Tendon Pain is Common
If you have ever had elbow, shoulder, hip, knee, ankle or heel pain there is a high probability that your tendons are to blame for the pain. Terms like Tennis Elbow, Golfers Elbow, Achilles tendonitis, and Patellar tendonitis are names that we use to describe these conditions that occur when tendons are struggling to cope (aka tendinopathy). The good news is that there are lots of things we can do to take care of our tendons as we age to prevent tendonitis (or tendinopathy).
Why do we get tendon problems and why are women more susceptible?
Low oestrogen levels are one of the factors that may contribute to the development of tendon pain and problems. This goes some way to explaining the higher prevalence of tendon problems in post-menopausal women who often present with multiple areas of pain. Conversely, ‘Oestrogen-like compounds’ appear to have a positive effect on overall collagen synthesis in tendons and ligaments. (1)
Common sites for tendinopathy are at the hip, shoulder, elbow, knee and heel. Oestrogen reduction negatively affects tendon metabolism and healing, reducing the rate of cellular proliferation (production), increasing apoptosis (rate of cell death) and influencing a tendon’s composition in terms of collagen I, aggrecan and elastin. (2)
The impact of low oestrogen levels is not limited to post-menopausal women. Low oestrogen levels also occur in the early post-partum period and this may be extended for longer in breastfeeding women. This can be one of the reasons why new mums returning to running experience hip pain; a combination of low oestrogen levels and ‘too much loading too soon’ postpartum. There are also cancer treatments that impact hormone levels that can contribute to the development of tendon pain.
Why is tendinopathy more common as we age?
As we are ageing collagen is changing. Collagen is not just in skin but in muscle, tendon, ligament, cartilage and bone. Decreasing blood oestrogen levels is associated with a reduction in the strength of tendon tissue. This is in part due to a decreased rate of collagen synthesis, we also see a decreased fibre diameter and density and the rate of cellular renewal is reduced. (3).
Altered ratio of type I and III Collagen
There are lots of different types of Collagen present in skin and soft tissues. Collagen I and Collagen II are the main types present in tendons. These two collagen proteins have distinct physical properties in nature. Collagen I is a stiff fibrillar protein that provides tensile strength, and Collagen III provides an elastic network that stores kinetic energy to provide an elastic rebound.
A decreased ratio of collagen type I/III has been shown in the arcus tendineus fasciae pelvis (ATFP) that supports the anterior wall of the vagina. This altered ratio compromises the tensile strength and contributes to the occurrence of pelvic organ prolapse. (4)
Altered tenocyte proliferation
Tenocytes are the cells that produce collagen, they also repair proteins and matrix proteoglycans. Thus, the function, mechanics and homeostasis of tendon tissue depend on the activity of tenocytes, which is essential to maintaining tendon characteristics. (1)
Age-related changes in tenocyte behaviour are responsible for altered migration and proliferation rates, leading to ineffective repair processes and an increase in the frequency of tendon injuries
Weight Gain and Tendinopathy
Weight gain can also be a contributory factor to the development of tendinopathies. Increased physical loads imposed on weight-bearing tendons play a part as well as metabolic factors. For example, the release of inflammatory cytokines by fat cells results in low-grade systemic inflammation.
There is a lack of research in this area however, by increasing our understanding of the regulation of tendon cellular and molecular biology, new approaches to preventing disease development and treatment of existing diseases may evolve. (5),
Oestrogen decline is not just a condition of older age.
Menopause is a part of the puzzle that provides the context in which clients present in the clinic with pain and problems. Women may have had a hysterectomy with or without oophorectomy. It is worth knowing that ovarian failure occurs four years earlier than natural menopause after hysterectomy. Many women are not offered HRT and are thrust into menopause overnight. (6) Also, premature ovarian insufficiency occurs in 1% of women before the age of 40. (7)
Even women who have a smooth menopause transition, touch wood and think they got away with Menopause, are living with declining oestrogen levels that if left untreated can contribute to musculoskeletal conditions down the line. Conversely, ‘Oestrogen-like compounds’ appear to have a positive effect on overall collagen synthesis in tendons and ligaments. (3)
HRT and Tendons
Oestrogen has a protective role on the bones, joints, muscles, tendons, brain, heart and pelvic organs. However, it is highly unlikely that Hormone Replacement Therapy (HRT) would be prescribed based on tendon pain alone. But if multiple sites of tendinopathy are present in the context of raging hot flushes, insomnia, palpitations and mood disturbances, make an appointment to chat with your specialist nurse or Doctor.
Tendon Care
We all need to look after our tendons as we age but Women in particular need to look after their tendons post menopause. But what does that look like? There is no one magic recipe for all, but there are some key ingredients for us to consider to optimise the situation for Women experiencing tendon Pain or tendinopathy.
1. Lifestyle Medicine
Lifestyle factors can have a bearing on tissue health. A healthy lifestyle that includes a balanced diet, regular exercise, adequate sleep, stress management, and avoidance of harmful substances such as tobacco can help to support tissue health and prevent tissue damage over time.
2. Posture Matters
I am in no doubt of the contribution of Posture to the development and perpetuation of Pain and Problems. Proper posture plays a crucial role in the optimal functioning of joints and muscles. The distribution of load through the various structures and the mechanical efficiency of muscles is heavily influenced by joint positioning.
- Proper head and neck posture is an important consideration for optimal upper limb function
- Pelvic position is an important consideration for symptoms around the hip and buttock
3. Load Management
How we ‘manage load’ is an important consideration in the prevention and treatment of tendinopathy. How we hold our bodies as we stand and move can alter the loads placed on the various structures, particularly if we perform these postures or movements repeatedly.
Scissor walking where the feet are crossing like a model on the catwalk, standing on one leg with a hip sticking out or sitting with the legs crossed can all be reasons why lateral hip lain (gluteal tendinopathy) begins or refuses to go away.
If tendon pain rears its head, take a moment to think about any concurrent changes in your behaviour. Have you embarked on a new or repetitive activity? Something as simple as changing your footwear for a holiday could be the culprit. When I first moved to Cyprus, everyone was coming down with plantar fasciitis. We were all walking about in flip-flops instead of our sturdy shoes and socks and our bodies were reacting to this change in behaviour;
4. Strength Training
Strength training is crucial to attenuate the changes associated with ageing. A gradual increase in tensile loading of the tendons will improve their resilience to loading.
Lengthen to strengthen
The recommendation is that treatment approaches for older adults should include the general preservation of eccentric strengthening in preference to traditional concentric training strategies. Eccentric exercise is promising in the prevention of tendon disorders in post-menopausal women. (1)
This means resisting the lengthening phase of a movement, think of straightening the arm slowly lengthening the biceps whilst holding a weight instead of lifting it.
5. Optimise Movement Control
Think of a skill like hitting a golf ball or a tennis ball. Being able to repeat a movement with precision; the muscles acting in the right way at the right time in the right amount means that movement is efficient and effective. This is movement processing or movement control and it is a skill worth mastering. It is one that I endeavour to teach my clients every day.
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1 D.R. Leblanc, et al, The effect of estrogen on tendon and ligament metabolism and function, The Journal of Steroid Biochemistry and Molecular Biology, Volume 172, 2017, Pages 106-116, ISSN 0960-0760, https://doi.org/10.1016/j.jsbmb.2017.06.008
2 Olivio F, et al. Hormones and tendinopathies: the current evidence, British Medical Bulletin, Volume 117, Issue 1, March 2016, Pages 39–58, https://doi.org/10.1093/bmb/ldv054
3 Frizziero, A, et al. (2014). Impact of oestrogen deficiency and ageing on tendon: a concise review. Muscles, ligaments and tendons journal, 4(3), 324–328. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4241423/
4 Moalli, P. A., et al (2004). Impact of menopause on collagen subtypes in the arcus tendineous fasciae pelvis. American journal of obstetrics and gynecology, 190(3), 620–627. https://doi.org/10.1016/j.ajog.2003.08.040\
5 Hart, D. A., Archambault, J. M., Kydd, A., Reno, C., Frank, C. B., & Herzog, W. (1998). Gender and neurogenic variables in tendon biology and repetitive motion disorders. Clinical orthopaedics and related research, (351), 44–56. https://pubmed.ncbi.nlm.nih.gov/9646746/
6 Huang, Y. et al (2023). Effect of hysterectomy on ovarian function: a systematic review and meta-analysis. Journal of ovarian research, 16(1), 35. https://doi.org/10.1186/s13048-023-01117-1
7 Chon, S. J., Umair, Z., & Yoon, M. S. (2021). Premature Ovarian Insufficiency: Past, Present, and Future. Frontiers in cell and developmental biology, 9, 672890. https://doi.org/10.3389/fcell.2021.672890
