I’m a physical therapist who specializes in treating common musculoskeletal complaints in perimenopausal and postmenopausal women. Due to my past experience as a yoga teacher for many years before venturing down the clinical path, the majority of my patient population is made up of long-time yoga and Pilates practitioners and teachers.
Within this population, I encounter a number of people who’ve been walking and doing bodyweight movement practice as their primary forms of exercise. Primarily engaging in bodyweight exercise (or movement with very light weights), combined with the tissue changes that occur in menopause, presents a general problem of underloading.
The solution is resistance training to build up the strength and thickness of the tissues of the body, along with improving cardio-resperatory fitness.
Read on to find out why good old strength training and cardio conditioning is not only the solution to preventing and treating menopausal related joint and soft tissue pain, it’s arguably the most effective, research-backed anti-aging strategy!
Every day at the clinic I hear reports from patients who are in menopause that sound like this:
- My body doesn’t feel like my own.
- My joints ache all the time, especially in the mornings. I feel so stiff.
- Sleeping on my side is uncomfortable because of the pain in my outer hip. I have hip pain walking and going up stairs.
- I’ve never had injuries in my yoga practice, and now for no reason this shoulder pain… or this hip pain… It’s preventing me from staying active and enjoying the practice I love.
- I feel more easily fatigued and achy with exercise and it’s made me become more sedentary.
- Walking is my primary form of exercise and it’s becoming too painful. I’m worried about what will happen if I can’t walk as much as I did in the past.
- I’m putting on weight in areas of my body I didn’t before.
- The same exercises I’d done in the past to alleviate my pain aren’t working anymore.
- I used to love running but not anymore with these knees.
- I got my DEXA scan results and I have osteoporosis. I don’t understand. I’ve been active my whole life.
You might be experiencing these common menopausal pain symptoms:
- Aches, pains, and sensations of tissue tightness arising in multiple body regions.
- Joint and tendon sensitivity that seems to bounce around—your left hip one day, right shoulder the next—but everything hangs around relentlessly for months.
- Pain that is difficult to localize. Like a tea bag in hot water, a deep ache infuses and spreads from one body region to another neighboring area.
- Increased joint sensitivity after exercise, later that day in the evening before bed or a spike in pain and stiffness the next morning after a day of increased activity.
- Difficulty finding positions of comfort at rest. Discomfort in sitting and sleeping positions.
If you’re feeling these things, you’re not alone.
I’ve just described the types of symptoms I treat most often here in a physical therapy space that specializes in menopausal persistent pain conditions.
Rest assured, there are steps we can take preemptively to minimize the impact of menopausal changes on fitness routines and daily activities, and to support the musculoskeletal system for long-term health and resilience at any age.
What might seem like random aches and pains with no apparent cause is likely due to the changes that occur in muscles, tendons, cartilage, and bones due to loss of estrogen.
Menopause: A stage of life marked by changes
Menopausal age varies between roughly 45 and 52, and perimenopausal symptoms can last for years. A number of factors at this stage of life contribute to loss of tissue density and decreased strength.
- It’s a time when life responsibilities such as career, parenting, or caring for aging parents can take center stage.
- Major life changes and shifts in habits and routines can lead to increased stress, less exercise, and a more sedentary lifestyle.
- Symptoms of perimenopause such as decreased energy, brain fog, and poor sleep can limit one’s ability to exercise and optimally recover from exercise (it’s in the recovery phase when the body rebuilds, stronger than before).
For both men and women, physical performance declines with age. However, research suggests a more rapid decline in women compared to men in middle-age. This difference is likely due to hormonal changes in women during menopausal years.
Age related changes in women are of particular importance for longevity. The health risks that come from loss of fitness are many:
- Decreased strength and power (the ability to produce force quickly) are associated with slower walking speeds, mobility limitations, and increased risk of falls among older populations.
- Loss of bone density increases the risk of fracture.
- Loss of muscle mass and frailty are associated with a higher risk of cognitive decline.
- Women are more likely to die from a cardiac event than men.
Why does loss of estrogen in menopause cause tissue changes in middle age?
Estrogen isn’t just a sex hormone responsible for reproductive health and regulation of the menstrual cycle. It plays a vital role in the maintenance of musculoskeletal health. Estrogen, specifically estradiol (E2 – the primary form of estrogen prevalent during reproductive years), is a potent anabolic hormone. This means it helps build the body up with increased muscle mass and other soft tissue strength, collagen production, and maintains the health and density of bones.
When E2 levels decrease in menopause, it not only becomes harder to build muscle and bone, it also becomes harder for the body to repair following injury or recover following intense exercise. This is a time when insidious musculoskeletal complaints (ones that arise gradually over time) become more disruptive to daily life.
Let’s take a look at how loss of estrogen affects various tissues of the body and common conditions that occur as a result.
Muscle: Decreased strength and soft tissue resilience in menopause
The anabolic property of estrogen helps muscles grow. It also helps muscles recover more efficiently after physical activity.
Decreased muscle mass in menopause can lead to:
- Loss of strength and power which can lead to slower walking speeds, higher risk of falls, frailty, and increased risk of fractures.
- Decreased insulin sensitivity and higher risk of developing type 2 diabetes
- Loss of independence later in life
Injury can arise from deconditioning, underloading, or loss of strength:
- The definition of injury is when the forces involved with a movement or ongoing activity are greater than what the tissues of the body can withstand or recover from.
- Injuries or aches/pains from daily activities and exercise become more likely when the body has a lower threshold for tolerating forces. This includes episodes of low back pain, persistent neck pain, soft tissue strains, joint pain and sensitivity, ligament sprains, etc.
Affects of menopause on tendons and ligaments
Estrogen increases collagen content in connective tissues like tendons and ligaments, making them stronger.
Changes to connective tissue in menopause can lead to:
- Loss of strength and thickness in tendons and ligaments, increasing the risk of injury.
- Rotator cuff related shoulder pain
- Frozen shoulder
- Gluteal and hamstring tendinopathy
- Elbow tendinopathy
- Ankle and foot pain such as achilles tendinopathy and plantar fasciitis
Cartilage and joint changes in menopause
Changes in cartilage can lead to:
- Knee osteoarthritis
- Hip osteoarthritis
- Foot and ankle pain
- Neck, shoulder, and low back pain
Arthritis is primarily a problem of inflammation. That’s what causes the pain symptoms and loss of function, anyway.
Among the general population (not professional athletes who push the human body to the extremes) it’s not actually an issue of “wear and tear.” It’s a problem of underloading and deconditioning. One that worsens with disuse and avoidance of activity.
The good news is that heavy loading (squats with heavy weight for example) and impact (running and jumping) actually have a protective effect on cartilage. The extra good news—if you’re willing to invest some time and effort—is that improvements in metabolic health via improved cardio fitness can greatly decrease pain with inflammatory conditions like knee and hip arthritis.
Decreased bone density during menopause
Oh this is a biggie! The “talk of the town” in my little clinical town.
Estrogen stimulates the activity of osteoblasts, the cells responsible for bone formation. This leads to increased bone density and can help prevent osteoporosis, especially in postmenopausal women.
The only two research supported ways to improve bone density without medication are:
- Heavy (for you) strength training with weights
- Impact such as jumping, and of course… landing
The tricky thing about bone loss is that it’s “silent.” We can’t see or feel it. There are no common pain complaints like the conditions listed above. That’s why it’s important to be proactive about your bone health.
There’s no time to waste. If you haven’t been lifting weights in your 20s and 30s, now’s the time in your 40s, 50s, and beyond.
Why yoga and walking aren’t going to be enough to combat changes during menopause
I was a yoga teacher for 14 years before beginning school for my clinical doctorate in physical therapy. I can say with confidence from my perspective on the clinical side, from poring over the research and applying my understanding to patient cases:
When the root of the problem is spending decades only doing activities that involve your own body weight, you’re not going to make any progress in the tissue capacity department with more bodyweight practice.
HARD TRUTH: You’re not even going to keep pace with normal age related loss of tissue strength.
You’ve made it over here to my blog and read this far. I’m going to assume you’ve probably heard a bit about the benefits of strength training.
I’m not talking about warrior 2 with little pink dumbbells, no. Or the Pilates reformer that has a maximum weight in spring resistance with no ability to progress. I’m talking about lifting the appropriate weight for you right now that drives strength adaptation, and gradually progressing that weight over time.
- This is what gives out muscles, tendons, cartilage, and bones the stimulus they need to get stronger.
- You need to send a stronger signal—one that’s well above and beyond what your body is accustomed to in daily life activities.
- This will help alleviate common musculoskeletal pain problems in menopause.
- And will bolster your health and independence in the second half of your life.
Next steps: The key is finding an appropriate on-ramp so you feel safe and supported in initiating a strength training routine in menopause
Are you experiencing the symptoms listed above and think physical therapy could help you sort through the mixed messages and finally find pain relief strategies that also address your long-term health?
- My PT practice expects more of you in middle-age!
- I can help you build a robust and resilient body that will keep you doing all the things you want to do.
Are you looking for a beginner strength program custom made for perimenopausal and postmenopausal yoga and Pilates practitioners?
I got you. Here are three ways I can help you avoid the negative impacts of menopause:
1. Physical Therapy for Women During Menopause
If you are local to New York City (Nomad, Flatiron, and Chelsea neighborhoods), come see me for physical therapy. I’ll conduct a thorough clinical examination that covers whole-system health factors as they relate to common musculoskeletal complaints in menopause, a movement screen and physical exam, as well as advice for implementing a strength training program to prevent and treat osteoporosis. Practice Human proudly accepts Medicare and works out-of-network with most insurance plans.
2. Small Group In-Person Strength Classes for Women Post-Menopause
For those local to New York City (Nomad, Flatiron, and Chelsea neighborhoods), Durability for Life is Practice Human’s signature small group strength training course. Designed for women ages 65+ who want to feel more confident and capable in daily life and with more demanding physical activity. Appropriate for people with osteopenia, osteoporosis, knee and hip arthritis, and persistent low back pain. Led by physical therapist and strength & conditioning coach Caitlin Casella.
3. Online Strength & Conditioning for Women in Menopause
The Slow Cooker is a comprehensive 15-week online small group strength & aerobic conditioning program designed for women ages 40+. Appropriate if you are perimenopausal or postmenopausal, training with knee or hip arthritis, have osteopenia or osteoporosis, or working with persistent pain. Led by physical therapist and strength & conditioning coach Caitlin Casella.
Next on your reading list: Hip Pain with Menopause: A Strength Focused Guide to Treating Gluteal Tendinopathy
