Hormones have a great influence not only on the balance of the endocrine system but also the effect on the musculoskeletal system. Constantly changing hormones, especially estrogen levels, are certainly something to consider when it comes to treating people with musculoskeletal issues.
Having too much estrogen can weaken tendons and ligaments, and lead to systemic inflammation. Having too little of it, can toughen tendons and ligaments, and cause a decrease in muscle fibers and collagen production.
Taking this into account when working with patients is key to being able to effectively design a treatment program to help alleviate their symptoms.
When hormones are out of balance, a whole host of symptoms can occur such as:
And these symptoms can show up whether estrogen is too high, or too low. Here’s a clip from my course Hormones Matter: Considerations For Treating Women With Musculoskeletal Pain, where I discuss what happens with high and low levels of estrogen.
If you’re looking at this list and think it looks like central sensitization, you’re right. When the hormones go out of balance, it can be a driver for central sensitization and other problems like:
*Chronic fatigue syndrome
*Complex Regional pain syndrome
*Chronic back pain
*Pelvic pain syndromes
So what does this mean as far as treating patients with hormone imbalances?
It means we really need to listen to what the patient is saying to us, evaluate how important that is, and then consider what else might be going on in their lives.
Often when someone comes in with back, knee, or hip pain, we are really quick to say “You have tendinitis or tendinosis.” Or “You have this problem in your back.” or “ You have a hip labral tear.” But is this really what is going on? Are you asking them what else is going on in their life? Are they any other symptoms or factors such as stress or lack of sleep that are going to cause systemic inflammation, flaring up these conditions?
We also want to think about their lifestyle and diet choices. There are certain foods that can help balance out hormones. Things such as:
Taking biopsychosocial factors into account, as well as whether someone is estrogen dominant or estrogen deficient will influence how we treat them.
Someone with high estrogen levels will most likely show signs of a chronic inflammatory state from the breakdown of estrogen. This increased systemic inflammation then cascades resulting in the breakdown of collagen and muscle tissue. Ligaments and tendons also become lax and more prone to injury in an estrogen dominant state.
Someone with low levels of estrogen has a completely different situation going on. The tendons and ligaments become stiff and inflexible. There is a loss of type II muscle fibers, decreasing quick reaction times. Muscle and collagen changes are happening here too, but not because of inflammation, but because the lack of estrogen decreases testosterone and protein synthesis.
So when you treat someone with shoulder pain in their 30s versus their 60s, you’re going to have to consider different drivers.
There is conflicting evidence in the literature, but based on what I’ve been able to find and my own conclusions, it seems that a continuous loading exercise program, one focusing on more isometric exercise, may actually be better for stiffer tendons. Whereas eccentric exercise, which is currently the gold standard for treating tendinosis, may actually cause more damage to the tissues and increase inflammation.
There needs to be more research, but what has been studied alludes that people with low estrogen can increase tendon and muscle health by performing isometric loading between high-intensity activities. What we do know for certain though, is that if these patients don’t stay consistent with their program, then the benefits of increased collagen production will eventually drop off.
The takeaway, we can just assume everyone with musculoskeletal issues is the same. And as such, they can’t all be treated the same way. We have to look at all the factors going into the system to be able to diagnose the driver and create positive change.
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