Tendon Pain Linked to Type 2 Diabetes
February 12, 2016
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By Dr. Mercola
Tendinopathy refers to pain that occurs in and around your tendons (your tendons connect your muscles to your bones). Typically, tendinopathy is the result of overuse or repetitive movements, but in people with type 2 diabetes chronically elevated blood sugar levels may increase the risk.
A recent systematic review and meta-analysis published in the British Journal of Sports Medicine shed light on this association, providing “strong evidence that diabetes is associated with higher risk of tendinopathy.”
More than 30 studies were analyzed, which showed not only is tendinopathy more prevalent in people with diabetes, but the opposite also holds true in that diabetes is more prevalent in people with tendinopathy.1
Type 2 Diabetes May Triple Your Risk of Tendon Pain
The study revealed that people with type 2 diabetes are more than three times as likely to have tendon pain compared to those without diabetes. Further, people with tendinopathy are 30 percent more likely to have diabetes than those without tendon pain.
There are multiple reasons why this association deserves increased attention, not the least of which is the fact that tendinopathy can be quite painful and may interfere with a person’s quality of life.
Beyond this, there is evidence that Achilles tendinopathy in diabetics may lead to increased forefoot pressure and the development of plantar forefoot ulcers, which may cause deep infection and lower extremity amputation.2
However, one of the greatest risks of tendinopathy to people with diabetes is that a painful tendon may stop you from being physically active, which is one of the most important and effective treatments for diabetes.
Exercise Is Crucial if You Have Diabetes
If you’ve been diagnosed with type 2 diabetes, your fate is not “sealed.” You can do far more than simply try to control the condition; you can likely cure yourself of this disease. A key aspect of that cure is exercise.
One of the amazing things about exercise is that it exerts its effects very quickly. There are long-term benefits, too, but you'll also get acute, nearly instantaneous benefits — you don't have to exercise for a year or six months to experience benefits.
Research published in Medicine & Science in Sports & Exercise even found that one single session of moderate exercise can improve the way your body regulates glucose.
It may also reduce the spikes in blood sugar that occur after a meal (elevations in these spikes, known as postprandial glucose, or PPG, are associated with type 2 diabetes, heart disease and death).3 Further, according to research published in Advances in Physiology Education:4
“Exercise is a well-established tool to prevent and combat type 2 diabetes. Exercise improves whole body metabolic health in people with type 2 diabetes, and adaptations to skeletal muscle are essential for this improvement.
An acute bout of exercise increases skeletal muscle glucose uptake, while chronic exercise training improves mitochondrial function, increases mitochondrial biogenesis, and increases the expression of glucose transporter proteins and numerous metabolic genes.”
If You're Diabetic, High-Intensity Workouts Are Especially Important
Most people can benefit from adding high-intensity interval training (HIIT) to their exercise routine, but this is especially important if you have diabetes. HIIT involves short periods of maximum exertion followed by a short period of rest.
In one study, older overweight type 2 diabetics improved their glucose regulation in just six HIIT sessions done over the course of two weeks.5
They also increased their mitochondrial capacity, which means their bodies became more effective at producing energy. Their total time investment was just 60 minutes per week.
The key to the benefit is intensity. In this study, participants performed 10 bouts of 60-second cycling at 90 percent of their maximum heart rate, interspersed with 60 seconds of rest.
Another HIIT approach is the Peak Fitness method, which consists of 30 seconds of maximum effort followed by 90 seconds of recuperation, for a total of eight repetitions.
Super Slow strength training is another option that allows you to turn strength training into a high-intensity workout.
Exercise Lowers the Risk of the Leading Cause of Death for Diabetics
Engaging in a six-month moderate-intensity exercise program led to significant health improvements among people with diabetes.6 Specifically, they had decreases in fat in the abdomen, liver and around the heart, all of which are associated with an increased risk of heart disease.
Heart disease is the No. 1 cause of death among people with type 2 diabetes. It’s estimated that at least 65 percent of those with diabetes die from some form of heart disease or stroke.7
While the exercise program didn’t lead to direct changes in heart function, the reductions in dangerous visceral fat around key organs — as well as reductions in pericardial fat, which is the second layer of fat around the heart — will undoubtedly improve heart health among this at-risk population.
Also noteworthy about the study was the relatively small amount of exercise needed to prompt such beneficial changes. The participants exercised between 3.5 and six hours a week (and ended the program with a 12-day trekking expedition), which is a reasonable goal for most people.
Further, the benefits were gained from exercise alone; no other lifestyle or dietary changes were made, which shows just how powerful staying active can be in improving your health — even if you’ve already been diagnosed with a potentially chronic disease like type 2 diabetes.
Tendinopathy Versus Tendinitis
You certainly do not want tendon pain to get in the way of your regular workouts, so if this applies to you, you’ll want to see a physical therapist who is experienced with treating tendinopathy.
Unfortunately, most tendon injures are automatically treated as inflammatory issues and prescribed non-steroidal anti-inflammatory drugs (NSAIDs), often in conjunction with corticosteroid injections. This will not address the underlying cause of your tendon pain and may expose you to unnecessary side effects.
A large part of the problem is that tendinopathy is often used interchangeably with tendinitis, but the two are not the same. The latter, tendinitis, involves inflammation of the tendon while tendinopathy involves degeneration of the tendon’s collagen in response to chronic overuse.8
The treatment methods for tendinitis and tendinopathy are markedly different, and treating the latter with NSAIDs may actually make the condition worse.
While addressing inflammation may be useful for tendinitis, treatment for tendinopathy needs to break the cycle of injury and optimize collagen production so the tendon can regain normal strength. An article published in the International Journal of Therapeutic Massage & Bodywork explained the differences well:9
“Think tendinitis and you think pain and burning in the affected area, decreased strength and flexibility, and pain caused by everyday activities. As it turns out, tendinosis is far more often responsible for these symptoms than tendinitis.
Tendinitis is the inflammation of the tendon and results from micro-tears that happen when the musculotendinous unit is acutely overloaded with a tensile force that is too heavy and/or too sudden. Tendinitis is still a very common diagnosis, though research increasingly documents that what is thought to be tendinitis is usually tendinosis.
Tendinosis is a degeneration of the tendon’s collagen in response to chronic overuse; when overuse is continued without giving the tendon time to heal and rest, such as with repetitive strain injury, tendinosis results. … The most prominent treatment goal for tendinitis is to reduce inflammation, a condition that isn’t present in tendinosis.
In fact, some treatments to reduce inflammation are contraindicated with tendinosis. Ibuprofen, a nonsteroidal anti-inflammatory, is associated with inhibited collagen repair. Corticosteroid injections inhibited collagen repair in one study, and were found to be a predictor of later tendon tears.”
Treatment Options for Tendinopathy
If you have tendinopathy, a physical therapist or other specialist can help you to recover, although the healing process may take months. It’s important to find a health care provider who is experienced with tendinopathy (as opposed to tendinitis). Treatment and self-care recommendations may include:10
When the above changes are applied correctly, it’s possible to eliminate tendon pain, according to the International Journal of Therapeutic Massage & Bodywork.12
Rest, especially at the start of treatment. A break from repetitive work tasks is important. Adjust ergonomics and biomechanics. Small changes, such as pressing keyboard keys as lightly as possible and keeping your wrists in a neutral position while typing, can make a big difference. Use appropriate support, including bracing or taping if necessary, to reduce stress on the tendon. Stretch and keep moving. This will help increase circulation, supporting the healing process, and elongate the muscle-tendon unit, which may help reduce degeneration. Apply ice. This may help resolve tendinopathy for reasons that aren't yet fully understood. Eccentric strengthening, which is “lengthening a muscle while it is loaded and contracting,” helps stimulate collagen production and improves tendon strength.
“ … [L]engthening one’s bicep while holding a dumb-bell in one’s hand would stimulate eccentric contraction,” according to the International Journal of Therapeutic Massage and Bodywork.11
A physical therapist can help you to maximize the benefit of eccentric strengthening, stretching and other exercises for tendinopathy.Massage. Deep-friction massage may help generate new collagen. Myofascial and trigger-point therapy may also be useful. Nutrition. Vitamin C, manganese and zinc are important for the synthesis of collagen production, while vitamin B6 and vitamin E are important for tendon health.
“While the cellular damage is unlikely to be reversed completely, these treatments and self-care recommendations can increase the strength of the tendon by stopping the cycle of injury, introducing healthy collagen into the area, addressing unhealthy vascular changes, and decreasing the over-abundance of ground substance.
Proper treatment of tendinosis should eliminate or significantly decrease pain, increase range of motion, increase strength, and return the patient to pain-free, normal daily activities.”
What Else Can Help You Overcome or Prevent Type 2 Diabetes?
Type 2 diabetes involves loss of insulin and leptin sensitivity, which is easily preventable, and nearly 100 percent reversible without drugs, by addressing your diet and other lifestyle habits, such as exercise, sleep, and intermittent fasting. I suggest taking a lifestyle inventory to see where you might have room for improvement and implementing the steps below.
Also, make sure to monitor your fasting insulin level. This is every bit as important as monitoring your fasting blood sugar. You'll want your fasting insulin level to be between 2 and 4. The higher your level, the greater your insulin resistance and the more aggressive you need to be in your treatment plan, especially when it comes to altering your diet.
- Swap out processed foods, all forms of sugar — particularly fructose — as well as all grains, for whole, fresh food. A primary reason for the failure of conventional diabetes treatment over the last 50 years has to do with seriously flawed dietary recommendations.
Fructose, grains, and other sugar-forming starchy carbohydrates are largely responsible for your body's adverse insulin reactions, and all sugars and grains — even "healthy" organic whole grains — need to be drastically reduced.
If you're insulin/leptin resistant, have diabetes, high blood pressure, heart disease, or are overweight, you'd be wise to limit your total fructose intake to 15 grams per day until your insulin/leptin resistance has resolved. For all others, I recommend limiting your daily fructose consumption to 25 grams or less to maintain optimal health. The easiest way to accomplish this is by swapping processed foods for whole, ideally organic foods.
This means cooking from scratch with fresh ingredients. Processed foods are the main source of all the primary culprits, including high fructose corn syrup and other sugars, processed grains, trans fats, artificial sweeteners, and other synthetic additives that may aggravate metabolic dysfunction. Besides fructose, synthetic trans fat increases your risk for diabetes by interfering with your insulin receptors.13
Since you're cutting out a lot of energy (carbs) from your diet when you reduce sugars and grains, you need to replace them with something. The ideal replacement is a combination of:
- Low-to-moderate amount of high-quality protein. Substantial amounts of protein can be found in meat, fish, eggs, dairy products, legumes, and nuts. When selecting animal-based protein, be sure to opt for organically raised, grass-fed or pastured meats, eggs, and dairy, to avoid potential health complications caused by genetically engineered animal feed and pesticides.
Most Americans eat far too much protein, so be mindful of the amount. I believe it is the rare person who really needs more than one-half gram of protein per pound of lean body mass. Those that are aggressively exercising or competing and pregnant women should have about 25 percent more, but most people rarely need more than 40 to 70 grams of protein a day.
- As much high-quality healthy fat as you want (saturated and monounsaturated). For optimal health, most people need upwards of 50 to 85 percent of their daily calories in the form of healthy fats. Good sources include coconut and coconut oil, avocados, butter, nuts, and animal fats.
Remember, fat is high in calories while being small in terms of volume. So when you look at your plate, the largest portion would be vegetables.
- As many non-starchy vegetables as you want
- Exercise regularly and intensely. Studies have shown that exercise, even without weight loss, increases insulin sensitivity.14 High-intensity interval training (HIIT), which is a central component of my Peak Fitness program, has been shown to improve insulin sensitivity by as much as 24 percent in just four weeks.
- Improve your omega-3 to omega-6 ratio. Today's Western diet has far too many processed and damaged omega-6 fats, and has far too little omega-3 fats. The main sources of omega-6 fats are corn, soy, canola, safflower, peanut, and sunflower oil (the first two of which are typically genetically engineered as well, which further complicates matters). Our bodies evolved for an optimal 1:1 ratio of omega-6 to omega-3.
However, our ratio has deteriorated to between 20:1 and 50:1 in favor of omega-6. This lopsided ratio has seriously adverse health consequences. To remedy this, reduce your consumption of vegetable oils (this means not cooking with them, and avoiding processed foods), and increase your intake of animal-based omega-3, such as krill oil.
Vegetable-based omega-3 is also found in flaxseed oil and walnut oil, and it's good to include these in your diet as well. Just know they cannot take the place of animal-based omega-3s.
- Maintain optimal vitamin D levels year-round. Evidence strongly supports the notion that vitamin D is highly beneficial for type 2 diabetes. The ideal way to optimize your vitamin D level is by getting regular sun exposure or by using a high-quality tanning bed.
As a last resort, consider oral supplementation with regular vitamin D monitoring to confirm that you are taking enough vitamin D to get your blood levels into the therapeutic range of 50 to 70 ng/ml. Also, please note that if you take supplemental vitamin D, you create an increased demand for vitamin K2.
- Get adequate high-quality sleep every night. Insufficient sleep appears to raise stress and blood sugar, encouraging insulin and leptin resistance and weight gain.
In one 10-year-long study of 70,000 diabetes-free women, researchers found that women who slept less than five hours or more than nine hours each night were 34 percent more likely to develop diabetes symptoms than women who slept seven to eight hours each night.15 If you are having problems with your sleep, try the suggestions in my article "33 Secrets to a Good Night's Sleep."
- Maintain a healthy body weight. If you incorporate the diet and lifestyle changes suggested above you will greatly improve your insulin and leptin sensitivity, and a healthy body weight will follow in time. Determining your ideal body weight depends on a variety of factors, including frame size, age, general activity level, and genetics. As a general guideline, you might find a hip-to-waist size index chart helpful.
This is far better than BMI for evaluating whether or not you may have a weight problem, as BMI fails to factor in both how muscular you are, and your intra-abdominal fat mass (the dangerous visceral fat that accumulates around your inner organs), which is a potent indicator of leptin sensitivity and associated health problems.
- Incorporate intermittent fasting. If you have carefully followed the diet and exercise guidelines and still aren't making sufficient progress with your weight or overall health, I strongly recommend incorporating intermittent fasting. This effectively mimics the eating habits of our ancestors, who did not have access to grocery stores or food around the clock.
They would cycle through periods of feast and famine, and modern research shows this cycling produces a number of biochemical benefits, including improved insulin/leptin sensitivity, lowered triglycerides and other biomarkers for health, and weight loss.
Keep up your intermittent fasting schedule until your insulin/leptin resistance improves (or your weight, blood pressure, cholesterol ratios, or diabetes normalizes). After that, you only need to do it "as needed" to maintain your healthy state.
- Optimize your gut health. Your gut is a living ecosystem, full of both good bacteria and bad. Multiple studies have shown that obese people have different intestinal bacteria than lean people. The healthier your microflora, the stronger your immune system will be and the better your body will function overall. Fortunately, optimizing your gut flora is relatively easy.
You can reseed your body with good bacteria by regularly eating fermented foods (like natto, raw organic cheese, miso, and cultured vegetables).
- Consume adequate amounts of magnesium. Magnesium plays a key role in preventing insulin dysregulation and type 2 diabetes — yet 80 percent of Americans are likely magnesium deficient. One study found those with the highest magnesium intake reduced their risk of metabolic problems by 71 percent.16
The best source of magnesium is whole, organic foods, especially dark green leafy vegetables; other good sources include seaweed, dried pumpkin seeds, unsweetened cocoa, flaxseed, almond butter and whey, but it can be difficult to get enough from diet alone.
Of the many forms of magnesium supplements available today, a newer form called magnesium threonate shows particular promise due to its ability to penetrate cell membranes.
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