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Unraveling Cortisol: The Hidden Knot in Pain

Updated: 4 days ago

A Rope Tied in Knotts

As MSK (musculoskeletal) practitioners, we must consider the effects that cortisol can have on our patients. Often, I see patients with chronic conditions. Their bodies are inflamed, they are extremely sensitive to pain, full of muscle tension, have terrible sleep patterns, and are generally not happy people. Without a doubt, there is one unifying factor in most of these patients: "CORTISOL."

High cortisol levels in the body lead to pain. Lowering cortisol can reduce or eliminate pain. Cortisol, a glucocorticoid hormone released by the adrenal glands, plays a crucial role in the body's stress response. While it is essential for various functions, chronic high levels of cortisol can have highly detrimental effects, including the exacerbation and perpetuation of pain.

Article Index:


Cortisol Formula

The Effects of Cortisol

Inflammatory Effects

Prolonged elevated cortisol levels can disrupt the immune system, leading to a chronic pro-inflammatory state often seen in conditions like arthritis and other inflammatory diseases. Although cortisol naturally has anti-inflammatory properties, consistently high levels can paradoxically interfere with glucocorticoid receptor function and impair feedback mechanisms. This results in an overproduction of pro-inflammatory cytokines such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). Lowering cortisol levels helps restore immune balance and reduce chronic inflammation, which can alleviate pain associated with these conditions.

Modulation of Pain Sensitivity Effect

Cortisol affects how the nervous system perceives pain. Elevated cortisol levels can make pain receptors more sensitive, lowering the pain threshold and making the body more responsive to painful stimuli. Reducing cortisol levels can decrease the sensitivity of these pain receptors, resulting in a lower perception of pain. Cortisol binds to glucocorticoid receptors, altering gene expression to reduce inflammation and modulate immune responses.

Neurotransmitter Regulation Effect

Chronic stress and elevated cortisol levels can dysregulate neurotransmitter homeostasis, notably affecting serotonin and dopamine pathways, crucial for mood regulation and nociception. Cortisol-induced alterations in the hypothalamic-pituitary-adrenal (HPA) axis can reduce the synthesis and release of these neurotransmitters, leading to mood disturbances and heightened pain sensitivity. The hypothalamic-pituitary-adrenal (HPA) axis is a complex set of interactions among the hypothalamus, pituitary gland, and adrenal glands that regulate stress responses, mood, and energy metabolism by releasing cortisol.

Lowering cortisol levels helps to normalize the function of serotonergic and dopaminergic systems, thereby enhancing mood stability and attenuating pain perception by restoring neurotransmitter balance.

Muscle Tension Reduction Effect

As a practitioner focused on treating musculoskeletal (MSK) conditions, "Muscle Tension Reduction" is particularly compelling. Elevated cortisol levels are linked to increased muscle tension and spasms, significantly contributing to MSK pain. Cortisol influences the hypothalamic-pituitary-adrenal (HPA) axis, enhancing the excitability of the neuromuscular junction, which leads to heightened muscle contractility and sustained tension.

This persistent muscle contraction results in discomfort and pain, often worsening conditions such as myofascial pain syndrome, fibromyalgia, tension-type headaches, and back pain. By lowering cortisol levels, the excitability of the neuromuscular junction decreases, promoting muscle relaxation, reducing muscle tension, and subsequently alleviating MSK pain.

Improved Sleep Quality Effect

Chronic elevated cortisol levels can disrupt your circadian rhythm, affecting melatonin production and the sleep-wake cycle. This often leads to trouble falling asleep, frequent awakenings, and poor sleep quality. The disruption also boosts hypothalamic-pituitary-adrenal (HPA) axis activity, increasing pro-inflammatory cytokines like interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α), which can sensitize pain receptors and heighten pain perception. The circadian rhythm and melatonin secretion can be restored by lowering cortisol levels, improving sleep quality and reducing inflammation, thereby decreasing pain perception and increasing pain tolerance.

Enhanced Endorphin Production Effect

Endogenous opioids, such as endorphins, are natural pain-relieving compounds produced by the body. Reducing cortisol levels can enhance the synthesis and release of these endogenous opioids, which act as natural analgesics. Endorphins bind to μ-opioid receptors in the central nervous system, particularly in brain regions involved in pain modulation, such as the periaqueductal gray matter and the limbic system. This binding inhibits the transmission of nociceptive signals and activates descending pain-inhibitory pathways, thereby diminishing pain perception and inducing analgesia and euphoria.

Smoking & Cortisol - The Negative Effect

Smoking significantly elevates cortisol levels by stimulating the hypothalamic-pituitary-adrenal (HPA) axis through nicotine intake. This increase in cortisol contributes to a sustained stress response, exacerbating stress-related health issues such as cardiovascular diseases, metabolic disorders, and mental health problems. Additionally, the fluctuations in cortisol levels during nicotine withdrawal make smoking cessation more challenging, further impacting overall health.

Body Fat Percentage Effect

Increased body fat percentage, particularly visceral fat, is linked to elevated cortisol levels due to its role in chronic low-grade inflammation. Adipose tissue, especially around the abdomen, secretes pro-inflammatory cytokines, which activate the hypothalamic-pituitary-adrenal (HPA) axis. This activation leads to the sustained release of cortisol from the adrenal glands. Elevated cortisol levels, in turn, can further promote fat accumulation, creating a feedback loop that exacerbates metabolic and inflammatory conditions. Understanding this relationship highlights the importance of managing body fat to maintain hormonal balance and reduce inflammation-related health risks.


Cortisol Lowering Strategies

Woman in Lotus Pose

Meditation and Tai Chi

Reducing cortisol levels can be approached through several scientifically-backed methods, each contributing to stress reduction and overall well-being. Meditation has been shown to significantly lower cortisol levels by activating the parasympathetic nervous system, which promotes relaxation. Regular mindfulness meditation or deep breathing exercises can help calm the mind and reduce the physiological effects of stress. Similarly, Tai Chi integrates slow, deliberate movements with deep breathing and mental focus, effectively reducing cortisol levels by enhancing mind-body awareness and promoting relaxation. Another great way to reduce to cortisol is to do meditation or Tai Chi in Nature. In Japan they call this Shinrin-yoku (Forest Bathing), for more on this check out my blog "Transforming Health: Forest Bathing & Tai Chi".

Healthy Food

Dietary Choices

Dietary choices play a pivotal role in cortisol regulation. A balanced diet rich in whole foods, such as fruits, vegetables, lean proteins, and whole grains, can stabilize blood sugar levels, which helps control cortisol production.

Nutrients like vitamin C, omega-3 fatty acids, and magnesium have been shown to lower cortisol levels. Research has found that taking 1,000 mg of vitamin C daily significantly reduced cortisol levels and improved students' stress responses (NCCIH). Magnesium supplementation at doses of 300-500 mg per day can help reduce cortisol levels and improve stress resilience (PLOS). Additionally, omega-3 supplementation at around 2.5 grams per day can significantly lower cortisol levels (NCCIH).

Foods such as citrus fruits, fatty fish, nuts, and leafy greens can be particularly beneficial. Staying well-hydrated and limiting caffeine (2 to 3 cups per day) and sugar intake can further support cortisol balance, as these substances can exacerbate stress responses.

Sugar intake can increase cortisol levels by causing rapid spikes in blood glucose, which triggers the body's stress response to stabilize blood sugar levels. This stress response involves the release of cortisol to help manage the fluctuations, thereby increasing overall cortisol production. Excessive sugar intake can lead to insulin resistance, obesity, and metabolic syndrome, all of which are associated with increased cortisol levels.

Woman Sleeping

Sleep and Exercise

Adequate sleep and regular exercise are crucial for maintaining healthy cortisol levels. High-quality sleep, achieved by maintaining a consistent sleep schedule and creating a restful sleep environment, can significantly lower cortisol levels. Poor sleep disrupts the hypothalamic-pituitary-adrenal (HPA) axis, increasing cortisol production.

Regular physical activity, including aerobic exercises, yoga, and daily walking, helps regulate the HPA axis and reduce cortisol levels. Exercise promotes the release of endorphins, which counteract stress hormones and enhance overall stress resilience. Combining these strategies can create a comprehensive approach to effectively managing and reducing cortisol levels, promoting better health and well-being.

Man Receiving a Massage

Manual Therapy

Manual therapy, including massage, chiropractic, MSR, and myofascial release, can lower cortisol levels by engaging the parasympathetic nervous system. This system promotes relaxation and counteracts the stress-induced activation of the sympathetic nervous system, thereby reducing cortisol production. By alleviating muscle tension and pain, which are common physical manifestations of stress, manual therapy decreases the overall stress load on the body, leading to lower cortisol levels. Improved circulation and the release of endorphins, the body’s natural painkillers and mood enhancers, further support this process.

Additionally, manual therapy enhances sleep quality by reducing stress and anxiety levels, which helps regulate the sleep-wake cycle and ensures proper functioning of the hypothalamic-pituitary-adrenal (HPA) axis. The psychological benefits of manual therapy, including increased well-being and reduced anxiety and depression, are bolstered by the release of oxytocin, a hormone associated with social bonding and stress reduction. Integrating manual therapy into a comprehensive stress management plan can lead to immediate and long-term reductions in cortisol levels, promoting overall health and well-being.



Woman holding her baby up

In conclusion, managing cortisol levels is critical for improving the health and well-being of patients with chronic musculoskeletal (MSK) conditions. Elevated cortisol levels are often a common denominator in these patients, exacerbating inflammation, increasing pain sensitivity, contributing to muscle tension, and disrupting sleep patterns. By addressing cortisol levels, MSK practitioners can help mitigate these symptoms and improve patient outcomes.

Techniques such as meditation, Tai Chi, dietary modifications, adequate sleep, regular exercise, and manual therapies like massage and myofascial release are effective strategies for reducing cortisol and alleviating its detrimental effects.

Furthermore, understanding the intricate relationship between cortisol, body fat, and chronic inflammation underscores the importance of holistic approaches in MSK practice. Increased visceral fat contributes to a feedback loop of inflammation and elevated cortisol, perpetuating pain and metabolic dysfunction. Integrating lifestyle interventions targeting cortisol reduction and body fat management can break this cycle, enhance hormonal balance, and promote long-term health. By incorporating these evidence-based strategies, practitioners can provide comprehensive care that addresses chronic MSK conditions' physiological and psychological aspects, ultimately leading to better patient health and quality of life.



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Photo of Dr. Brian Abelson

Dr. Abelson is dedicated to using evidence-based practices to improve musculoskeletal health. At Kinetic Health in Calgary, Alberta, he combines the latest research with a compassionate, patient-focused approach. As the creator of the Motion Specific Release (MSR) Treatment Systems, he aims to educate and share techniques to benefit the broader healthcare community. His work continually emphasizes patient-centred care and advancing treatment methods.


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