Have you ever felt limited by joint pain? The truth is, very few of us haven’t experienced injury, stiffness, or pain in our joints. And unfortunately, many of us are given diagnoses like ‘tendonitis’ without any promise of recovery.
In this episode, we chat with Steven Low, author of Overcoming Gravity, Overcoming Poor Posture, and now Overcoming Tendonitis, about how to overcome tendonitis and tendinopathy based on the latest research and his own clinical experience.
We answer questions you all brought up, including:
- how a pain ‘habit’ can be the biggest inhibitor to recovery
- how to address a longstanding elbow tendonitis
- how to adjust or modulate your activity levels
- how to know when you can start working out and doing stuff again
- the efficacy of diet and supplements
Whatever damage you were told you have, Steven shares how you can recover from tendonitis with patience and a well directed program.
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- Steven Low’s Site
- Steven’s Article on Overcoming Tendonitis
- The Book: Overcoming Tendonitis
- Our Review of Steven’s Book Overcoming Gravity
- Overcoming Poor Posture, co-written with Jarlo
Transcript for Overcoming Tendonitis
Jarlo: Hey everyone. I’m Jarlo Ilano, one of the co-founders for GMB Fitness. Welcome to the GMB Fitness Podcast. I have here as a guest, and one of my friends… We did work together a few years ago, Steven Low. He is a physical therapist out… Where are you again?
Steven: I was in Maryland, but now I’m out in California at the moment.
Jarlo: See, that’s right. I knew you moved but I forgot where. So, this is Steven Low, everybody.
Steven: I’m glad to be here. I think I’ve done one before, but yeah, it’s good to be back.
Jarlo: Yeah, I think it had been a while.
Introducing Steven Low
Jarlo: So, if you don’t know too much about Steven, we’re going to have him introduce a little bit of his background. But he’s pretty well known in the body weight exercise community. How long ago was this? About like 10-15 years ago, you were doing a lot of body weight fitness stuff before you went to therapy school, and then came your first book, Overcoming Gravity, which was very well received, and still very well received and popular in the second edition which is massive. Overcoming Gravity is just a great textbook for body weight fitness. And then went on, finished his physical therapy studies. Now as a clinician has a couple more books. And then what I mentioned earlier, we co-wrote Overcoming Poor Posture together a couple years ago. Which was again, really happy with how it was received, and a lot of good feedback from that. So right now, you’re mostly doing a lot of work in the clinic, is that right?
Steven: Yeah. I’m mostly doing online consultations for training and injuries.
Jarlo: Oh, that’s awesome.
Steven: Yeah, I’m branching out there.
Jarlo: Yeah. Especially now, to be able to do that. It’s crazy.
Steven: Yeah. I was a few years ahead of the game for that for physical therapy.
Jarlo: Yeah. There’s definitely a lot more telehealth in the last couple years. But even before that, it was just wild to even think of it. And I think even in the profession itself, we’re like, “Oh, how could we do therapy online? We need to be with the patient. We need to be with these people.” But even, we discovered in our company, many years ago, we were able to do quite a bit through all that. So, let’s talk a little bit about your history before. So, how did you get into training and fitness, and eventually into therapy?
Steven: I did gymnastics when I was younger, up to about 10 or 11-years-old. But then I got back into it in college, where they had an exhibitional gymnastics team. So I took a bet, and at the same time around that Parkour was starting to emerge so I joined up in that movement as well. And from there I got my degree in biochemistry and was really into working out with gymnastics and body weight strength training. After I graduated I went to look at physical therapy and medicine as potentially something I wanted to do in the future. And eventually chose physical therapy. And from there, my website actually grew. So I started writing Overcoming Gravity, the book during that time as well. And that’s how it kind of branched out from there.
Jarlo: That’s a lot of varied interests actually, if you think about it. I mean, biochem is not therapy. Well, it can be, but, I mean, it’s very distinct. So yeah, that’s a lot of… the Parkour is super interesting too. Because actually I remember that. But it doesn’t seem like as emphasized for you in the last 10 years or so.
Steven: Yeah. I’ve been more recently into rock climbing and getting outside, especially in Southern California they have Joshua Tree and a bunch of other nice places to climb outside.
Jarlo: That’s awesome.
Steven: That’s been the past several years.
Jarlo: I’m sure that all the gymnastics training and all that really helpful for climbing.
Steven: Yeah, it helps some. But I think I went too hard on the strength initially. So I kind of neglected technique, but I’ve been really trying to focus on that in the past few years, which just helps significantly.
Jarlo: I think that’s a lot for getting into any kind of new endeavor. You really try to work on… not work, but you end up falling back on what you do best. And trying to get something quicker, we got to get quicker. The technique is better, seemed to be the mantra for just basically any activity.
Steven: I got to cough. Okay.
Jarlo: And so, right now with your consultations online, do you basically work with people? Do you do one-offs, or do you continue to do ongoing training with people?
Steven: It’s both. A lot of injuries I get are kind of one-offs, or a couple months. I’d say I get more of the tougher cases. People have gone to physical therapy in person and maybe had it fail for a few times. So, sometimes it takes a little bit longer. But most of my injury clients are done in a month or two. So not too long. It’s more of the training ones that are more longterm. They want to stick with it. Or some people just want to get the big picture, how to train, and then they want to run with it… Got kind of both for training and more one-offs for injuries.
Jarlo: Oh, that’s great. That’s awesome. To me that makes a lot of sense. Because with the injury, or trauma, or even like you said chronic problems that maybe they’ve gone to different people. Sometimes they just need a different approach, right? A different attack, and should be able to be on their own and get going within a month, six weeks. Versus being what we used to call in therapy, those anniversary patients. Patients who keep coming and coming. Which I think is one of the really positives about the way therapy is now versus… I graduated in ’98, and that was just the beginning of a lot of the pain science thing. There was still a lot of therapy on that was pretty junk, I’ll admit it. And so, it’s nice to see this sort of vanguard of evidence-based, but also this practical. And being able to take a lot of your experience from a lot of different areas, your body weight and fitness, gymnastics, and bring it into therapy. I think that’s massive, it’s massive.
Myths About Tendonitis
Jarlo: And so, that’s part of what I wanted to have you talk about today, with your new book, Overcoming Tendonitis. And I think it’s a… So, I remember you sent me a copy a few months ago, and I loved it, went through it. The first, it took me a few days, right? One of the things I was talking with my wife, who is also a physical therapist. And I was showing her the book. She was like, “Oh, this is great, but it’s a little technical for a lot of people.” And I said, “Yeah, I think it’s awesome.” One of the things you talked about this book is meant to provide a lot of information, the best quality information we have to date. That’s another hard thing about a book, right? Because evidence continues on, right?
Jarlo: And evidence-based therapy and informed therapy continues. So anytime you write a book, a physical copy, you’re sort of setting in stone something that maybe will change, and it’s supposed to change. But one of the things I really enjoyed about this book was is that, bring everything that’s up to date, but also leaving room for, “Okay, what are we looking at here? What are the principles of where you can take this?” And so that’s one of the things I want us to talk about and for our audiences. What do you want people to get out of the book, and a couple of really main points that you want to head home for people?
Steven: The first thing I would say is, just dispelling a lot of the myths around tendonitis. Especially since it’s commonly known as tendonitis, but there is very little to no inflammation in tendinopathy as it’s called by most medical practitioners now. So, if there’s no inflammation you have to treat it differently than you would with something like ice, which is used in serious inflammation, resting, NSAID pain relievers. All those things aim to decrease inflammation. But if you don’t have any inflammation then they’re not necessarily going to work for actual rehab. And then there’s also other things. A lot of the current research has divided tendinopathy into stages such as reactive, disrepair and degenerative.
Steven: And these things are classified as something that gets progressively worse. But most of the outcomes that you see with good rehab, is that people are getting back to their normal activities, and also sports to a high level. So it’s not something that is a very terrible thing, like you can’t get back to the level of activity you want to. Especially if you had it for a very long time, even years, there are ways to rehab effectively to get back to the things you like to do.
Jarlo: I think there’s a couple important things just out of those, what you just said. The first is the natural inflammatory process, the natural healing process. And when you mentioned ice, that’s kind of a bigger thing in the last, I don’t know, 10 years or so is like, not using ice, right? Versus we used to slap ice on everything, for hours even. And of course there’s a use for it. But the main thing and the point I think you’re trying to get at is that, there is a natural healing inflammatory process, that when done correctly is needed. Versus inflammation that gets out of control, and all of those types of things, that’s distinct, right? So, it’s the nuance of you need inflammation, you need that process to start and finish. That was one of the theories about tendinopathy and tendinosis, is that perhaps you aren’t getting out of that first stages of inflammatory process.
Jarlo: And again, sometimes that was disproven in certain conditions. But sometimes it seems like that. Remember the whole cross friction massage thing, 20, 30 years ago. Which is interesting. So, cross friction massage for those of you that kind of… well, I think, maybe… I don’t know how many people are aware of it. But, it was ostensibly a way to get back to that first part of the inflammation cycle. You go and you massage on the tendon, and then supposedly it takes you back into the beginning. I remember that was the theory behind it. And it’s not true, right?
Jarlo: It’s not true. But for some reason it was helpful, again, for certain people. But those are the types of things that we’re talking about when we talk about evidence and the evolution of actually medicine itself, not just rehab and therapy. And then the other point you made there is that, when you look at these in tendinosis, tendinopathy, and then people get these scans, and get these MRIs. And they’re looking at all this damage. And damage that sometimes doesn’t change on those scans. And you can really get like, “Oh, well, that’s it. My tendon is hash. How can I get back to climbing, or Parkour, martial arts, or anything?” But we’ve see it over the years, that people can. And think one of the things we’ve seen especially over the last 5-10 years is that, disengaging that pathology, like that tissue pathology from pain.
Jarlo: And I think that’s a massive thing in your work that your doing with Overcoming Tendonitis in all of this. It’s like, rehab is improving your conditioning and your tolerance. So yeah, I think that’s super important.
Steven: Yeah. That’s also one of the big things about we want to hammer home, the difference between acute and chronic pain. If you’re having a lot of tendon pain but it’s very disproportionate to the movements you’re doing. If you’re having a lot of pain with doing a one pound dumbbell curl, that’s obviously pain disproportionate to the activity your doing. So there’s likely at least some semblance of chronic pain there that you need to break. And chronic pain is also not something that is like a death sentence. Most people think it’s like, “Oh, you’re going to have it for the rest of your life.” That’s not true. It’s basically, the way I describe it is that it’s more of a habit that your nervous system built. Any normal movement with chronic pain can be movement that causes pain. But when you address it with various physical therapy interventions, you can break that cycle of chronic pain, so that normal movements will not hurt anymore.
Jarlo: Mm-hmm (affirmative). Yeah, I think that’s massive. I mean in terms of, “Well just get people moving, and they just need to get going and doing all”… well yes, of course. But there has to be some sort of intermediary between that. You can’t just tell people, “Well, don’t worry about it. It’s not as bad as you think. Here are some exercises to keep going.” I think the nuance to it is, what are the exercises that we’ve seen in therapy and in evidence that are the most efficient, the most worthwhile, and that people can do and not get frustrated with. I think that’s a massive thing, I’ve seen in the clinic, and even online.
Jarlo: It’s like, okay, when we prescribe certain things to people, it might be okay, this would be the best thing for this person. But what’s the reality of them doing it? You have to understand the temperament of the person, where they’re at. And this is where, it’s that consistent… and this goes back to why you’re calling it a habit. If you have the habit of chronic pain, and pain associated with some movements, to break that habit you need a consistency of replacing it with another habit.
Elbow Tendonitis Scenario
Jarlo: Yeah. So, with that, I want to kind of take it a little bit, not practical but, when you first encounter… let’s say, let’s have a scenario. Case studies are always nice to talk about. So you have a scenario where you have someone who’s coming to you for a consult. And say they’ve have elbow tendonitis. Whether it’s lateral or medial, the golfer’s elbow, or the tennis elbow, whatever. And they’ve had therapy before. And for whatever reason, it was not working for them, right? So, say they’ve had… let’s go ahead and make this a little bit harder. They had like six months pain, they’ve gone to therapy probably for a month, six visits or whatnot. And then they’re still having trouble and they come to see you. What would be the first couple things you’d want to go over with them?
Steven: Yeah. So the first thing is probably just pain education. Especially with somebody who’s had it a very long time. I’ll look for signs of chronic versus acute pain. When somebody has the chronic pain it’s usually very disproportionate to the movements you’re doing. It’s also very, usually when you do certain movements, it always comes. But if you passively move the joint it’s usually not there. Then do a bunch of comparisons of the strength and flexibility between the joints where the tendinopathy is at. So elbow, and then also check wrist and shoulder strength as well, because you can be getting compensations that can go into that area as well.
Steven: And then, from the pain education it’s basically, if it is chronic pain then you have to go over a lot of the information about chronic pain and it’s kind of a habit, and you have to work on breaking the habit while increasing the strength and function of the particular area at the same time. Because as you increase the strength and function, the pain will usually start to go away with the habit breaking stuff for chronic pain. If it’s just something that is really acute and just very reactive, then obviously you just go with the normal rehab route where you get specific exercises to work on that. And what I mean by reactive for tendinopathy is, in some cases an area will get very easily aggravated, usually like with specific exercises the symptoms really flare up to a high level, where it’s like, “Oh, I did something really bad,” when maybe you actually didn’t do something that bad.
Steven: So, a very reactive tendon, usually they wouldn’t go into movement exercises. First you would use isometrics for the first few days to maybe even a week or two, to help the area calm down but still keep up the conditioning of the area so it doesn’t start to atrophy or reduce any of the work capacity that it has. So you’d usually do that first. It usually helps, decrease your activity, and then movements you regularly have after that.
Jarlo: Kind of going back a little bit, where you’re saying you’re doing a lot of consults online. You mentioned checking strength, in this case at the elbow, or the shoulder, all of that. If you have someone online as a client, how would you direct them to check strength as an assessment there?
Steven: Usually as best you can with isolation exercises. You can use things around the house like putting soup cans in a backpack, or using soup cans themselves as things. But, just having them go through a bunch of different motions to see how they’re doing with them. And oftentimes people are telling me what specific exercises on the floor, and with what weights. So you can kind of get a good idea even before you do any testing with those things.
Jarlo: Right. I think I remember a lot of the objections back when people were doing more of this telehealth stuff, beginning to. And they’re like, “Well, how are you going to assess? How are you going to do your manual muscle test? How are you going to check nerve stuff? How are you going to do all of that?” Anda yeah, you can’t. And you can’t turn this person or their partner, or their friend into a professional assessment person, right?
Jarlo: But just like you said, through observation, through a good history, you can get a lot from that person. And a lot of times we see that in an evaluation, the assessment even in person, face-to-face, that in the history that first 10-15 minutes of talking to someone you’re going to get a lot out of it already anyway. And I think that’s good to know, especially now, right, with COVID. People are seeking help. I think it’s important for them to know and be confident that, if you have to go get help, and it’s through a telehealth provider or a consultation online, that it’s going to be useful, it’s going to be helpful. And it’s not going to be substantially worse, right? I think we’re all… And being a clinician I’m always going to be like, “Well, that’s the best if you can come see me in person.” Well sure. Well sure. But it’s also not going to be 0% helpful to get on a Skype call, or on Zoom and treat somebody.
Steven: Yeah. I’ve made the estimate that you can do about 90-95% of what you do in clinic. Obviously you can’t do a lot of hands-on stuff. But you don’t necessarily need hands-on stuff. Because exercise and education is really the big foundation of physical therapy. So…
Jarlo: Oh, yeah, absolutely. Absolutely. I think a lot of people get kind of trapped into, “I got to use my hands,” or, “I got to be a manual therapist.” And at the same time as being a patient. If you’re used to, “Oh, I’m here on the table. This person is going to massage me, manipulate me, do all these things to fix me.” And that’s not really a model that either is tenable anymore, or also isn’t useful for them to continue on and take care of themselves, right?
Steven: Yeah. You can get negative outcomes with that. You get the “No, Steve,” they’re like, “The person has to be doing this to me for me to get better.” So they won’t get better as effective.
Jarlo: Right? Absolutely. And then, we’re really now in therapy and rehab, and actually even in fitness and training, really hammering in the education. Like, how can we get our patients and clients to understand these things? To take it within themselves, and being able to go on, not feeling like they have to have a question answered before they can do anything by an expert. And so with your books, first Overcoming Gravity, and then the second edition, and then Posture, and then just tendonitis, I think I really appreciate what you’re trying to go for there for sure.
New Research in Tendinopathy
Jarlo: What else would you like people to take away from this book, Overcoming Tendonitis?
Steven: So the tendinopathy science isn’t really good compared to a lot of the other science that is out there in terms of resistance training. In resistance training you have a lot of defined populations where you have your beginners, your intermediates, your advanced. And they’ve done enough studies to show how much exercise, how much frequency, how much volume and load you can use with those particular patients, or clients, or athletes. But with tendinopathy there’s just so few studies, and so few I guess, protocols that you can do. And in a lot of the cases you get what you get, so you’re not able to screen the populations for somebody who has had a tendinopathy for only a few weeks or a couple months. Versus somebody who has had one for a few years. Where okay, one might be more acute-based, and one might be more chronic-based.
Steven: And then some people’s tendinopathies are more reactive, and some are less reactive. So, when you’re applying these sort of cookie cutter rehab plans to somebody, you’re going to get a huge variance of successes and failures. And then you’re not going to be able to distinguish why something failed or why something was successful. As good as, if you had a more, I guess, free flowing approach to how a patient is presenting in person, and then adapting to that as…
Jarlo: I think that’s a important to say. Because in terms of research with exercise science, in particular resistance training, it’s a longer history for sure. It’s a longer history, that accumulation of studies, and all of that type of thing really does matter. Because in good research, you’re trying to cut it down to one variable, two variables. I mean, that’s just what it’s supposed to be. Whether that’s useful for a general population, that’s kind of the way science works. And then what you’re looking at is an accumulation, you do a ton of meta-analyses of everything. And the difficulty with tendinopathy and tendinosis and all that is, again, it’s relatively young.
Jarlo: And so when you have these things where they’re trying to find one variable, they’re automatically not going to be like you said, free flowing and understand what the individual patient is going through. At the same time you can’t do that and have a research study. So I think that’s a very important point. If you’re only going on 20 years of science versus 50, 60, that’s definitely one thing. Also too is, what were the models they were using before, right?
Jarlo: You’re looking at a lot of tissue models of, “Okay, what are we looking at when we see this damage?” And then, so if there are marker points, we’re like, “Does this damage improve?” Right?
Jarlo: And then, just like we were talking about earlier, it doesn’t. So if you correlate that, then you’re like, “Well, what are we doing to this tissue,” versus a person that’s in pain and separating themselves from that, from just always the tissue damage versus, is this person even in pain? And so I think that’s a massive part of why the research can fail sometimes. And I think that’s really important. Also too, you’re looking at tendonitis, tendinopathy, in particular it’s so common, so common, right? People have it. They either go and see somebody about it, or they don’t. And then they just have, “Oh, my elbow’s bad, my wrist is bad and my shoulder is bad.” And that’s it. Right?
Jarlo: And they sort of get trapped in it. Yeah. Especially difficult for people that are athletic. Either you were not a professional but competitive. Competitive in school, maybe you’re still competitive as a person even though it’s not your job, you’re not a professional at it. But you love it, you still enjoy it. You’re either going to think, “Okay, I’ll just have to quit it.” Right? Which sucks. Or, “I’m just going to have to live with it and do it.” Which also sucks, because those are not the options to me, I think. I think we need to help people understand… help our patients and clients understand that there is that balance of, perhaps you have some pain, perhaps you’ll have some difficulty doing some things. But it doesn’t mean you have to stop. Plus it doesn’t mean that that has to be so significant that you have to grit your teeth and go through it.
Steven: Exactly. We divided a lot of the interventions based on how much research there was into major and minor. And then tried to classify them as which may help a little bit, or may not help at all. And yeah, basically what the science said about it, and I guess science wasn’t too clear in a lot of cases. So that’s why you’re kind of went with things like, may help, right.
Jarlo: No, no, I think that’s super important. Yeah, I think that’s super important. There’s a lot of that. And what I really liked too in the last few years of people trying to help, not regular people, but help people that don’t have this sort of science background, or medical background, rehab background, or anything really kind of make sense of the research out there. And I really like that approach of, may not help, does help, could help a lot. Versus like no evidence for, right? And that was one of the issues I had with a lot of evidence-based practice other than based even fitness, is in the beginning… or not even in that. But like when people first get into it they’re like, “Oh, that’s worthless. This right here is worthless.” And to even say that is shows a lack of nuance. Or for example, I mean, staying on topic, the whole eccentric training for tendinopathy. I remember when that first came out. Like okay, that’s it, that’s all we’re going to do then, right?
Jarlo: We’re just going to… for Achilles tendon, we’re just going to put everybody on the stairs, and they’re just going to do like sets of negatives. That’s just as bad as not following the evidence, right?
Steven: Yeah. For those of you who don’t know, you would just kind of use both legs, or the healthy leg to raise yourself up, and then go down slowly with your injured leg. And a lot of the more recent studies are like, okay, it’s literally the same, very similar outcome if you do both at once. But if you’re trying to get back to a sport you need to learn control in both eccentric and concentric contractions. Especially with running where you’re going to be at very high speeds. So maybe you’re starting slower with both the eccentric and the concentric, but then you’re also… just start speeding it up, the plyometrics in the long run. So, you have to have this continuing of building up with both eccentric and concentric, and then speeding it up in the long run.
Jarlo: Yeah. We kind of laugh about it now. But that’s the example of taking one thing and just going hog wild with it, right? Or taking a particular research tactic and seeing whether it’s helpful. And then just blowing it out of proportion and just saying, “Oh this is it,” right? Which is not great. But there’s a lot to talk about with that. but I think that’s what can make it hard for people if you’re not going to go and read the research, read all the studies, do all of that. You’re going to need… It’s helpful for someone to break it down for you, and look at it and say, well how can this be helpful for you? Which again is why I really appreciate what you’re doing in the book. Now, I think those are great.
Jarlo: The hard part is, this is such a big topic, so expansive. And that’s why I asked you, “Okay, let’s have just a few things to really take home.” But I think one of the… Why I also earlier like, “Oh, let’s do a little case study,” and you know, I think that really helps people to kind of frame it. And then that’s also why we asked a bunch of our audience. So we told them we’re going to have you on, and we’re like, “Oh, we have Steven Low on? Do you guys have some questions? What would be good?” And it was great, we got a whole bunch. So I’d love to go through at least a handful of them. I know it’s going to be hard to do a lot, but here, let’s start with this one. So, this person is saying, after he was doing rehab for a while for his shoulder, he says here in particular supraspinatus tendon.
Jarlo: So one of the rotator cuff muscles, the tendon, supraspinatus. This is a good one because I think it’s a good general question. So at what point do you think it’s okay to start applying force to it and get back into working out? So this is a really common question we always get. Is that, I’ve been injured, whether it’s a shoulder, or neck, or your back, tendonitis or other type of thing, that’s one of the first questions we get. It’s like, “Okay, I’m going to do the work for it, I’ll do the rehab. When I can get back into my training?” So, what would you say about that, Steve?
Steven: Yeah. Generally speaking I assess if the pain is chronic or acute. And also the level of work capacity and strength in the affected area. So depending on if it’s acute or chronic, you kind of divide it into those as we discussed before. And then as far as the rehab goes, usually if there’s a lot of pain or a very high reactivity, you start with your isometrics first. And then move on to your isolation exercises, like your rotator… although a rotator cuff has, your infraspinatus and teres minor, and subscap also has a little bit of function of the supraspinatus, which is to inferiorly glide in the humorus at the shoulder joint. So I know those well.
Steven: And you can even do bicep exercises for the long head of biceps because that stabilizes the shoulder. And then you got to look at the scapula to see if all those muscles are operating correctly and moving correctly, and if they have their requisite flexibility to go overhead if going overhead is painful. So, looking at all those things, and then moving from those isolation exercises as the strength and function are improving. Hopefully the pain is decreasing as you move on. And then go into compounds after that. And you know, obviously the process is fluid depending on how reactive the tendon is being during the rehab process.
Steven: But usually you can move to your compound exercises within a week or two, or maybe a month at the latest. And then get to your sports by a few weeks to a month, depending on how severe is. Obviously the less severe, a lot of a shorter time likely it’ll be. But if someone’s had like six months before coming in, it’s probably going to be several weeks-ish to get back to regular sports, specific activity, at least from what I’ve seen.
Jarlo: I think what you say there about reactivity, or irritability is huge. I think a lot of people come to the assumption that, “Okay, four weeks from now everyone who has this can do this,” right? It’s sort of like the protocols that we used to get from surgeons after say an ACL or after the rotator cuff tears. Like, “Okay, six weeks out you can do this at this degrees,” right? And it’s kind of helpful to have that piece of paper. But it’s also not very realistic. It totally depends on, like you said, it’s a fluid process. How is this person reacting? And I think that’s really important to understand too is, even when you’re ready, say your strength is good, your shoulder blade mobility is good, all of that stuff is going and you get started. It’s a wave, you’re going to have ups and downs. So to be able to roll with it and auto-regulate there is important. And it’s not so much, “Okay, I’m six weeks out, I’m seven weeks out. I should be able to do 15 pounds,” all that type of thing.
Jarlo: Right? It is good to have those guidelines though, I think what you’re saying is super important. That kind of goes-
Steven: Yeah, and it-
Jarlo: Oh, go ahead.
Steven: One thing I wanted to add about that is, flare ups are generally a normal part of the rehabilitation process.
Steven: That’s one of the big things I’ve recently been harping on in my consultations that actually has provided a very positive effect. Just like, because when people have flareups they get this negative mindset, and it will contribute to a nocebo effect like a worsening of not only their symptoms, but their mindset and the rehab all together. So yeah, just knowing that flareups are pretty normal. Sometimes we’ll take a one extra rest day here and there. If we actually added more intensity or volume, maybe we will dial back. But if the rehab program has not increased or decreased, sometimes you get flareups here and there, even if you’re doing the same exact thing and progressing very slowly. So just continuing to stay the course and knowing that you’re going to have some variation day-to-day. But as long as the trajectory is upward in the long run, you’re doing good.
Jarlo: Yeah, super important. Even just knowing that’s normal. Yeah, that’s good, that’s a good point. And that kind of brings us to one other question, and you sort of answered it already. This person asked, isolation versus integration, is it even good to have your shoulder isolated from your whole body? Well, that’s the thing, you sort of have to in the beginning, or you sort of have to if you’re into this sort of acute or even high reactive stage. It becomes this fluid thing of… I think that’s one of the things too. And the reason I like this question is that, it’s indicative of this kind of, where are we at in the trends of fitness, and even therapy and rehab.
Jarlo: People are trying to do either/or stuff now. “Oh, isolation is bad. Why should you even isolate it?” Versus, you have to use your whole body, you got to do everything together. Your body is a whole. Well yes, it is. But what do you mean? What are you trying to get out of that? It shouldn’t be either/or. What you’re looking at, in what you just said, it’s part of a process. It’s part of a process and you have to look at it day by day, event by event.
Steven: Yeah. You can kind of think about it as… what I explain is, you can think about it as a weak link. Obviously you don’t want to strengthen the whole chain while a specific area is injured or weak. So that’s why you would generally go with very isolation or isometrics first. You want to strengthen that link before you’re going to work the whole thing. The weak link is always going to be the area that is going to have the possibility for injury, especially if you’ve been injured there. So you don’t want to go too hard on things that can stress the whole chain, or you bring up the weak link strength and otherwise work capacity.
Jarlo: That really fits into training too, right? And in Overcoming Gravity, especially, you do a lot on that. If you’re looking at progressions for the plantar, muscle up or something like that. You have to look at all of the links. And I think it’s the same way in rehab and in injury. And so, I think that’s another thing I really enjoyed over the last 15 years or so, is really this interplay between what is rehab and what is physical training. Because initially, in terms of physical therapy, very poor on exercise progression. As a profession, I thought it was… I mean-
Steven: Yeah, I agree.
Jarlo: Yeah. And then over, from the ’90s into early 2000s on that, it got so much better, so much better. And so moving on for other questions. Here, there’s another one. I like the way we structured this. Because this is sort of answered already too. It’s like, well this person is, how do you get rid of lingering elbow tendonitis? Every time I start to get active it flares up. And this other person below it says the same thing of like, I’m in the same boat, I go too hard climbing in January, I pushed through and then it got worse. So you’re talking about continuing… they’re talking about continuing flareups here. What would you say to people that go up, go down, go up, go down, and it sort of continues on like that?
Steven: Yeah. Nine times out of 10 there it’s just too fast progression. You just have to take it very slow. So if you’re jumping back into climbing, which a lot of people really want to do it, you’re going to have to… in your primary a boulder, you may have to go to top rope and just do maybe two, three very easy climbs just to start. Because you want to see how it responds. You don’t want to go too high intensity or too high volume, because that is going to usually with a very reactive tendon, going to cause a lot of symptoms. And then okay, if it’s causing symptoms, is your function and strength decreasing again? Okay, that’s not good at all. Then you need to modulate the volume intensity to basically the work capacity of the tendon at that particular point.
Steven: One other thing I found, especially with golfer’s elbow is, since the common flexor tendon is composed of a wide frame of muscles connecting into it, hitting it from a lot of different angles usually helps. So what we’re talking about there is, wrist flexion type, dumbbell wrist flexion exercises to the flexor carpi, and carpi radialis and carpi ulnaris, pronation, supination, hits the pronator teres. And then also finger curl type movements to hit the flexor digitorum superficialis. So all those connecting to the tendon. And then having an exercise in rehab for all three of those, I found is generally particularly helpful. I’m not sure, I speculated that maybe it hits the… So, tendinopathy is not a thing where it affects the whole tendon. Usually there is just a small portion of the tendon that becomes either reactive, in disrepair, or degenerative.
Steven: And the rest of the tendon is healthy and generally asymptomatic. So I speculated that possibly hitting it from all the variations may strengthen the tendon, the healthy portions of the tendon, in a way that can help I guess, compensate for the injured portion. And then also doing exercise for the more injured area to bias that part of the tendon, if it’s not degenerative, may help to specifically rehab that as well. So, yeah, from my own experience in consultations at least, yeah, hitting all three of them tends to be a lot more effective than just doing one or two exercises like just the wrist flexing exercises and pronation/supination. And I guess I’m not really sure why it’s that effective, but I think my speculation is maybe on point.
Steven: I’ve seen some people say, the whole tendon is being stressed, but usually in a lot of the tendinopathy research you see a particular wear pattern on the tendon. Like the rotator cuff, the supraspinatus usually the tendinopathy is in the anterior/superior portion of the tendon, not like the posterior region. So usually there’s a certain wear pattern in a lot of the tendinopathies that are based on the particular activity you are doing. So I think spreading out the rehab to a lot of different exercises that can hit the tendon in completely different ways is usually probably helpful.
Jarlo: Yeah. I think especially in terms of, with the elbow and shoulder. You’re looking at really such a wide range of activities that affect it, right. The elbow throughout the day, shoulder throughout the day, not even just in sports like climbing and other higher level activities like that. So, to parch that out a little bit. The first part of climbing different… or changing the difficulty level, I think that’s important to kind of summarize. Because it can take a lot of trial and error, right?
Jarlo: You can always tell people, “Oh, you need to go a little bit easier than what you’re doing now.” But that’s not as helpful as, “Okay, let’s analyze what you’re doing right now, what is an incremental step below that, or below that?” And sometimes it’s even helpful to say, “Let’s go super far below it, and then kind of ramp up again.” I think-
Jarlo: Right? I think, it’s interesting. So if we talk about climbing, it’s already built in like that. Because you have certain levels. Whether it’s indoor climbing, or bouldering, or outside, this route is harder. This particular way of doing it is harder. So that’s nice for this particular example. And other things like, just even say recreational strength training, or body weight training, or you’re looking through different progressions. It’s nice when they have a list and you can tell this person, “Oh, you need to do this level then.” Or, “You’ve been doing this level and you’re kind of here, let’s take it two down.”
Jarlo: So I think that’s really important. The other thing here, the last part about hitting the muscle from different angles, is super interesting to me. Because that’s almost like the bodybuilding thing. Like, how many different ways can we approach this muscle. And in that case, they’re like, to make it bigger. Well, in this case, it’s to make it more tolerant and more conditioned.
Jarlo: Yeah. That’s awesome. So there’s other questions here. Which is, it’s a little off topic, but, do you have… So what’s your opinion on… here he’s like sugars, olive oil… so basically is there any type of food or any type of things like that. Probably let’s even say supplements to there, for recovery if you’re older, all of that type of thing. What’s your take on that, Steve?
Steven: Yeah. The research is pretty sparse. But in general the supplements are fairly questionable. Some of the newer research on possibly supplementing the specific building blocks of tendon exercise, so you would supplement the specific building blocks of tendon such as gelatin which is collagen, and Vitamin C which helps hold the collagen together. You would supplement that before exercise, and supposedly there might be increases in collagen synthesis. But from what we know from degenerative tendons, they don’t necessarily have to be, I guess, fixed. The degeneration is still there, but the tendon is able to become normal functioning and healthy, and able to do sports again.
Steven: So you don’t necessarily need to increase collagen synthesis above a certain level to get good outcomes. So I’d say it’s just generally fairly questionable so far. Maybe there’s a few percentage point gains from focusing on supplementing collagen and Vitamin C, but it’s not something that is very effective. But to go back to the larger point of food. Obviously if you’re allergic to something, or that is going to be a bigger issue of your body’s under a lot of stress, probably not going to be functioning as well. The trial and error elimination method of removing certain foods for a few weeks, and then adding certain foods for a few weeks tends to be, I guess the best method if you haven’t done any allergy tests or anything.
Jarlo: Okay. I think a lot of that comes from the sugar, the fats, and all of that is, are we encouraging the whole thing of inflammatory, anti-inflammatory. That kind of goes back to what we were talking about in the beginning. You do need certain levels of inflammatory process. So eating a lot of antioxidants or decreasing your sugar, or upping your fish oil versus decreasing your trans-fats. These are types of things that, yeah, could be helpful. But also might be just taken considerably out of context, right?
Steven: Yeah. That reminds me of some of the big vitamin supplement studies that actually show like no effects at all, because most people… the only people who it is going to help is the deficient people. The people who already have enough of vitamins from regular food are going to be fine.
Jarlo: Right. That’s the really hard part about this. Again, it goes back to a little bit earlier, like being so reductionist. What is the one thing that is going to help? And it’s really natural to fall into that of course. Because if you’re thinking, “Well, if I can do this one thing, then good, I’m going to be able to get out of it.” Unfortunately, it’s not like that. I wish it was, it would be so much easier. But that goes into here, one of the next question that’s kind of random, but I think it fits into the bigger picture. This person is asking, what is your opinion on a medial nerve block in treating lower back pain? For those, let me just kind of frame this a little bit. There’s a lot of… oh, how do I say this? It’s back to the pain science. Where, okay, nerves are the whole thing before. The old way of thinking is that these nerves are causing pain.
Jarlo: This person is asking about low back pain in particular, and a particular nerve block in particular. But the idea was, and I’ve seen this throughout my career, is that there’s pain generators, right, Steve? There’s pain generators. And if you get rid of the pain generator you get rid of the pain. So that’s essentially what this person is asking. And whether it’s right or wrong, it’s hard… Am I going to say it’s right versus what I’m going to say it’s wrong. But that’s sort of where this question is coming from. And it could be applied here. Like okay, we have a tendon tendinopathy. So what do you do? You cut out that part, right? I don’t remember in the book, did you talk a little bit about the prior medical intervention? Where they would go and debride and doing all these types of things.
Steven: Yeah. We discussed the surgery a little bit. It’s generally helpful, in Achilles at least, you get about 75% positive outcomes. I mean, they’ve also done like sham surgeries. A bunch, a large portion of the people actually get better. Is it because they’re thinking that surgery is going to fix their problem, and it’s like a very positive outcome as a thing there? Or is it just because-
Jarlo: It’s hard.
Steven: … degenerative tissue that isn’t helping the tendon.
Jarlo: Oh, it’s so hard. Me and Steven are laughing about this a little bit. Just because we know, we’ve read these studies and we’ve seen patients. And it shouldn’t be making light of it, but it also goes to the larger picture of, we really have to get out of the mindset of one thing is going to help, or you need to get fixed. Especially in terms of pain. All of these nerve blocks, or nerve ablations, right? That’s another thing too, especially in back pain is essentially destroying the nerve. So there’s nerve blocks where you have chemical interruptions, and then there’s the nerve ablation where you’re essentially destroying the nerves.
Jarlo: One of the things, and I think this is important to talk about, is that sure, they’ve seen it helps. But then that shit grows back, right? It’s brutal. And that’s why we’re laughing. It’s because we’ve seen this. And it’s not that we’re laughing at the people that are having pain and trying to figure out how to get out of it, but there’s been so many things like this. And this is just an example. And that’s why, especially in your book in Overcoming Tendonitis, and the other works that you’re doing is, is getting out of that reductionist model.
Steven: Yeah. A lot of it goes down to pain education. And I talked about a little bit of this earlier. But, just to delve into that a little bit more. The pain system in the body is basically like an alarm system. That goes from the body to the brain and back. And a lot of times, especially in chronic cases, which is usually, we generally classify about three months or longer. Like if you’ve been resting a lot and doing rehab, and your pain isn’t getting any better, it’s higher like as you’re getting chronic pain symptoms three plus months out. And especially if you’ve got it more than a year or two. And basically the system can get out of whack where the nervous system gets more sensitized to having this pain signal occur.
Steven: So that’s why I refer to it more as the habit. Now your any type of normal movement you do after the tissues have healed completely, and you’re still having pain, you’re having normal movement. Maybe even with a very light weight which shouldn’t necessarily cause any more damage, or any… having that normal movement, and you’re getting a lot pain. It’s very disproportionate to the types of movements you’re doing. And so, yeah, you got to do specific physical therapy exercises to break that cycle of pain so that… It doesn’t go away immediately. Usually it’ll start to decrease over a couple weeks, maybe six months in some cases. But almost always it eventually goes away completely. Sometimes, not always, but a lot of times it does go away completely if you have a lot of interventions addressing breaking the habit of pain.
Jarlo: Yeah, absolutely. Super important. I think that’s something that we can’t repeat enough. And I think almost every time I’m on a podcast talking about any kind of pain, I try to put that in, so important, super important. Next is-
Steven: I think that’s why a lot of the physical therapy fails in the clinic. The physical therapist may not have necessarily been educated on some of the newer pain science. So they’re just trying to treat the patient’s chronic pain as something that is acute and needs just to be rehabbed normally. Whereas if you had educated them about pain, and then had them go through a lot of pain breaking exercises, they would start to have that chronic pain go down. And maybe you don’t even need to do a lot of the super strengthening or super functional exercises. You just need to educate them and do a lot of the pain breaking exercises and it goes away.
Jarlo: Oh, absolutely. Super important. That goes onto the next question, which I think is interesting. This person says, thoughts on heavy slow resistance protocol for tendon health. When to apply a load and a tempo versus when to rest. I know you went over this a little bit. It’s fluid, and it’s all of that. Any particular insights into… I’m not sure if this is in regards to, whether it’s eccentric training or heavy slow resistance. I wonder if that’s a trademark thing or something too.
Steven: Yeah. It’s one of the four different rehab protocols we saw in the science that we talked about in the book. In general, heavy/slow is basically you’re starting with about three to four steps of 15 reps with a three second eccentric and three second concentric motion. And then over time you’re going to increase the weight and decrease the reps progressively down to like six reps eventually. And this does actually work effectively in… I think it’s around like 50-70% of cases. But it didn’t work in some. I think especially because it’s very aggressive in increasing the intensity.
Steven: It doesn’t work a lot in the tendons with very high irritability reactivity. So if you have a tendon that may be having, has very little reactivity, it’ll tend to work well. But if you have a very high reactive one it would probably definitely not work well. And from our investigation of the research on tempo, usually I think one study did one second time under tension, and six seconds or something like that. Basically the one with six seconds did about the best. So, yeah.
Jarlo: That’s interesting.
Steven: Yes. It’s somewhere around those numbers. But yeah, I would generally recommend about a two to three second eccentric, and a one to two second eccentric. So pretty close to at least to heavy/slow protocol. And then, now if you’re getting back to a sport, eventually you have to start speeding the tempo up to get back to running or explosive exercise.
Jarlo: Yeah. I think that’s one of the benefits and drawbacks to having a strict protocol. And one of the benefits is you know where you have to head. What you just said was super interesting. You’re looking at around six seconds versus ‘a fast’ seems to be better. Those types of things you can really take with you. But the drawback would be, forging ahead in a protocol just because it says, right?
Jarlo: Like you said here, it depends on your reactivity and your irritability. And this goes with too what we were talking about with recognizing that there’s going to be a lot of trial and error. Well, hopefully not too much trial and error. But there is going to be that in terms of what you can tolerate. This kind of goes to the next question here. This person, and we kind of answered this a little bit earlier. Tips on how to assess or auto-regulate load balancing for recovery. This person specifically with tennis elbow, lateral epicondylitis. We talked a lot about that. It’s sort of like finding your baseline, and where are you in terms of our irritability for that baseline I think is the main thing.
Steven: Yeah. And generally it starts at or below what is that baseline? And then slowly work your way up. Don’t try to add sets and reps every workout. Every other workout is generally better, especially for very highly reactive tendons, having that slow progression. Because you can always speed it up if you’re responding well and getting better quickly. But if you start with too much, you can not only necessarily set yourself back, but it takes longer to find out what is working effectively.
Jarlo: Right, right. This is where it really… It’s hard to be patient, but it can really pay off to be patient. Because essentially it will take you longer if you try to rush it, right? That’s one of the things. There’s something philosophical about that I think.
Steven: Yeah. And one of the great things to add to that is, well, what you usually call the flareups and setbacks aren’t really a bit deal since tendinopathy is an overuse, primarily overuse exercise. You’re not going to do any significant damage to the tendon in one rehab session. Unless you have tendinopathy and then went and ran a marathon or something. You’re not going to do any significant damage or anything like that. You’re just going to have it be a little more irritable. So there’s actually nothing very negative that is occurring. So you just kind of get that out of your head.
Jarlo: Yeah. That’s super important. Because that’s another thing too. People are telling you, “Oh, you take it slow, take it easy.” And then it’s easy to go beyond that and go, “Well, I got to be so careful, I got to be so careful because I’m going to hurt myself if I do this wrong.” And it’s important, just like you said, to realize that’s probably not going to happen, unless you just egregiously just being really crazy about it, it’s probably not going to happen. It’s just going to make you, again, flare up. It’s probably going to make you more sore than you need to be for a few days, but you can get out of it. I think the whole thing of taking it easy and progressing slow is the main point out of that, is that so you can continue on, and you don’t have unnecessary increased pain, unnecessary flareups.
Jarlo: That’s the main point. That’s super important. Because again, that takes us out of that nocebo of, “Okay, you can’t move. You got to stay in this cast. You got to do this.” And these are the extremes that we really want to avoid. And again, so important. And really, what’s been super helpful about the pain science, and especially in the last 5-10 years, is really understanding when we talk to patients, when we talk to clients, what are we saying to them, and what are they interpreting from that?
Steven: They don’t want to say anything that kind of builds up that catastrophization of pain, where okay, it’s something to avoid at all costs. Or if you have any, then it’s a very negative thing that is going to affect your habits, it’s–
Jarlo: Yeah. Unfortunately that’s–
Steven: … the alarm system, it’s messed up a little bit. So you got to address that. But rehab is often very straightforward and as long as you’re not aggressive about it, then it’s successful.
Jarlo: Yeah. Unfortunately it hasn’t been like that for a long time. And so now that’s why we’re really harping on it, and really maybe even exaggerating it to some… because it was really detrimental before for doctors to tell you, “Oh, your knee is shot. Your arthritis is super bad. You’re bone on bone.” All of these types of things really stick in your head. And your like, “Oh, I guess I’m screwed then.” Right?
Jarlo: And so, again, I can’t repeat it enough that most of the time you’re fine, you’re fine. You and your therapist, or your trainer, need to just figure out the best plan for you to improve your conditioning, improve your tolerance. I think that’s massive. One last thing, because I know you’re busy. But here, this is a really common question, and it’s to stretch, and how to or not to stretch for recovery. I think that’s a really common question and it’s a important one.
Steven: Yeah. So, for tendinopathy specifically, what a lot of studies are basically saying is, stretching actually doesn’t help, doesn’t hurt. Except if you’ve lost range of motion. So, I guess the premise behind that is, lost range of motion, and you’re doing exercise, there’s a shorter range of motion for the muscle tendon to absorb force. So potentially with less range of motion there’s more force on the tendon in that specific range. So that can contribute to overuse. But otherwise if you have normal range of motion, as your not affected limb, or compared to I guess normal physical therapy standards, you don’t really need to stretch at all for tendinopathy or really any other type of thing, unless you have flexibility goals at least.
Jarlo: All right. And I think that’s another thing too. Which is why I think this is an interesting question is, what are your goals, or what are you trying to get out of it? And in this particular context, is stretching going to help your pain in this tendonitis? Maybe, maybe not, probably not, right? That type of thing. And so it kind of goes back to this motif of, what is the one thing that’s going to help? Or, should we throw a whole bunch of stuff at it and see what happens? And so to me that’s what it is. It’s like, shotgun approach versus, “Oh, let’s go one at a time.” You know, there’s a balance there.
Jarlo: And what you’re looking at, and stretching in particular… And we’ve always said this too within our company. And also, you’ve said it in Overcoming Gravity, and all these things, stretching is a means to an end for getting into positions, right? Getting into your… If you’re a climber, that’s a good one. Yeah, it totally helps for you to be able to get footholds and handholds. If you’re a gymnast, well yeah, you have to. It’s part of the sport. But if you’re not, and you’re kind of doing fine, and you don’t feel stiff in the things that you want to do, maybe you don’t need to stretch, right?
Steven: Yeah. I saw on a study on sprinters, and stretching their hamstrings too much actually decreased their speeds. So they needed that stretch cycle with the relatively tighter hamstring to get their speed up to the max.
Jarlo: Right. Absolutely.
Steven: So, a lot of stretching can be detrimental to your goals.
Jarlo: Right. It can be good or bad, it’s all in the context I think. I like that. Because that’s a good statement for everything in rehab, training and all of that. Well, thanks a lot, Steve. So that was a good… there was a lot to talk about. But thanks so much for your time, I know you’re super busy. What we’re going to do is, we’re going to have different show notes. We’ll have links to Steve’s site and all of his projects. What’s coming up for you? What’s new coming up for you?
Steven: Actually, I’m kind of in transition I guess. So, I was thinking about writing another book, but I haven’t selected a topic. Maybe potentially setting up a workout app, or-
Jarlo: Oh, wow.
Steven: … trying to get a Patreon online, mostly about that.
Steven: So I’m kind of in transition right now, enjoying the time with my boys, and yeah, just trying to work on consultations and for training injuries as well.
Jarlo: That’s awesome. So, for all you listening, if you have any other questions for Steve or for us, hit us up, firstname.lastname@example.org and again, we can direct you over to Steve and give you different links and all of that. Well, thanks again, Steve. I really appreciate it. Thanks for coming on.
Steven: Thanks for having me.
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