Frequent Tendinopathy Questions

Hi, I have some questions about tendon health:

I’m 22. I can’t tell whether I’m prone to tendinopathy or I’m just doing things wrong, and what I’m doing wrong. Currently, I feel discomfort right around where my pec major inserts to my arm, both sides, and when I’ve felt this before, it tends to get better with rest. But in the past, I’ve felt the same kind of discomfort in my lat, bicep, glute, tricep tendons. It’s tenderness to touch as well as a bit of pain/discomfort in the stretched part of movements and especially after doing a stretched movement.

My history is that, I grew up with a pretty bad eating disorder that left me with osteoporosis, and unrelatedly also have severe scoliosis and hip impingement and labral tear. I developed a bunch of joint (not tendon) pains around age 15 (2017) or so, blamed it on the scoliosis, and stopped doing many activities. I became convinced that I could never get stronger or be healthy and this fueled my eating disorder even more. But then a few years ago, I read about pain on barbellmedicine website, and also made a post here, and thought that perhaps I was being overly cautious and needed to give my body time to adapt, and that perhaps I could get stronger. My whole outlook changed, and I began to gain weight while doing bodyweight exercises and light weights, gradually building up, and my joint pain pretty much went away. This was around late 2021 or 2022. By mid 2022 I was no longer underweight, although still on the border of being underweight, and I felt like I could do almost anything, I was amazed how fast I was recovering from everything and how good my joints felt, and a bunch of other weird problems I had from being very underweight also went away, like constant nail infections, coldness, etc. So certainly, this experience tells me that my mentality and behavior played a huge role in limiting myself, and I am really thankful for the content on this website having allowed me to have that experience. However, some tendon pains have surfaced since later in 2022, and as I ramp up the weight I lift and I can’t tell whether there really is some predisposition for me to get tendon problems because of either my health habits/behavior or genetics, or if I’m just letting my old limiting beliefs get to me again. Continuing:

Sometime in 2022, I had quite a few episodes of insomnia (amidst an already-short sleeping time of 5.5 hours or so before the insomnia), some stressful situations in life, and as I continued to increase the weight I lifted, I started to experience some tendon pains: bicep, tricep, lat, chest, never all at once, always getting better with rest, and always at the insertion point of the muscle. In early 2023, I think I mildly injured my lat tendon doing AMRAP chinups which made upper body exercising hard for a while. I also stopped gaining weight then, but maintained and made sure not to lose any weight. I was way overdoing volume, working out 6 days a week then, too, doing push/pull/push/pull/push/pull/rest. I took note and changed my program up then, doing PPLPPL and it let me continue to make gains in pushing and legs, and recently changed to full body 3x a week because my back just feels better with less days of lifting (no pain, but the big scoliosis feels a bit sticky/uncomfortable after I’ve done exercises where I’m holding heavy weight, and 3x a week plus some stretches on off days seems to make it feel better?).

I’ve made some progress since 2022, have gained some weight, and have progressed to doing dips with 70 lbs, barbell row 100 lbs, split squats with 80 lbs for around 8-12 rep range, I weight 123 lbs. I usually would be at RPE 8-9 I would say, maybe lower on the split squats. Currently, my only tendon complaint is some tenderness to touch where my pec major inserts to my humerus on both sides. And it seems to get better with rest, as I’ve had this before. But I can’t quite figure out what I’m doing so wrong to bring this sort of thing on, it happens so regularly to at least some of my tendons although never all at once (be it pec, bicep, tricep, etc.). It seems like I have to be so careful with load management, whereas I remember that before I had those episodes of insomnia and stress in 2022, I had a period of time where my joints felt 100% fine, I stuck to my program but felt like I could do so much more, and I felt like my body got stronger with each session (I was lifting lighter weights back then though). I know some people that seem to be in that state perpetually, they keep getting stronger and they never have any joint pains or overuse problems and they do more than me. They just do whatever exercises they feel like, and don’t care or think about load management and they have no pain or discomfort. I had a brief period where I felt like that, too, which is why I’m trying to figure out how or if I can get back there, or if the fast recovery I experienced back in 2021/22 was just some temporary overcompensation my body had to being underweight for so long and waking up for the first time so to speak, like a second puberty, and that how I am now is how I will feel and recover for my future adult life?

Just in typing all this up, I’m already thinking maybe part of what I’m doing wrong is RPE 8-9, maybe I should dial back the intensity even more on my dips, keep more reps in reserve, and do this for my other exercises too? Perhaps I should go back to PPL to give 2 days of rest in between upper body workout days? Or even stack upper body days and do PL, rest, PL, rest?

Some final questions:

  1. Is it of any importance that I only sleep 5 1/2 hours a night, in broken patches: 3 hrs, then intervals of 30 mins (no sleep apnea that I know of according to a home sleep test, although perhaps a lab sleep test is in order). This has actually been going on since age 15 (2017), although to be honest, in 2021/22 it probably got 1 hour better (when I had that great period in 2021/22, I was sleeping closer to 7 hours, probably 6 1/2). I always feel 100% cognitively, and even physically not tired (unless I have an insomnia episode, then I do feel effects) but I do wonder if my tendons take the brunt of my lack of sleep somehow? Does sleep disproportionately affect tendon recovery even if you have no cognitive trouble (evidenced from good performance in schoolwork, reaction-based things like driving, speed chess, etc.), and do not feel physically/systemically tired? I may be catastrophizing, but I sometimes feel like my brain’s figured out how to hack my sleep to get me lot of REM so it functions just fine on very little sleep, but I’m missing out on deep sleep as a result, and deep sleep = growth hormone/physical body recovery?
  2. I still get occasional episodes of insomnia, not as bad as in 2022, and I do have a heavy course load at school, too, which I guess is a little stressful (and of note, part of the time I felt really good in 2021/22 I was on a leave of absence from school, although part of the time I wasn’t, so… not sure the effect of that?) I also obsess over things sometimes and that probably adds some stress, too. Just how much does psychological stress hinder your tendons’ ability to recover? Or is it more likely it’s just increasing my pain response? A bit of both?
  3. Does it sound like I actually have tendinopathy, or is my brain somehow just producing pain there because I’m kind of scared of injuring a tendon?
  4. I have heard that there is a ratio of 5 : 1 for muscle mass : bone, and that athletes generally can’t get over this ratio. When I enter my measurements into one of those “maximum lean mass” calculators online, it predicts roughly 145 lbs of lean mass as my max natural potential. However, my bone density in hip and spine is shown by DXA scan to be only 2/3 of the normal. So if the calculators online assume normal bone mass, and I only have 2/3 the normal bone mass, then I seem to be at my maximum muscular potential already, as rough bodyfat measurements put me at around 105 lbs of lean mass. Is this how it works, is the fact my bone mass is so low somehow influencing my body’s ability to develop muscle and perhaps tendon? Is this why I’ve semi-plateaued around 2023? Or at least, it has been slow progress since 2023, mostly because of on/off tendon pains that I have been juggling with only slight success. Does the fact my bone mass is so low somehow mean that, despite my numbers still being beginner or intermediate on strengthstandards website, I should really be considered “advanced” for my skeletal frame and as a result should only expect to make progress at the rate of an advanced lifter?
  5. Does the fact my malnutrition was severe enough to cause osteoporosis also imply it retarded the development of my tendons? Or is tendon just like muscle, and can be built any time of your life to the same degree?
  6. Are there any examples of really strong people with chronic insomnia and sleep problems I can look to for inspiration, just as I looked to Lamar Gant for scoliosis inspiration when I first started exercising again in 2021? It would be nice to be able to tell myself: “Even if your sleep problems get as bad as they were in 2022 again, with better load management and planning you can still make a lot more progress”. Not sure if that is true but it would be nice to find such an example for inspiration. Even at the height of my sleep problems in 2022, my hormones were all in normal ranges, although a bit on the lower end of normal for some of them, so that’s promising I guess, that it is possible to get stronger with poor sleep, even though I only made a little progress in late 2022/2023.

Sorry for the super long post, and thank you so much in advance, as well as for the help I got the first time I posted here!

Hi there,

I’m glad to hear about how much benefit you got from the material here, which seems to have set you in a positive direction. I think your thought process about your training sounds reasonable, and pulling back a bit on the RPE targets for a bit would be one of the first things I’d do here, yes. Other strategies are described in our articles on tendinopathy & pain management.

To your questions:

  1. Sleeping 5.5 hours per night, in broken fashion, is not ideal for a variety of reasons. We have no way of knowing whether / to what extent it may be impacting your pain symptoms, but there is an association between sleep restriction and pain/injury issues. We have a podcast on sleep (#93) and consultation with a primary care physician and/or sleep physician may be helpful here.

  2. Acute insomnia in the setting of life stressors that resolves is not unusual, and isn’t much to worry about, although it may require some temporary modification to your training (for example, adjusting loads accordingly).

  3. It does sound like you may have tendinopathy. I generally don’t provide explanations like “your brain is producing pain” to patients, as it is all far more complex than this. A consultation with a rehab professional (or someone from our rehab team) would be more helpful to fully clarify this and provide a management plan moving forward.

Unfortunately I don’t have great answers to #4, 5, or 6. I think these are probably beyond the scope of what we can feasibly address via the forum and would be more well-suited to a one-on-one consultation.

Thank you so much Dr. Baraki, makes sense! I will try and book a consult soon and am going to check out the sleep podcast and tendinopathy articles in the mean time, and decrease RPE.