Tendon Training and Recovery

Tendinosis can be very frustrating for athletes to contend with. Included with this blog are two great interviews with the world’s foremost expert on the subject. They are long but worth the listen. If however, you are disinclined to take the time to hear it from the horse’s mouth, I will summarize here my key takeaways in the hope that you will find it useful.

For most of us our interest probably revolves around three main concerns: what causes tendon injuries, how to treat them if and when they arise and how to prevent them from happening in the first place.

Causes of Tendon Injury

Too much loading is applied to the tendon too soon/frequently, such that the tendon does not have time to recover from loading and becomes injured or inflamed. Bet you already knew that. What kinds of movements are most likely to cause tendon injury? Generally, dynamic movements like swinging a golf club or tennis racket, running, jumping, explosive lifts, etc. Those repeated, small impacts and sudden changes of direction are all it takes to damage or irritate a tendon. So, we can prevent injury just by avoiding those movements, right? Not so fast. We’ll address that in the prevention section because it is not as straightforward as that.

You’re no dummy so you already suspected tendon overload was the root of the problem but why are pull ups okay for some folks and cause injury in others? Well, it seems that statistically, athletes are most likely to experience tendon injury when returning to training after a layoff. Christmas holidays, family vacation, sick in bed for a week and then you come back ready and raring to go and a couple of workouts into your comeback – ouch – trouble starts. At Empower, coaches brace themselves every January for the carnage as athletes whose training has been spotty from Black Friday through to New Year’s Day suddenly charge back, determined to fulfill their New Year’s resolutions. We’ve dubbed it “Post Christmas Carnage”.

Why does this happen? Well, your connective tissue is built up of collagen layers. The more you train a movement pattern, the more collagen layers your body lays down to protect you. However, it turns out that for every 3 days of inactivity, you lose 15% of those collagen layers. That means if you take 6 consecutive days off from training and then return to the same loads and intensities you were using prior to your brief layoff, you have 30% less tissue strength. This is why we see more tendon injuries in folks who train two or three times per week compared to those who train five times per week (incidentally, it was one of the reasons we stopped offering discounted 2x per week memberships; those folks were just wrecking themselves).

Women are more prone to tendon injury because of their greater laxity especially during the luteal phase of their menstrual cycle. But menopause offers no relief because perimenopausal women are also more susceptible to tendon issues due to fluctuating hormonal cycles. This is when issues like frozen shoulder and plantar fasciitis are most likely to plague them. Connective tissue laxity is also one of the contributing factors to the higher incidence of ACL and MCL tears in women versus their male counterparts.

But ladies, before you start feeling sorry for yourselves and thinking that you got a raw deal, let me assure you that male athletes have their own set of problems. Men do tend to have stronger, stiffer tendons that result in statistically fewer tendon injuries in the male population, but they are not immune to injury, something has to give. If it’s not the tendons, then it’s the muscles. Yes, men experience far more muscle strains than women, And that’s not all. All that stiffness makes them more susceptible to cardiopulmonary events. And as aggravating as frozen shoulder might be, it is far less likely to kill you than a heart attack.

Treatment of Tendon Injuries

DO NOT ice.

DO NOT rest.

DO NOT immobilize.

DO NOT use anti-inflammatory pharmaceutical interventions.

Flies right in the face of everything you’ve been told, right? Well, that’s why I’m writing this post and why I’ve included links to the interviews with the world’s leading tendon expert because why should you believe me over the hundreds of medical professionals who’ve advised you in the past?

Inflammation is part of your body’s natural healing process. Anything that impairs the inflammatory response (ice, anti-inflammatories) slows down and prevents healing.

And remember what we said about losing 15% collagen for every 3 days of immobilization? If you rest and immobilize the injured connective tissue which was weak to begin with, well, you can see where this is going, can’t you? You will just accelerate the tissue degradation and end up with much weaker tendons than before.

So, what should you do?

1. Continue to move the injured joint through its PAIN FREE range of motion.

2. Hold an isometric contraction with slight PAIN FREE tension in the injured position for 10-30 seconds a couple times per day, 6 hours between sessions.

3. Continue this protocol for 8 WEEKS (even if the pain is gone before then).

Your body heals through movement just don’t further aggravate already injured tissue. There are no days off. Just keep moving as best you can. Do not make the pain worse but continue to strengthen the tendon in all its positions, rebuilding the damaged collagen layers in order to recover full, pain free mobility around the joint. But be warned, just because the pain is gone, it does not mean your tendon has fully recovered. It can take up to 8 weeks for complete tendon rebuilding.

Preventing Tendon Injury

Well, based on what we know, the first couple of suggestions seem obvious:

1. Don’t take days off training. This doesn’t mean wreck yourself daily but keep on moving so your body maintains the protective, injury-preventing collagen layers you need to stay healthy.

2. If you take time off training, return to the gym at lower intensity. Three days off? 15% less intensity for your next couple weeks of training (remember it can take as long as 8 weeks to rebuild collagen layers – this is why athletes who regularly miss a week or two of training may never see progress, they are always in a stage of rebuilding the collagen they lost by missing workouts)

3. Build your training volume and intensity in an incremental manner.

But wait, there is more!

1. Isometrics build thick collagen. All that’s required is a 10-30 second hold. More is not better. In studies, the group who performed an isometric contraction twice a day for 30 seconds (6 hours apart) saw the same collagen gains as groups that held longer isometric holds. There appears to be a dose maximum for collagen adaptation. A little is all you need.

2. But what about those dynamic movements that are implicated in tendon injuries? Turns out that though they damage collagen unlike isometric movements, they also stimulate your body to lay down collagen layers in resilient matrices. Without dynamic movements, the collagen forms thickly but does not form a resilient matrix and remains weaker. Your connective tissue requires explosive dynamic movements for optimal strength. But as with the isometric holds, more is not better. Short, explosive, low volume plyometrics are all you need to stimulate the cross-hatching effect of collagen growth.

3. Studies demonstrate that supplementing with a whey protein powder, collagen and vitamin C helps speed up connective tissue growth and recovery. Natural sources of vitamin C are sufficient to support this.

Bonus material:
Z-Health: Yielding vs overcoming isometrics