Addressing

Tendonitis
thorfalk.wordpress.com
Twitter @thorfalk
March 2011

“Fitness is a journey,
not a goal”

Community-tested approaches of how to

contents deal with tendonitis and similar pain
Definition of tendonitis
Overview over the different
treatments For the purpose of this note, tendonitis is (incorrectly) defined as
The treatments in detail any overuse-type condition that results in pain coming from the ar-
Conclusion ea of the tendons (and. even more specific, near the elbow).
This type of injury is generally rather persistent, in then sense that
it takes a long time to heal, and that it can easily flare up again at a
later stage, even without excessive loads.
Please read the full disclaimer at the Proper treatment and rehabilitation is there-
! end of the publication. In brief: the
information presented here does not
fore very important, otherwise training pro-
gress can be seriously affected.
constitute advice, it might be wrong or inap-
propriate, and could even result in further dam- In this note I review a number of treatments
age. You are solely responsible for the course of that people who suffered this condition have
action you are taking, and you need to take ad- actually used, successfully or not.
equate medical advice before implementing it. This is not a medical article however – it is
simply an aide-memoire of some of the infor-
mation that can be found on the Web, and that can be used in dis-
cussion with the health care professional when deciding how to best
tackle the problem.
1

We (incorrectly) define “tendonitis” as eve-

ry injury that results in a sensation of pain
seemingly coming from one of the ten-
dons. Particular focus will be on the “ten-
nis elbow”, a tendonitis of the forearm,
and what can be done about it

How this note came about

My special thanks goes
to the members of
Mark Sisson’s “Primal
Blueprint” forum who
have so readily shared
their knowledge and
experience.
bit.ly/eMSJcH
Note: Word for Mac does
not allow hyperlinks in the
pdf, so I have shortened all
URL’s used using bit.ly
bundle: bit.ly/fnQeWm
I am not an expert in tendonitis – I am merely a sufferer: during
my weight training I have developed a tendonitis in one of my el-
bows (“tennis-elbow”, I blame it on my lack of grip strength in
relation to deadlifts and pull-ups) and despite trying to give it a
rest the situation has not improved for over two months now.
I have asked the community at Mark Sisson’s Primal Blueprint
forum for advice, and the responses I have got were very plentiful
and useful. Based on those responses I have done some further
research on the Internet, the results of which I have written to-
gether in this note.
At this point I should point out that I have no particular back-
ground in health and medicine, so other than common sense I
have no means of judging whether or not the information I have
found (and that I am presenting here) is right. I believe that it
nevertheless is worth sharing, as it can be a good basis to start the
discussion with your doctor or health professional. It is evident
that you are solely responsible for what you do with the infor-
mation – please do read the disclaimer!

What do we exactly mean in this note

I call everything that feels
like a tendonitis a “ten-
donitis” even though this is
not technically correct. It
simplifies the language and
it does not impact my con-
clusions.
when we talk about “tendonitis”?
Technically, tendonitis is an acute inflammation of the tendons,
ie the pieces that connect the muscles with the bones. The main
symptom of a tendonitis is a pain in an area where there are no
muscles, but only tendons. One classic example of tendonitis is
the “tennis elbow” where the pain is located on the outside of the
elbow, close to the joint.
It is important to understand that there are a few other conditions
that have very similar symptoms as tendonitis. One is called ten-
donosis, which in effect is a “chronic” version of the tendonitis

2 Addressing Tendonitis - March 2010

2
The treatments suggested
fall into the following cate-
gories: (1) exercises, (2)
physical treatments, and
(3) nutritional and pharma-
cological support
3 Addressing Tendonitis - March 2010
where the tendon is permanently damaged after the inflammation
of the tendonitis is gone.
The second condition is very different: it is known that problems
within a muscle can cause pain somewhere else. For example, a
problem with muscles in the forearm (and especially certain
“trigger points”) can cause pain in the elbow region, which is very
similar to the pain caused by tendonitis.
For the purpose of this note we will account for all of the above
conditions as tendonitis, even though those are different condi-
tions. The point is that it does not really matter from a practical
point of view, as the treatments are beneficial in any case.
What are the treatments (and how have
they been selected)?
As laid out in the disclaimer, I am not a medical professional, and
no medical professional has reviewed this document for accuracy.
What I am presenting here is simply the knowledge that I have
gained from interacting with numerous people, many of which
had to deal with tendonitis at one point in their life. It is obvious
therefore that you should not simply go ahead and try to cure
yourself – see a health care professional, discuss those options
with him or her and then decide what to do. In particular please
do keep in mind that some of the treatments described do involve
stressing the tendon in question, and this could well cause the
condition to worsen rather than to get better – so get adequate
advice, and use common sense.
The majority of treatments presented here have been suggested
by members of Mark Sisson’s Primal Blueprint community, and I
am very grateful to them [bit.ly/eMSJcH].
The treatments suggested fall into a number of categories: (1) ex-
ercises, (2) other physical treatments, and (3) nutritional and
pharmacological support.
♦ RICE – Rest, Icing, Compression, Elevation (also: heat)
♦ Eccentric loading of the affected area, eg using weights, or
specific exercise tools
♦ Mobility and postural alignment exercises, in particular
putting the arm in traction using an elastic band
♦ Stretching of the affected areas
♦ Deep tissue massage of certain trigger points
♦ Nutritional support through an anti-inflammatory diet
♦ Pharmacological support (eg NSAIDs, cortisone)
3
Band traction exercises –
that stretch the arm and the
shoulder – can address the
problem by improving
mobility and alignment
There is only one sure
fire fix for tendinitis […]:
eccentric contractions.
bit.ly/htF5tW
Eccentric loading – ie ex-
tending the muscles
against resistance – stresses
the affected areas, which
can lead to a remodeling
and repairing of the ten-
dons
4 Addressing Tendonitis - March 2010
Exercises
Mobility and postural alignment
The idea behind the mobility and postural alignment exercises is
that pain coming from the tendons (actually or apparently) is of-
ten caused by some other factor upstream or downstream. So ra-
ther than working on the tendons themselves, those exercises ad-
dress impact adjacent tissues. This makes those exercises slightly
safer as the tissues impacted might not in effect be under stress.
For treating a tennis elbow, they key exercise are for example
band traction exercises: using a strong elastic band, the arm and
the shoulder is stretched in various directions in a dynamic man-
ner, as for example shown in this video [bit.ly/ftz2AF], or in this
video [bit.ly/fhwzLW].
Eccentric loading of the affected area
The idea behind eccentric loading is that intense eccentric load
causes micro-damage to the tissue affected, and that the body,
when repairing this damage, will repair the pre-existing issues.
This is consistent with the theory of muscle growth, where the ec-
centric part of the exercise is believed to cause the damage that –
when repaired – will cause the muscle to grow. See a good de-
scription of the overall approach in the post here [bit.ly/htF5tW].
There is a risk associated with those kind of exercises – after all
they are intended to make the condition worse, with a view of it
getting better afterwards. So clearly – this exercise should not be
embarked on without adequate medical advice, and of course a
common sense approach should be applied: people report results
rather quickly – within days, or at most 1-2 weeks – so if the con-
dition does not get better within an appropriate timeframe the
athlete would certainly need to reassess and reconsider.
The way this works is that the tendons in questions are stressed
with a (relatively) heavy load when the muscles is extending. Sug-
gested parameters are 3 sets of 10-15 reps, with a cadence of 5 se-
conds on the extension.
The weight should be such that it cannot be lifted concentrically
for the number of reps required (meaning that either some self-
spotting, or momentum is used to lift it), and that the pain on the
eccentric movement in the focus area is uncomfortable but not
excruciating.
In this video [bit.ly/ial68s] an example of this approach is shown
with kettlebells, but dumbbells work equally well. An alternative
approach – which is described in this article [nyti.ms/gBpjrI] – is
4
Icing and heat are a stand-
ard treatment, as well as
protecting the affected area
using compression devices
Deep tissue massage can
clear knots in the muscles,
which might or might not
cause the pain experienced
from the tendons
5 Addressing Tendonitis - March 2010
using Thera-Band Flexbar which allows to eccentrically stress the
wrist extension tendons which are often at the center of the prob-
lem with a tennis elbow.
Other physical treatments
Rest, Ice, Compression, Elevation (“RICE”)
RICE – Rest, Ice, Compression, Elevation – is a standard recipe
for treating inflammations. It seems to be only partially applica-
ble here. Whilst rest is certainly important – continued overuse
can prevent healing and even worsen the situation – the recom-
mendation in many cases seems to be to do some targeted work –
see for example the point on eccentric loading. Elevation might
be impractical in many cases given the long-term nature of this
particular injury. Compression can give temporary relief, and es-
pecially protect the tissue in cases where it needs to be used. Fi-
nally icing is generally recommended – maybe 3-5x per day, 15
minutes each (avoid frostbites!).
Some people also recommend applying heat on the affected area,
generally alternating with icing. My understanding here is that in
cases of tendonitis a balance needs to be struck between bringing
the inflammation down, and properly repairing the tissue. As
tendonitis often develops in areas with limited blood supply the
latter is often an issue, and therefore this see-saw approach (heat-
ing & icing) is often taken.
Deep tissue massage at trigger points
Not every pain that feels like coming form the tendons does actu-
ally originate there – this is the theory of trigger points which
states that pain often radiates from such points to other, second-
ary locations. Often those secondary locations are the only one’s
where pain is perceived under normal circumstances.
The possible trigger points – which for the purpose of this discus-
sion are all located within adjacent muscles – are generally well
known and described in the relevant literature. For elbow ten-
donitis important trigger points are located in the muscles of the
forearm.
The prescribed treatment is often deep-tissue massage with a
view to release the “knots” in the muscle. For the forearm, it can
either be done with a ball (tennis or lacrosse), or with a foam roll-
er. It is easiest applying the pressure when wedging the foam roll-
er or ball between the arm and a wall and applying pressure with
the body and legs. The idea is to seek out areas that are particu-
larly painful when under pressure, and then maintaining pressure
5
Dietary support is fish-oil
plus a diet that controls
carbohydrates, eg Zone, or
Paleo/Primal
The use of NSAID’s and
cortisone is subject to con-
troversy because of the risk
that by masking the symp-
toms the underlying cause
is aggravated
6 Addressing Tendonitis - March 2010
on this area for about 10 seconds so that the knots can be re-
leased.
Note that if the tendonitis pain is related to the trigger points then
it should be triggered during the massage (unless the pressure
applied is too strong for some reasons), so if it is not chances are
the tendonitis pain is not related to those knots. Be that how it
may – releasing those knots is generally a beneficial thing to do,
even if it has no direct bearing on the tendonitis pain.
Nutritional and pharmacological sup-
port strategies for tendonitis
Anti-inflammatory nutrition
The topic of anti-inflammatory nutrition is vast and complex, and
the reader is invited to perform his or her own further research if
interested. In a nutshell: there are many recent diets that claim to
reduce inflammation in the body, for example the Zone diet, or
the various flavors of Paleo/Primal diets. Most of them focus at
least to some extent on controlling carbohydrates, especially bad
one’s (sugars, low glycemic etc).
Also, fish-oil (and in particular its constituent fatty acids
EPA/DHA) are claimed to have a strong anti-inflammatory im-
pact. It should be noted that Dr Sears (of Zone fame) does rec-
ommend daily doses in the multiple-grams-of-EPA/DHA daily
whilst other professionals warn that those high doses can have
negative side-effects, especially thinning of the blood. Both camps
agree however that if high dose fish-oil is used, then it should be
highly concentrated and refined to remove toxic components, in
particular the heavy metals nowadays often found in fish
NSAID’s (eg Ibuprofen, Aspirin)
The experts seem to be split on Non-Steroidal-Anti-Inflamma-
tory-Drugs (“NSAID’s), such as Ibuprofen and Aspirin. Propo-
nents of taking those drugs point out that they reduce inflamma-
tion and reduce pain. Opponents suggest that (a) the reduction in
pain can be dangerous as it might lead to further straining the tis-
sue in question, and, more importantly (b) that NSAID’s not only
reduce inflammation, but also impair the body’s ability to heal
and repair the tissue.
Cortison
Cortison is a very powerful (steroidal) anti-inflammatory drug
6

which is generally directly injected into the affected area. The ar-
guments pro and contra its use are the same as for NSAID’s
Anecdotal evidence (eg personal experience from forum partici-
pants) suggests whilst cortisone can break the cycle, there is a risk
of the injury coming back with a vengeance once the effect of the
cortisone wears off. This is particularly the case if the damaging
activity is maintained (which is made easier by cortisone), and
potentially also when appropriate restorative exercise is avoided.

Exercises, massages,
hot/cold treatment, and an-
ti-inflammatory diet, but
Conclusion
This is the information that I have found on the Internet and talk-
ing to people regarding the treatment of tendonitis and related
injuries.
As of now I have not had the chance of implementing any of the
treatments, but I am considering to give in particular the exercis-
es and the deep tissue massage a try, as well as a hot/cold treat-
ment, all of that of course after consulting with my doctor.

no drugs I will probably hold off the medication, but I am eating Paleo and
taking fish-oil anyway, so from a nutritional point of view my ba-
ses should be covered.
I will update my blog thorfalk.wordpress.com with my per-
Copyright Notice
sonal progress from time to time, so ensure to check it out!
This work is copyrighted
© Thor Falk 2011.
It is licensed to be shared under
the Creative Commons Attribu-
tion License (CC BY 3.0) as pub-
lished on creativecommons.org.

IMPORTANT DISCLAIMER

Every situation is different and unique, and courses of action that are beneficial in one situation can be detrimental in another one, even
if the situations appear similar. Nothing here constitutes medical or other advice, and in particular it should not be assumed that it is
applicable to any particular situation. In fact, the course of action presented here could result in a further deterioration of the current
situation, or result in further injuries, or even death.
This publication has neither been prepared nor reviewed by medical or health practitioners, and it may contain omissions of relevant
facts, or even factual errors. It is possible that the courses of action presented here are not appropriate in the situations described, and
that they result in a further deterioration of a typical situation, or result in further injuries, or even death.
For any person affected by an injury or illness it is crucial to obtain adequate advice by a medical and/or health professional. Any in-
formation presented here must be verified with an adequately trained professional before a course of action is determined and imple-
mented. Failure to do so could result in a further deterioration of the current situation, or result in further injuries, or even death.
ULTIMATELY IT IS THE RESPONSIBILITY OF EVERY PERSON (AND HIS OR HER PERSONAL ADVISORS, WHERE RELEVANT) TO ENSURE THAT THE COURSES
OF ACTION TAKEN ARE ADEQUATE IN ANY GIVEN SITUATION. NEITHER THE AUTHOR OF THIS PUBLICATION OR ANY OTHER PERSON OR INSTITUTION IN-
VOLVED IN ITS PREPARATION OR DISTRIBUTION CAN BE HELD RESPONSIBLE FOR ANY DAMAGES CAUSED (INCLUDING, BUT NOT LIMITED TO, INJURY OR
DEATH) BY PERSONS RELYING ON THE INFORMATION IT CONTAINS, EVEN IF THIS INFORMATION IS INCOMPLETE OR CONTAINS ERRORS. For the avoid-
ance of doubt, all of the above applies even in situation where the author – or any other persona involved in preparing or distributing
this document – is aware of errors and/or omissions and/or their potential implications, and/or should be aware of it, even where this
is due to reasons of gross negligence.

7 Addressing Tendonitis - March 2010