It’s Monday morning. You wake up, pound your coffee and head to the gym. Heavy squats are on the menu today, but as you start warming up, your appetite for destruction begins to wane. That pesky pain in the front of your knee you thought was gone is back with a vengeance. Time to assemble your Iron Man suit; you pull on your compression tights, slip on your doubly-ply knee sleeves, and lace up your lifting shoes. Damn it! Forgot the ben-gay again! After stripping everything off, applying half a tube of menthol-scented goodness, and re-assembling your armor, it’s time to get after it!
Do you feel invincible now? These accessories may provide you with the perception of security, but you haven’t addressed the true underlying issue responsible for the pain in your knee. There is an Infinity War going on between the muscle and bone, with your tendons caught in the crossfire. Battling through tendon injuries can be extremely frustrating; the focus of your training shifts from improving performance to surviving the session, along with dealing with the anxiety of how this will affect your health, longevity, and athletic potential.
The role of this article is to lay the foundation for understanding tendon structure, function, and adaptive capacity, as well as ways to build a framework for your training to ensure a proper stimulus to address the problem.
Has Your Spring Just Sprung?
Your tendons are what make you an athlete. They are also what helps keep you safe. According to PA Radio alum and strength coach Cal Dietz, tendons act like springs,connecting muscle to bone and transmitting forces that facilitate movement and absorb external impact. Because of their work requirements,they are super strong and can withstand a lot of stress. If you pull on muscle connected to bone, the first thing to go is the muscle-tendon interface; this is a muscle strain, like pulling your hamstring. Increase the force and the bone will fracture...there goes the bone-tendon junction. Finally, after repetitive wear and tear the tendon will begin to break down; this breakdown is what is referred to as “tendinopathy.” (3,5)
But, before you can effectively manage a tendinopathy, you need to make sure you actually have the condition.
Here’s a checklist you can use, to help identify if you’re suffering from tendinopathy:
Where is your pain? (6)
- Tendon pain remains very localized; you can point to it with one finger.
- It doesn’t move around or spread to other areas of your body, regardless of how long you’ve been experiencing pain.
- This localized pain gets worse with increasing amounts of applied load.
- Lastly, the hallmark feature is pain when asking the tendon to act like a spring, including running, jumping, and change of direction.
What has changed?
Tendons hate change (4) and this change can come in many different forms:
- Environment: This could be as simple as wearing new shoes or running on the track vs. pavement. Change could also mean altering biomechanics like switching up your running gait, swimming stroke, or squatting technique. (7)
- Load: Have you significantly increased your training weight?
- Volume and Intensity: If you are a parent and you think it is ok to have your kid throwing a baseball year-round, you are setting them up for failure. (8)
How Much is Too Much? The Dose Response Continuum
Ok, we’ve identified your tendon as the culprit. Now what? First, you need to understand that your tendon still has immense tensile strength, even when you are experiencing pain. If you are imagining your tendons as a fraying rope, STOP IT! Next, we need to figure out where you fall on the tendinopathy continuum because this will dictate the management and loading strategy to be implemented for rehabilitation.
Dr. Jill Cook (1,2) has organized the continuum into three distinct phases:
Reactive tendinopathy: believed to be an acute (weeks to months), reversible process brought about by a rapid increase in mechanical loading. This is what happens when runners drastically increase their milage or when you start the Smolov challenge without properly building a base level of strength.
It was thought that this reaction involved inflammation, but we now understand that this is not the case. There is no fire, so stop trying to put it out with ice and anti-inflammatory medication. The tendon can swell, but this is due to movement of water into the tendon and not inflammation brought about by acute trauma. Structurally, the tendon remains intact, and the water retention is a protective response to reduce stress along its collagen fibers. This is a short term adaptation to overload that thickens the tendon, reduces stress, and increases stiffness. Essentially, your body is mounting a defense to limit movement at the joint in reaction to your bull-headed ego telling you that you can handle too much too fast.
Tendon dysrepair: may follow if loading continues to exceed tendon capacity for a long period of time (3-8 months). Here, we continue to see increased fiber diameter - the tendon thickens with neural and vascular growth, but now structural components begin to break down. This is what you get when you ignore the problem with bandaids that provide temporary relief. There is no amount of Kinesio-tape, foam rolling, or joint bracing to magically fix the problem and take away the pain.
Degenerative state (>1year): characterized by further collagen disorganization, advanced matrix breakdown, and increased fiber thickness. There are multiple structural changes that take your tendon from looking like a white, shiny, and highly organized pillar to a dull and dilapidated bunch of jumbled up wet spaghetti - making it extremely less efficient at dealing with load. This is typically seen in the older/more seasoned athlete, who has been complaining about that “knee thing” for decades.
Today’s Youth: The (Tendon) De-Generation
Tendinopathy incidence rates are on the rise with youth athletes, particularly with the push for early sport specialization in hopes of scholarships and playing at a higher level. However, research indicates that kids who had higher levels of specialization at a young age (less than 12 years old) are at about a 50 percent greater risk of sustaining an injury, predominantly of the reactive tendinopathy variety. This is because young athletes have underdeveloped musculature with fast growing bones that make them prone to overuse injuries. In fact, delaying specialization for the majority of sports until after puberty will minimize these risks and lead to a higher likelihood of athletic success.
The strain to a developing body also may increase their risk of injury as adults; as a parent, are you willing to risk the future health of your child? Leading sport orthopedic surgeon Dr. James Andrews proclaims the best medicine to help prevent youth sports injuries is to avoid playing year-round, and not to specialize in one sport until between the ages of 14 and 16 years.
He also states that, with so many injuries, one of the best ways to protect youths is by teaching proper technique. A great way to accomplish this task is to develop a base level of strength with the Power Athlete Bedrock Program. Properly executing this will help develop the tissues of the body, including tendons, to withstand the forces incurred during sport and training.
Master Your Movement: Adjust Load
We’re all the same, but we’re all different. Every athlete is going to show up with different starting points and performance goals. Before you whip out Prilepin's chart and talk about rest intervals, remember the Power Athlete Mantra: what are you training for? That question will determine what your program should look like. However, no matter the training, maintaining and building capacity in the tendons is a requirement across the board, since this is how we can effectively recover and continue to push adaptation.(4,6)
Load is that ‘67 Shelby we hijack and drive down the highway like a bat out of hell; it’s the primary stressor which our tendons detect, and functions as the vehicle that powers our rehabilitative efforts. Load improves capacity, and improving capacity allows us to drive greater change.(3) So, what is your current capacity? Are you a Mustang, or are you a Prius? From what we covered here, you should now have a basic idea of where you stand. The only way to improve capacity is to gradually increase load exposure to the tendon, while still keeping it happy.
So, how do you do this? If you want to get a jump start on rehabbing your tendon injury that’s keeping you from trading in the keys to the hybrid for the keys to the V-8, set up a Remote Coaching program with Physical Therapist and Power Athlete Block One Coach, Dr. Matt Zanis to get you on the right track with an individualized program.
- Buckley PS, Bishop M, Kane P, et al. Early Single-Sport Specialization: A Survey of 3090 High School, Collegiate, and Professional Athletes. Orthop J Sports Med. 2017;5(7):2325967117703944.
- Brenner JS. Sports Specialization and Intensive Training in Young Athletes. Pediatrics. 2016;138(3)
- Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409-16
- Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?. Br J Sports Med. 2016
- Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol. 2010;6(5):262-8
- Rio E, Kidgell D, Moseley GL, et al. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med. 2016;50(4):209-15
- Roberts TJ, Konow N. How tendons buffer energy dissipation by muscle. Exerc Sport Sci Rev. 2013;41(4):186-93
- Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am. 2005;87(1):187-202
- Schoenfeld BJ. Squatting kinematics and kinetics and their application to exercise performance. J Strength Cond Res. 2010;24(12):3497-506
- Yang J, Tibbetts AS, Covassin T, et al. Epidemiology of overuse and acute injuries among competitive collegiate athletes. J Athl Train. 2012;47(2):198–204.
Dr. Zanis utilizes the Power Athlete Methodology to optimize performance, reduce injury risk, and rehab his clients and athletes through movement assessment, coaching, and individualized program design.