Why does my elbow hurt all the time?
My complaints of right elbow pain gradually started with arm workouts at the gym. There was no specific mechanism of injury, no fall, and my workout hadn’t drastically ramped up. I have been consistently working on getting stronger for the last 6 years.
The elbow would ache after exercise for about an hour then resolve. Then it became a little more frequent. I began to notice it during push ups and farmers carry’s and it would linger for most of the day. After a few months my elbow would ache in the morning or when gripping small items around the house. Then it became stiff and achy with general every day movement.
If you’re in perimenopause and noticing more aches, stiffness, or even unexpected injuries, you’re not alone. Many women, including my 49 year old self, find that their joints start feeling more sensitive or prone to pain during midlife.
At this stage of life you may expect vasomotor sympoms. As well you may experience or heard about expecting genitourinary symptoms, weight gain, low libido, brain fog, or anxiety. But did you know you can also experience musculoskeletal symptoms where it feels like your body is just breaking down on you no matter how consistent you exercise?
Lovely, right?!!
70% of all midlife women will experience the musculoskeletal syndrome of menopause, 25% will experience severe symptoms and 40% will have no structural findings. [Wright et al, 2024].
Menopause is a significant transition for every woman. For athletic women, these changes can feel particularly frustrating. as it can interfere with exercise performance, recovery, and over all well-being.
During perimenopause, estrogen (and other sex hormone) levels fluctuate rapidly. Estrogen plays a crucial role in musculoskeletal health by supporting bone density, muscle mass, and joint function. Additionally, it has anti-inflammatory properties that reduce swelling and pain, keeping muscles and connective tissues resilient. As estrogen levels decline, joints can become more susceptible to stiffness, swelling, and discomfort while tendons become stiffer, less elastic, and more prone to injury. [Wright et al, 2024].
The Journal of Neruoinflammation reports, “increasing and compelling evidence showing that estrogen decline during the menopausal transition drives a systemic inflammatory state.”
You can be very active in midlife and gradually begin to notice musculoskelatal symptom devoid of specific injury such as:
- Stiffness in the morning or post-exercise
- Nagging pain in joints like elbows, hips, and ankles
- Decreased range of motion and flexibility
- Increased muscle soreness and prolonged recovery times
- Increased sensitivity to repetitive movements
and further symptoms on this table from Dr Vonda Wright.
(Wright et al, 2024)
It is important to note that tendon pain is less likely from degenerative structural changes and more due to influences from neuroimmune factors which explains why pain doesn’t correlate to any specific findings on a scan. (Ackerman, et al. 2022)
Over the years, middle age women would come to the clinic with a diagnosis from their doctor of hip bursitis, or tennis elbow. They would tell me, “I don’t even play tennis.”
One (among many) known risk factors for tennis elbow is menopause or perimenopause due to its affects on tendon health.
By the way hip bursitis is more aptly named, Gluteal Tendinopathy as the bursa isn’t the culprit they once thought it was. For more of a deep dive, read this study on estrogen effects on tendon and ligament function
As a physical therapist my goal with helping midlife women is to consider the broader physiology at play and the concern over one’s quality of life. What’s needed isn’t soloing out a specific exercise protocol for the “itis” and telling someone to stop exercising all together.
Instead managing perimenopause while staying active, especially with joint pain, requires education, self-care strategies, targeted exercise modifications, lifestyle adjustments, and good communication with your doctor. Being educated that your body is adapting to changes, and empowering a person with the right approach, helps them stay strong through perimenopause and beyond.
How to adjust
Exercise & Lifestyle Adjustments
- Guidelines for exercise: A good guideline for approaching physical activity is recommended to be at least 150 minutes of moderate-intensity aerobic activity per week with 2x/wk strength training. This is the minimal dose. If MSK symptoms are keeping you from healthy doses of physical activity then seek out a physical therapist for personal guidance.
- Strength Training Modifications: Adjust exercises rather than stopping altogether.
- Low impact exercise and reducing weight doesnt have to be the only way to modify. While it’s necessary to stop the most aggravating movements that provoke pain, you don’t need to stop exercising.
- Pay attention to the specifics. For example, with my right elbow, the most painful exercises were the high pull, lateral raises, and pushups. I found I could still grip heavy weight with other exercises which allowed me to continue with arm day workouts. It just looked different for a while.
- Gradually progressing the weight with slower speeds can improve tendon health. (Cardoso et al, 2019) Think much slower reps than your typically perform. For example, in a bicep curl 3 seconds up, pause at the top, then 3 seconds down. (6 sec/rep tempo – Morrison, Cook 2022)
- Slow heavy resistance training is how you improve strength and reduce tendon strain. Lifting slow at a heavier load (70% -85%1RM) requires less overall repetitions, (approx 6 total reps).
- You could also slow dow the speed entirely and include isometric exercises which is equally less provocative for tendon pain. (Rio, et al 2015) Watch this video for an example of isometric exercises for lateral hip pain.
- The Right Dose is the Remedy: Instead of looking at the “what” meaning what type of exercise is best or worst. Consider the “how”. Exercise, like medicine, is most beneficial with the correct dosage. If you want to keep doing your favorite type of exercise, then your options are in altering your frequency, intensity, duration, or your overall volume in a given week. There are many personalized options here and can be best prescribed by working with a good fitness professional knowledgable in Menopaual health.
- Rest & Recovery: Change up your recovery days. Notice how your body responds within the first 24 hours of a workout. If you are more inflamed and in pain, then dial back the exercise regimen. If you feel good or have a tolerable soreness then keep up the good work. You may need more time between daily workouts or more time between sets. Time between sets is not something athletes do well but it can make a difference your body adapting better to the stimulus of exercise. Prioritize warm-ups and cooldowns as well.
- Get quality sleep: Sleep plays a critical role in muscle and joint recovery.
- Listen to Your Body: Work with what feels good. 100% effort doesn’t mean 100% intensity.
- A common rule in rehab is not to let the joint pain during exercise to exceed 3/10.
- How quickly estrogen levels start to decline is unique to each woman and varies day by day/ week by week. “During perimenopause levels fluctuate and become unpredictable. Eventually, production falls to a very low level,This means that you can have one symptom one day and an entirely different symptom the next. The intensity of symptoms can also fluctuate in the years leading up to menopause.”
Hormonal Support
- HRT/MHT: Consider speaking with a healthcare provider about Menopausal hormone therapy (MHT) to reduce the rate of change that tends to be so severe and distressing to quality of life.
- Studies suggest that MHT may have a protective effect on tendons, reducing injury risk (Ogbolu et al, 2019)
- Personal anecdote. My elbow pain significanlty reduced when I began hormone therapy prescribed by my MD and I had less bouts with hip and back pain while returning to my regular exercise routine.
- This is not medical advice. Talk to your doctor about what is best for your own physiology.
