Navigating tendon pain. No, there is no true inflammation in your joints!

We absolutely love working with tendon pain because it challenges so many of current beliefs on what recovery should be like. One of the advices that are often given, even by healthcare professionals, is to rest and to take it easy. Well, no. Tendons don’t actually like it when you take it “easy”!

Exercise is the supreme leader when it comes to tendinopathy

achilles tendinitis, chiropractor singapore, kingsley tay, beach volleyball
National athlete Kingsley Tay performing eccentric heel raises as per the Alfredsons 1998 Achilles tendinopathy treatment protocol Still works after two decades

Thanks to Alfredson and friends, we know exercise works awesome for tendon pain since as early as 1998! He was the guy who made eccentric calf raises famous for the treatment of Achilles tendon pain. So, you know, we know exercise works for a while now.

The good thing is science is never quite constant. We get new research being published on a daily basis and we every so often we do a breakthrough. Luckily for us, new research has demonstrated that there is a superior exercise approach. This is now known as heavy slow resistance or affectionately referred to as HSR in exercise science.

What causes your tendon to hurt?

tendinopathy, tendon painA study that was published just this month took a deep dive into tendinopathy to try to figure what exactly makes a tendon hurt. And the results are, as usual, mind blowing!

Believe or not, tendon degeneration is NOT correlated with chronic pain. If you have been following our blog, you would know knee generation also correlates very poorly with pain. Degenerative MRI findings of lumbar spine also correlates very poorly with pain. Research is very, very compelling that things like osteoarthritis and degeneration really isn’t something you should be concerned with if you have any sort of pain or whatsoever.

One of the interesting findings from the paper is that patients with chronic tendon pain had tendons that are innervated. By innervated, we mean that there is nerve sprouting that grows into the tendon proper. In comparison, health tendons do not have any fibre nerves within the tendon itself. Therefore, it makes sense why healthy tendon hurts and why an “injured” tendon may be painful.

A biochemical basis to a painful tendon

Having extra nervous development in your painful tendon is not the only reason it hurts. There are other biochemicals that are involved in tendon pain.

The two pain neuromediators that are identified are glutamate and substance p. Glutamate is an excitatory neurotransmitter and it is often associated with sensitisation in people with chronic pain. When we talk about sensitisation, we are referring to an area being more “sensitive” to a stimulus than usual.

For example, in case of being sunburnt, the affected area of skin is more sensitive to touch. The resulting effect is that the degree of tactile pressure you will need to trigger a pain response is quite small!

Sensitisation is problematic for chronic pain sufferers because this means the stimulus that is required for them to experience to pain response is lower than healthy people. So maybe healthy individuals can sit for 4-5 hours before getting back ache. In sensitised population, they may be sitting for 30 minutes before experiencing some form of low back stiffness. This type of sensitisation can be the result of glutamate activity in your body.

It’s not tendinosis or tendonitis. It’s tendinopathy.

If you look at medical textbooks (read: outdated), you will see terms like tendinosis or tendinitis being used. The difference being  tendinosis is the degeneration of the tendon’s collagen while tendinitis refers to inflammation of a tendon. This sort of distinction is problematic because, again, degeneration of tendons is NOT associated with pain. Also, there is contention to the involvement of inflammatory cells in tendon pain.

Evidence-based chiropractors today do not make the distinction between the two (because there is no clinical difference) and largely prefer the term tendinopathy when describing tendon injuries.

Recovery is complex and is not just about “fixing” your damaged tendon

There really are a lot of considerations to achieving a full recovery with tendon pain. No, it’s not just a case of doing calf raises to make your calves stronger. Strength alone, we promise you, is not enough to heal your injury.

(If strength is the cure to all injuries, then strong people should never be injured. We know from anecdotal experiences, and research, that strong people do experience pain and injury!)

Quite often, we have to consider that works from an evidence-based point of view. We also have to consider if there are any factors (e.g., sensitisation) that needs to be addressed.

At the end of the day, a good recovery programme is about taking a whole-person approach to what it means to be pain-free, and taking meaningful steps towards your ideal recovery state. This often varies from individual to individual. With this in mind, cookie cutters often do not work.

Why do you exercise? Aren’t you a chiropractor?

chiropractic clinic singapore

Yes, I am a chiropractor and yes we primarily use exercise in our recovery programmes. Why? The results are better.

Often we receive comments that we are not a chiropractic clinic because we use exercise in our treatments. Some people will refer our work as physiotherapy. Well, that’s simply not true!

While physiotherapists in Singapore do often use exercise in their treatments, exercise is very much also a core part of chiropractic!

In fact, exercise has been a big part of chiropractic since the very early days. The first chiropractors in United States did use exercise to help patients achieve alignment of their spines. What we are doing at Square One Active Recovery is 100% part of chiropractic!

Unfortunately, many chiropractors in Singapore choose to not offer exercise as part of their treatment approach. The reason is because exercise as a treatment takes consideration longer time than just a five-minute full spine adjustment.

Spinal manipulation (i.e., chiropractic adjustments) is just a short-term solution

Furthermore, the relief from getting cracked is fairly short. Research suggests that it lasts for only 30 minutes. While many chiropractic patients do experience relief for a few days or even up to a few weeks, they always need regular treatments. For this reason, traditional chiropractors make lots of money by offering only adjustment cos you have to keep coming back!

With the growth of science and research, we starting to learn more about body, and what actually helps with recovery. Both chiropractors and pain patients alike would have to keep up in order to achieve good outcomes. Yes, all of us have our own biases, beliefs, values. We are not denying that.

What we are saying is that, at some point, all of these have to go if we want good outcomes. We have to keep up with times. Especially if you are not getting better.

Have a think about it. You can’t keep doing the same thing and expecting a different result. What you need for extraordinary results is a radical change. This can start with the type of treatments you choose.



Frustrated by the lack of results-driven and ethical chiropractic clinics in Singapore, Chiropractor Jesse Cai found Square One Active Recovery to deliver meaningful and sustainable pain solutions.

Our goal? To make our own services redundant to you.

*We do not offer temporary pain relief such as chiropractic adjustments, dry needling, or any form of soft tissue therapy.