell the weight moves according to your body, but when you’re working on a machine your body moves along the machine’s predetermined and set path. Even something like a Smith machine, which incorporates a small degree of leeway, is much more limiting and allows for less “natural body adjustment” as you go through your sets than a free-weight barbell.

On the opposite end of the spectrum, there is Crossfit. I’m not a Crossfit hater. I think that the main idea of Crossfit – to do something different each day, and keep good track of your rest times – has merit for those who simply want to “be in shape”, and certainly the training is fun. But there are some drawbacks as well, especially when you look at Crossfit in relation to tendon injuries.

Basically, a Crossfit exercise session involves choosing two or three distaff exercises, and then doing a lot of those exercises using a set weight for time. The rest time between sets is usually about ten seconds, and you alternate exercises. To give an example, one of the videos on the website shows three women doing bodyweight squats, then pull-up/press on gymnastic rings, then hang cleans with a barbell.

If you just plain do too much of a movement, even if that movement is something completely “free”, like swimming, you can develop tendon problems if your exercise volume exceeds your capacity to recover from it. This is where I have an issue with Crossfit. I know that on their site they place a lot of emphasis on not doing too much and using good form, but in practice they use technically difficult movements (like cleans) and push well past the point where good form completely breaks down.

Of course, you have to push yourself to a certain extent if you want to improve your body. But the question of degree is very important. Without getting into a long discussion about exercise theory, the bottom line is that quite a few people order my ebooks, and lately a lot of them are complaining about injuries received from Crossfit training.

So if you’re suffering from tendon pain and are using an exercise program (or doing some kind of work) that incorporates too much pattern overload, either through limited and unnatural movement or by simply having too much volume, think about ways that you can reduce or get around the problem. You don’t have to quit exercising, but you may well be better off if you can find ways to vary your routine.

UPDATE: Scott Abel has written a critique of Crossfit that, while it won’t win any awards for style, makes several excellent points about the dangers and limitations of the training. You can find it here.

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Tendon Degeneration: What is it exactly?

I got a very interesting question the other day from someone who saw one of my videos on YouTube. He asked: “How can there be a quick recovery for tendonosis, which is tendon degeneration, if it takes collagen (what tendons are made of) 100 days on average to regenerate?”

This is a really excellent question, maybe the best one I’ve ever gotten. To begin with, it’s important to remember that “degeneration” doesn’t always mean “destruction”. Degeneration in the context of tendonosis can mean several things, one of which is destruction of the collagen fibers (such as is sometimes seen in the case of Levaquin patients, and in those cases recovery generally does take several months, if it happens at all), but most of the time it simply implies a degeneration in function or ease of movement rather than actual damage to the collagen fibers themselves.

What happens is this: in much the same way that adhesions affect muscle tissue, tendons that are affected by tendonosis develop points or sections along the fibers that begin to stick together. With muscle fibers, the mechanism is pretty clearly understood: tiny fibers are grouped into bundles to create larger fibers, which are in turn grouped into still larger bundles, until you have a three-tier structure.

These bundles slide along each other at every level when a muscle is functioning normally, but when adhesions develop they stick at certain points, which then causes pain during movement. A good physical therapist can usually find these points simply by feeling along the muscle, and then use finger pressure to break up the adhesions and get the muscle back into good working order.

With tendons, the situation isn’t as clear. For one thing, tendons don’t contract…but they do stretch. Perhaps because of this, generally speaking simple finger pressure or massage is not enough to break up the adhesions that form. This is partly because collagen isn’t as flexible as muscle fiber, and partly because the location of the tendon itself can be harder to get at. Also, since tendon fibers don’t slide along each other the way muscle fibers do, the theory is that the collagen fibers somehow get intertwined, developing what might be visualized as “crosshatches” of collagen. What’s needed is a way to re-align the fibers so that they no longer interfere with each other.

Here’s a picture of a healthy tendon. Note how the collagen fibers are basically nice and straight.

Healthy tendon

Here’s a shot of an unhealthy tendon. The arrows show some of the spots of adhesion, which show up as white in the picture.

Unhealthy tendon

If you could somehow run a comb through the collagen and “comb it out straight”, that would be ideal. But since that’s not possible, the next best thing is a regimen of targeted, specialized exercises that, over the course of a couple of weeks, will usually accomplish the same effect. This does not need to cost a lot of money; there is a large body of research that shows that simple tendon strengthening and rehab exercises done at home can be just as effective as platelet-rich plasma and other such “cutting-edge” treatments.

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Bye-bye, Food Pyramid

In a long overdue move, the United States Department of Agriculture (USDA) has gotten rid of the famous Food Pyramid that for close to two decades was supposed to tell you how to eat. The new symbol is a plate-and-cup that will hopefully be easier to understand.

Michelle Obama, Agriculture Secretary Tom Vilsack and Surgeon General Regina Benjamin got together to announce the new paradigm, but the message seemed to be a little contradictory. According to Ms. Obama, parents “don’t have time” to measure out portions of food…yet, according to Dr. Robert Post, Deputy Director of the USDA Center for Nutrition Policy, “We know that with proper planning, you can get enough protein” from a vegan diet.

Hmmm. I can tell you from personal experience that, once you have the scale, it takes about ten seconds to measure out a portion of anything. On the other hand, I know very few vegans who actually (a) combine plant proteins properly on a regular basis and (b) get enough overall protein into their bodies (which is probably why so many of them start looking gaunt and eventually go back to eating animal sources). I have nothing against any particular diet plan, so long as it’s healthy, but let’s be clear about the realities of eating. Weighing food takes almost no time at all, and there is no better way of coming to grips with the reality of what you’re putting into your mouth–it’s just that it’s a bit of a hassle.

Anyway, time will tell if this new plate-and-cup idea takes hold. Meanwhile, if you have long-term tendon problems, here are some food-based issues to consider:

If you are overweight, the first thing to look at is losing the excess poundage.
If you are underweight, are you getting enough good fats in your diet?
For any American male, do you eat a preponderance of red meat versus fish and nuts?

Any or all of these can be (and probably are) contributing factors to your tendon pain. Fixing them is one step toward having healthy tendons and preventing recurrences of tendonitis/tendonosis. For more information about nutrition and supplementation as they relate to having healthy tendons, check out my book Target Tendonitis.

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Levaquin and Tendon Problems

I am encountering more and more people who have taken Levaquin in the past and now have seemingly irreparable tendon damage. I’m going to do some research and write a more in-depth post about this topic soon, but for now let me just say that if you are suffering from tendon pain as a result of taking Levaquin, there unfortunately doesn’t seem to be much that you can to do about it.

One technique that I have been having some (very limited) success with is lowering the intensity of the exercises given in my book. The usual prescription is for about a 2-3 on a scale of 0-10, 10 being extreme pain, but if you’ve got Levaquin in your past it seems to work better if you just aim for a “1”, at least at the beginning. Over time, and with proper nutrition and exercise, you may be able to strengthen your tendons, even if they’ve been damaged by this drug, but you’re probably going to have to start out from a lower threshold than someone who has not had this particular sort of debilitation.

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Sign Language Tendonitis

Tendon problems aren’t just for athletes and computer programmers. It can strike people who you would never think would get it. One such group is sign language interpreters. Yup, it’s true: sign language tendonitis is a thing.

Just like anyone else who performs excessive repetitive motions, sign language specialists can develop tendon issues. Common problem areas are the thumb, wrists (similar to carpal tunnel syndrome), as you might expect, but also in the elbow flexors. Although it might be thought of as a sort of niche condition, the remedy is the same as for any other situation: icing, rest and NSAIDs for the short-term inflammation, and in more advanced cases a structured set of exercises performed in a particular manner to help reverse any actual tendon damage. (In this case you will actually have tendonosis, although most medical professionals don’t bother to make the distinction.)

If you work with sign language regularly, it would pay to treat your hands and forearms in much the same way an athlete does. Be sure to stretch your fingers, hands and forearms after long signing sessions. Pay attention to your nutrition, especially aspects that help prevent inflammation and support tendon regeneration. And try if at all possible to take regular breaks during work. Five to ten minutes every hour is a good rule of, er, thumb.

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How to tell the difference between Arthritis and Tendonitis

The initial symptoms of arthritis and tendonitis can feel very similar, so here’s an easy home-diagnosis way to tell the difference: try taking glucosamine for two weeks. If it helps, you likely have osteoarthritis. If not, it’s more likely a tendon problem.

What’s the reasoning here? Glucosamine (often packaged with MSM and/or chondroitin) has been shown in quite a few scientific studies to help with cartilage formation. Cartilage is what your joints are made of, and what arthritis attacks, so upping the rate of production in turn helps your joints. End result: you’ll probably feel better…if you have arthritis.

On the other hand, glucosamine will not help with collagen formation, and tendons are made of collagen. So it stands to reason that if you feel like you have “joint pain”, take glucosamine, and don’t experience any relief, one very likely culprit could be your tendons. (Tendon insertion points are often very close to joints and it can be difficult to tell exactly where the pain is coming from.)

Taking NSAIDs, using ice and so on can provide temporary relief for either condition, but since both arthritis and tendonitis are both the result of inflammation, using these treatments won’t help you distinguish between the two. And knowing which one you have is of course very important if you intend to treat the condition yourself.

If you do decide that you have a tendon problem, however, and you’ve had your pain for more than a couple of weeks, I caution you against assuming that the issue is tendonitis. More likely it’s tendonosis, which is an actual degeneration of the tendon. (This is especially true if you take NSAIDs and they don’t help.) If you think that this might be your problem, have a look at my tendon test. It’ll only take a minute, is completely free, will tell you whether you have tendonitis or tendonosis, and give you some options about what to do about it.

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Nutrition for Tendons

I recently received a question from someone who purchased Target Tendonitis. He asked about the advisability of fasting if you have tendonosis, so I thought I’d talk a little bit about nutrition for tendons.

Although fasting can have some beneficial effects, I do not advise anyone who is suffering from tendon or fascia problems to do it. The reason is simple: your body needs nutrients to heal itself, and if you’re fasting you’re not providing it with the basic “stuff” that’s necessary to do the job. I recommend some nutritional supplements in the book, but these recommendations are based on the assumption that your basic nutritional needs are already being met. If they aren’t, the supplements aren’t going to do you much good by themselves. A diet that is lacking in vitamins, minerals or protein (to say nothing of all three at once!) is going to pose serious, serious problems when it comes to healing your tendons.

Assuming that your basic diet is okay, one thing you can do to help heal yourself if you have tendonosis or fasciosis is get a good kelp supplement and take it regularly. Kelp contains iodine, which is helpful for the formation of collagen, the basic building block of tendons and fasciae. My favorite out of the products listed on Amazon is Icelandic kelp, which is harvested during the cold months and washed in high-mineral fresh water, which adds further minerals to the already good mix that kelp naturally contains.

Icelandic Sea Kelp for tendons

Note, however, that just taking a supplement isn’t going to be enough to cure yourself if you have long-term tendon pain. Anything over about two weeks is most likely going to be tendonosis, not tendonitis (I know, I know, but believe me, your doctor is wrong. Do the research yourself and see.), and in that case the collagen fibers in your tendon have become either bunched or damaged to the point that they are going to require actual realignment in order to work properly. This is what the exercises in Target Tendonitis provide (along with a lot more detail about the nutritional side of things), and why it has such a high success rate for people who haven’t seen much effect from nutritional therapies alone. A combined, holistic approach works much more quickly than any single measure.

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Plantar Fasciitis/Plantar Fasciosis

I recently received a question from a woman who bought Target Tendonitis in hopes of finding a way to heal her plantar fasciitis. The plantar fascia are not technically classified as tendons, but they are composed of collagen fibers, just like tendons, and doctors generally prescribe the same sort of rest/ice/NSAIDs/cortisone shot treatment for the condition. Furthermore, long-term pain in the plantar fascia is due to degeneration of the structure more than inflammation (does this sound familiar?) and is called plantar fasciosis, so it stands to reason that the techniques I give in Target Tendonitis might help with this condition as well.

I have to say here that, as far as I’ve been able to find, there have been no scientific studies that investigate how well these techniques work for the PF. But if you’ve tried everything else and are looking for an alternative to surgery, they might just help. So I’ve updated Target Tendonitis with some specific exercise recommendations in Section Six of the book, and if anyone wants to give them a shot I will be very interested to hear what sort of results they achieve. If it seems like the recommendations are helping, I’ll leave them in the book; if not, I’ll take them out. Either way, it’ll be your comments that determine what the final verdict is, so be sure to write in and let me know what happens if plantar fasciitis or fasciosis is your problem.

UPDATE (May 5th, 2011): Having now worked with several people to successfully cure their plantar fascia pain, I’ve expanded my recommendations into a new book, Target Plantar Fasciitis. It comes with a 30-minute video that shows you the exact exercises to treat plantar fascia pain and posterior tibial tendon pain. So if you have either of these – or any tendon issue below the ankle – please order Target Plantar Fasciitis instead of Target Tendonitis. (Link is on the main sales page here.)

Target Plantar Fasciitis