Hi guys! In this video I'm going to talk about triceps tendinopathy, or tendonitis, or tendinosis
is another name for it. We're gonna look at why do you get it and what does it feel like,
things you need to rule out to make sure that it is that,
and then I'm gonna look at the rehab for that; how do you actually get it better?
So, for those of you who don't know me, my name is Maryke, I'm one of the physiotherapists from
sports-injury-physio.com, where you can get online physiotherapy assessment as well as treatment for
your injuries. So, have a look at the description of this video if you want a link to our website.
Good! So, triceps. A little bit of a recap on the anatomy. The triceps are the muscles that
run down the back of your upper arm, and it's the ones that extend your elbow for you. So, it's
also … You know when you wave, women? Bingo wings! It's that; it's them that do that motion. So,
any exercise that extends the elbow under force. So, where you press away, or you do skull crushes,
like that, with a weight. Push-ups, because that extends the elbows. What else? Okay ... A throwing
action, so, if you throw a ball. All of that uses the triceps muscle. And that's also … Those
are the people who most often get a triceps tendinopathy. It's your weight trainers – guys who
lift weight quite regularly – and guys or girls, to be honest; I've had both of them as patients.
So, weightlifting, CrossFit type thing, anything where heavy weights are involved,
and you do a lot of high-level training for it. Also, if you do a lot of throwing and overwork
it that way. So, why does it develop? It develops right here where … So, muscle belly of the triceps
is here, and the muscles come together and attach into your elbow bone here – the olecranon – with a
thick old tendon, and the tendinopathy and the pain from the tendinopathy is mainly over this
part here. It's an overuse injury, so it means that you did too much training either over a long
period of time or in one session, and the tendon wasn't strong enough for it and it got injured.
So, we've got two types of overload injuries, or that can cause this: You've got an acute overload,
where it's one training session that you do that's a massive load compared to what you're used to,
and then the tendon becomes painful and sore, and then you've got the chronic overload,
where actually … Remember that when we train, you get micro damage in everything in your body.
So, bones, muscles, tendons, everything like that. And that's normal – that's what we're looking for.
Because it's when the body repairs this micro damage, it repairs it's stronger than before
because it realizes you need it to be stronger, and that's how you gain strength over years and
years and years. But now, the key here is that you actually need to allow the body to restore
that micro damage. So, say for instance you have a really hard training session today, where you
work those triceps, and tomorrow you wake up and you go, ‘Right! Another heavy training session!’
And it's a little bit sore and it's a bit stiff, but you stretch it out you just keep going,
then it may be that actually you're not giving it enough time to recover every time, and there's a
little bit of micro damage that just accumulates over time. And if you do that often enough, you
can end up with a proper injury like this. Now, if we look at tendinopathies under a microscope,
during the initial phases there's a little bit of inflammation involved, but in the long term
there's actually no inflammation in that tendon to be found. So, if you've had ongoing tendon pain
in your triceps tendon, inflammation is likely not part of this. Instead, if you look at it,
there's going to be part of that tendon that looks different from the rest. So, normally our tendons
are made up of loads and loads of collagen fibres in … all kind of in parallel. Now,
if you think of a string: If you have one piece of string, you can easily snap it.
Put the pieces of string together in parallel, you really can't. It becomes a really
strong rope, and you can't snap it. And that's why tendons are so strong, because of all these fibres
in parallel. Now, the fibres are also in bundles. So, you've got a few fibres together, bundle,
bundle, bundle, bundle. So, you've got all these bundles in parallel. So, that makes it even more
even more strong – even stronger. Now, when you have an injury to the tendon,
it actually only affects part of the tendon. So, one bundle or a few bundles, but not all of them.
So, that injured part becomes a little bit weaker, a little bit softer,
and it's not as strong as it used to be, whereas the rest of the tendon is still okay. Now,
when we think of tendons, people often think that it's overly tight things that cause the injury.
And that's just not true, because a stiff tendon and a tight tendon is a healthy tendon, because
tendons are designed in the body to absorb energy and give it back. So, they act like springs.
As soon as you've got an injured tendon and you look at how stiff they are with … they can send an
ultrasound wave through it to test the stiffness of the tendon … you'll find that the injured
tendon is actually softer than an uninjured tendon. So, if you've been told to do loads
and loads of stretches for your triceps tendon to help it loosen things off to give it more range,
stop doing it, because that can be the sole reason why your pain is continuing. You do not need a
flexible tendon; you need a strong tendon. And I'll talk about that in the discussion about the
rehab for this in a minute. Okay, so let me just think about what I'm leaving out here.
Now, … Ah! The other important thing here is, the triceps tendon, because of where it is, can you
see that when it works in this range, because it crosses over this bone, it also gets compressed
if you bring it … it pulls tight over that? Now, there are two parts to this injury: It can either
be just the load you put through it that overloads it in a tensile way, so, an attraction force,
but it can also be the amount of compression that was put through it that was more than what
it's used to. So, for instance if you did a lot of work just in that range or deep into that range of
dips that really took you deep, it can be that compression load on the tendon that contributed
to its injury. And we're going to use that in rehab to not aggravate it at the start.
Okay, so, to recap about why it happens. It's overload; you've either done too much in one
session or you have not allowed it to recover over several sessions – could be months – and that's
why you've developed it, and there's now part of the tendon that's not as strong as it should be,
and we do need to strengthen it back up to get it healthy. But remember, it's an overload injury,
so if we increase the strength training on it too quickly, it will just feel worse. So,
the one thing that you do need to understand is that there are other things that can cause pain
in that area. And one of the most common ones is if you actually have a tear in the tendon there.
So, how do you know if you've got a tear versus a tendinopathy or tendonitis?
A tendinopathy or tendonitis usually gradually comes on. So, you'll … It may be in one session
that this pain starts, but it's not a sudden sharp pain that you feel; it's kind of like,
‘Oh that feels a bit uncomfortable! Ooh that feels a bit uncomfortable!’ And it builds,
and it can often be a few hours after the training session or even just the next
morning that you wake up you go, ‘Ah, that is really painful and stiff now!’
Or you may just have that it builds gradually, niggles over several weeks,
before it properly gets painful. Whereas, if you have a tear, there's usually a sharp,
sudden pain with activity. So, for instance, you'll be doing an exercise and you go, ‘Ooh!
What was that?’ Or more commonly, you'll fall and put your arm out, and you'll go, ‘Oh! Okay,
that's painful now!’ Or it's that you throw a ball or something and you feel a sudden sharp pain.
If that's how your pain came on, you need to go see somebody for a scan,
that they can just rule out that it's not a tear, because then your treatment approach needs to be a
bit different. But if the pain came on gradually, it's likely a tendinopathy, and then the treatment
approach that I'm going to discuss now will work for you or will be appropriate. Good! So,
the first step to treating triceps tendinopathy is the same as for all tendinopathies:
we need to manage the load that goes through it. So, if we think of this as an overload injury,
you can't just keep on training on it, because you'll just continue overloading it because now
it's not even as strong as it used to be, and you'll keep that pain cycle going. So,
you have to identify what activities really aggravate it and cut them out and reduce them
totally to the point that they don't aggravate. Now, for some athletes it may be that they need
to avoid all exercise that involves the triceps action for a set period of time;
for others it may just be that they need to reduce the load that they put through that tendon. So,
for instance, if you were using 50 kilo weights, you now need to
use 20 kilo weights, that you don't get pain during or after the session or the next day.
It may also be that you just restrict the range of motion that you work through. So,
you'll find that often working the triceps in this deep angle, where you get a lot of compression,
can cause more pain. So then, by just actually working them in a range where you don't get
that compression can be useful. So, there's plenty of ways to offload that tendon to
allow it to calm down while we do the rehab. That doesn't necessarily involve total rest,
but it may be that you also need to avoid using it for a period of time.
Now, when you go back and you start your rehab, here's a few important things:
First of all, do not go and do loads of triceps stretches; they will likely just make your pain
feel worse. And it may not be in the moment; it may feel really good to stretch that tricep,
but then a few hours later it can feel worse, or it can just be that your pain just doesn't
calm down, and you can't link it to anything specifically, but every day you do your stretches
diligently, and the penny has just not dropped. So, if you are doing triceps stretches, see what
happens if you leave them out for a week: Are you starting to see any improvement? On that note,
also notice when you're stretching that area without thinking about it. So, examples of that
would be sleeping with your arms bent up like that, because that's going to cause a low-level
compression over that elbow or sitting like that while watching stuff. So, look at what you're
doing with that elbow when you're not actually training. Try to keep it a little bit straighter;
it doesn't have to be dead straight, but just keep it in a relaxed position that's comfortable for
it. If you take it out of a position and you think, ‘Oh, that stiff now! it was likely not
the right thing to do there. Okay, so that's Step 1: stretching is not the way to fix this. Step 2
is, you need to figure out at what level this can now start to strengthen. So,
it may be that you have to bring the weights right down and really start with baby weights
to get a level that doesn't actually aggravate it. And at the beginning, I would go for exercises
that do not cause a lot of elbow flexion. So, just working it from 90 to straight rather than from
all the range in there all the way through. So, if we think of exercises that could be useful is,
if you're lying on your back and you're just doing that motion, but not allowing it to come all the
way back. So, just that motion. Or with a cable; same thing, just pushing it down, coming back up,
that type of thing. But then eventually, if it's comfortable at that level and you've trained it
for a while, we do need to bring it into the more compressed levels. But it's not just about, ‘Okay,
I've done it for two sessions, now let's see if we can load it up and take it all the way through.’
You have to progress slowly through it and see how it reacts. Use pain as your guide. Any exercise
that you can just feel a little niggle there, so you just ... you know there's something there,
but it doesn't cause you pain while you're doing it, and there's no pain that flares up in the
hours afterwards, and especially it's not more painful the next day; that exercise was at the
right level. If you get a delayed pain response that lasts for more than just an hour or two and
it's more uncomfortable the next day, what you did the previous day wasn't right for it, and you need
to change that up. Let me think what else we need to talk about here. Okay, so what other treatments
could be useful? If we think of massage, it can make the muscle feel more comfortable, but it's
not going to heal it, because it's not going to actually strengthen the tendon. And if you really
grind the tendon over that bony spot, you can even make it feel worse, because you'll just irritate
that part that's injured. There are things like shock wave that can be used; the research at
the moment is showing that it's not really that useful; they've not done that much research on it.
But if you've tried rehab to the right level and it has not worked, it's something you could
consider. Again, with injections, there's not a lot of research out there yet about it, so I can't
really say whether it works or not, but if you've tried rehab properly and it hasn't really worked,
it's always worth to try an injection or something like that. Excellent! Let me know if you've got
any questions. But if you need more help with an injury, you're welcome to consult one of us
via video call – the link to the website is in the description of this video. Take care!