Tendon injuries: cause, treatment and recovery

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One of the most common injuries in fitness and strength training, if not the most common, are tendon injuries. Before discussing preventive and healing methods, I will first explain the purpose of attachments, which tendon injuries often occur and why.

Tendon injury inflammation of the attachment

An attachment is a tendon that forms the connection of the muscle to the bone. All the muscle’s power is transmitted to the bone through the attachment. Attachments are strong and flexible and normally move in a free path. There are hundreds of attachments in the body, but it’s often only a few that frequently encounter complications.

The problems in an attachment are often caused by poor blood circulation in combination with excessive use. Too great a contraction due to too heavy weight or too high a number of repetitions. The blood vessels in these tendons are located at the front and back of the tendons. The blood vessels are responsible for the supply of oxygen and nutrients that help repair the tendon. This transport must go through small vessels in the middle of the tendon, making the circulation here worse. This is also the part of the tendon that usually causes the injury.

I’ve heard attachments being compared to the canaries in the coal mine. They are a warning system of poor nutrition.

Excessive use of the tendon in combination with poor blood circulation can lead to inflammation. This inflammation can also occur when the tendon, due to anatomical abnormalities, cannot move or moves less freely, as is often the case with shoulder impingement. Depending on the complaint, a modified form of training or even a surgical procedure may be necessary. Such an inflammation of the attachment is called tendonitis or tendinitis. The inflammation itself is characterized by heating (the English word for inflammation is inflammation) sometimes accompanied by swelling and a painful, irritating feeling when tensing the concerned muscle.

Tendinosis, degeneration and damage of the attachment

To understand the difference between tendinosis and tendonitis, you first need to know how an attachment is structured. As mentioned, tendonitis is an inflammation of the attachment, a process of heating and/or swelling that leads to pain complaints and is often caused by overuse. Tendinosis can have the same cause, but in this case, the attachment itself is damaged. That it gets damaged is not strange.

Attachments consist of 65-80 percent collagen. Collagen consists of proteins (mainly built up from the amino acids lysine, proline, and glycine) that strengthen tissues such as cartilage, ligaments, bones, and thus attachments. 19 different types of collagen have been identified which are numbered with Roman numerals. The different types of tissues are reinforced in different ways and in different compositions of types of collagen. Attachments mainly consist of Type I collagen and to a much lesser extent Type III.

Besides, the attachments consist of proteoglycans, elastin, and fibroblast cells. To avoid an overly extensive biology lesson, I will limit myself here to explaining that the proteoglycans, elastin, and collagen form the so-called extracellular matrix in which the fibroblast cells are located. These latter can produce extra proteoglycans (especially in cartilage), elastin, and collagen. Proteoglycans are responsible for the ability to resist pressure (especially by retaining water), while elastin is responsible for the elasticity to prevent tears. The fibroblast cells thus make new tissue for the attachment. When this tissue is fully grown, the fibroblast cells become less active and are called fibrocytes. These fibrocytes will only produce new tissue when existing tissue is damaged or needs to be adjusted.

Fibrocytes in attachments are called tenocytes (in bones osteocytes and in cartilage chondrocytes). In the case of tendinosis, a part of the collagen is damaged. Normally, this is repaired and produced again, but in the case of chronic tendinosis, the body is not sufficiently able to do so. Then, less collagen is produced than is damaged. This is not visible from the outside but can be seen through MRI, X-ray, and surgery.

Rupture, torn attachment

Finally, an attachment can partially or completely tear. Depending on which attachment this is, it can cause various problems to different extents. Because these problems are very dependent on the type of attachment, I will not go into further detail here. In the articles about specific attachment problems, such as those of the shoulder, you can read more about this.

General causes tendinosis and tendonitis

Too high load

A tendon must, even more than a muscle, get used to the load of your training. The most common causes of attachment problems are thus training with too heavy weights or at too high a frequency. Progression is important here. Increase the intensity of your training by no more than 10% per week.

Too little rest

Just like muscles, tendons need time to recover. Maintain a minimum rest of 24 hours before indirectly training a muscle group (e.g., biceps during back training or triceps during chest training) and at least 48 hours before directly training the same muscle group again. However, this depends on the recovery at that time. If you still feel a lot of muscle soreness after 2 days, it’s not wise to train that same muscle group.

Poor training form

Perform your exercises in a controlled and measured manner. Don’t let a weight ‘fall back’ only to lift it again with momentum. For example, if you’re doing biceps curls and are at the top of the movement path, let the weight drop slowly. Especially the lower part of the movement, when the arm is (almost) straightened, is prone to mistakes. A good basic rule is: 1 second ‘up’ and 3 seconds ‘down’, the ‘negative’ movement. By doing this last movement in 3 seconds, you prevent rushing through this part to the detriment of the muscle group and safety for the tendons.

This principle can be applied to every muscle group.

Imbalance between muscle groups

Apart from some isolated exercises, you often use multiple muscle groups and/or parts of a single muscle group during an exercise. When there are significant differences in the attention you pay to these different muscle groups, there is an increased risk of attachment problems in the weaker muscle groups or parts of the muscle group you are training. Ensure that your training for your entire body is balanced by giving all muscle groups roughly the same amount of attention and training each part of the muscle group for every muscle group. If, for example, you do heavy exercises for the back while not separately training your biceps, there is a greater chance that you will encounter attachment problems in the biceps. Of course, you can have certain focal points, but the differences between them should not be too great.

Compression

In the case of, for example, the shoulder, compression (shoulder impingement) of the attachments of the biceps can occur. Due to too little space between the different moving parts, friction can lead to inflammation.

Preventing tendon injuries

There are several ways to reduce the risk of attachment problems:

Warming-up, general and specific.

The general warm-up consists of cardio where 8-10 minutes are sufficient. This can be any cardio exercise such as running, cycling, rowing, cross-training, etc. It is important that you do this at an intensity of 60-70% of your maximum heart rate (220 – age). Too much effort and you lose too much energy for the rest of your training and too little effort does not warm up your body enough. You want this because warming up your body produces synovial fluid. Synovial fluid provides lubrication for the joints, reducing the chance of inflammation due to friction such as shoulder impingement. Besides, it improves blood circulation and thus also the supply of oxygen and nutrients and the removal of waste products.

A muscle-specific warm-up, for example, involves starting your training with lighter weights and more repetitions. This ensures good blood flow for both the muscles and the attachments. Even if you’re already ‘warm’ because you did cardio first, it’s wise to prepare the muscle group itself for the training. Use your warm-up also to train the muscle over the entire range of motion. With training the biceps, you will quickly encounter problems with the attachment if you do heavy biceps curls from full extension, for example. This movement often becomes shorter when the weight becomes heavier.

Use the warm-up to also give attention to these parts of the muscle. For biceps, for example, 21s is a good warm-up. Perform bicep curls with a lighter weight where the first 7 repetitions are over the lower half of the movement (from full extension to a 90-degree angle in the elbow), the next 7 go over the upper half (90 degrees bent to the top), and the last over the entire movement. You can repeat this several times. However, be careful not to fatigue immediately while you still want to train heavily. One or two times 21s is enough as a warm-up.

Stretching and massaging

By stretching gently, you relieve tension on both the muscle and the attachment. Moreover, you stimulate blood circulation. Do not seek the pain threshold but stretch until you feel resistance. The same applies to massaging. However, it is important here that you know exactly which part to massage. In the case of persistent complaints, a physiotherapist can do little more than massage as the most successful remedy. Do not think of a relaxing massage, but a massage where the irritated area is continuously addressed (palpated).

Cooling

Cooling the attachment not only lowers and slows the irritation and inflammation but can also inhibit it before you notice it. Many an American Football player will say that his career has been extended by years through the ice baths they take after training and matches. Recently, I heard a sports scientist on the radio say that this was pointless because it did not contribute to better performance. I think he misunderstood. They do it not to perform better, but to prevent injuries. With such an ice bath, you cool the entire body and inhibit inflammations even before you knew you had one. Personally, I do it preventively only for muscle groups where I often have inflammation complaints (distal attachment of the biceps, for example) using an ice compress. Cool immediately after training until the cooled area becomes numb. Then stop immediately and wait as long as you have cooled it (every 2 hours for about 20 minutes).

Other training methods

The inflammation is, as said, usually caused by overtraining. You can prevent this, among other things, by doing different exercises in which the muscle is addressed differently. You can also do this by performing the exercises themselves differently or at a different pace. Try, for example, to focus on the negative movement of the exercise or to perform the entire exercise at a slow pace (for example, 8 seconds up and 8 seconds down). The latter is also an excellent form of warm-up and a good rehabilitation form.

Listen to your body!

Know the difference between a ‘good’ and a ‘bad’ pain. If you notice during training that something feels painfully wrong, stop immediately with the way you are performing the exercise. If, after adjustments, you still feel the pain, you should stop with that exercise and try another exercise for the same muscle group with adjusted weight. If the irritation persists, then you must stop training that muscle(group) entirely. If you had more sets on the agenda, too bad. Don’t stubbornly continue. It doesn’t help if you then can’t train that muscle group for weeks or months because you couldn’t restrain yourself.

Healing from tendinosis or tendonitis

OK, great that you now know how to prevent it. However, it’s tricky that there’s a good chance you’re only reading this after you already have an inflammation in the attachment. What now? With repetition, you might already know with reasonable certainty that you have an inflammation or damage to the attachment. For certainty, the correct diagnosis must be made (or have someone make it) before you can start treatment. If it is indeed an inflammation of the attachment, the following applies: RICE (Rest, Ice, Compress, Elevation):

Rest

An inflamed or irritated attachment is often due to overuse. It is important to stop this overuse. Rest, among other things, reduces the amount of blood that has to go through the tendon and thereby also the chance of further damage. It also gives the attachment more time to produce new collagen.

Ice

The English word for inflammation is inflammation, literally igniting or combustion. This is due to the heating that accompanies inflammation. By cooling the attachment, you limit this heating. Moreover, it also limits the supply of blood and thus swellings and pain. For this, you can use a compress, pieces of ice, or for example frozen beans in a bag. Even flowing cold water can help. Be careful not to place the ice directly on the skin! This can cause damage similar to burns. A damp tea towel around (the bag with) the ice is therefore recommended unless you have a compress that already has a protective layer. It is important that you cool/ice as soon as possible after the first signs of inflammation, for example, immediately after the training in which (the first signs of) the inflammation were noticed. Afterward, it is best to cool for 2 to 3 days every 2 hours for about 20 minutes. You can do this both for healing and for prevention.

Compression

With compression, you achieve two things. Firstly, it helps to reduce blood supply and swelling. In addition, it provides support for the affected area

Elevation

Elevating the affected area limits the blood supply and thus the swelling. For an Achilles tendon, for example, this means letting your foot hang higher. Elevation is not applicable for every attachment problem.

Supplements for inflamed attachment

There are various nutrients and supplements that can help prevent or repair damage to the attachment:

Fish oil: Fish oil works both preventively and healingly for inflammations in the attachments. Recommended amount: 5 grams per day.

Glucosamine: Glucosamine is often praised as a supplement for the joints because it repairs cartilage. However, glucosamine also causes the release of glycosaminoglycans. These are used to repair the tendons. The recommended amount is 1500mg and 4 times a day 1500mg if you already have an inflammation.

Vitamin C: Vitamin C promotes the production of collagen needed for the repair of the attachment. Recommended amounts vary between 1000mg and 3000mg per day for adults. This naturally varies per person. Vitamin C is often sold in ‘Time-released’ capsules that ensure a balanced, long-term release of vitamin C.

Magnesium: Magnesium can reduce the tension of the muscle and attachment and thereby the chance of inflammation. The recommended amount is 500mg per day divided into 2 moments.

Ginger and turmeric: Certain herbs such as ginger and turmeric have been shown to have anti-inflammatory effects.

Anti-inflammatories: such as Ibuprofen and aspirin.

A corticosteroid injection

An often last resort is the corticosteroid injection. These stress hormones, produced in the adrenal glands, are active in regulating blood sugar levels and inhibiting inflammatory responses. Corticosteroid injections are often given in combination with lidocaine, a local anesthetic. Such an injection is often given when other methods do not yield sufficient results but can also be used as a diagnostic tool. That is to say, to determine what the cause of the problem is. Pain complaints caused by inflammation (both bursitis and attachment) should immediately disappear.

The corticosteroids themselves start working after two days by inhibiting the inflammation and thus also the pain caused by it. The injection works for several weeks and sometimes that suffices to make the inflammation completely disappear, but sometimes multiple injections are needed.

The pain that disappeared due to the anesthesia can return after two hours because the anesthesia then wears off while the inflammation has not yet disappeared. For the pain, regular anti-inflammatory painkillers can be used. The inflammation itself often disappears within two weeks.

Short-term side effects are limited. The most serious are hormonal fluctuations that can lead to menstrual disorders and a deregulated glucose level in people with diabetes mellitus (diabetes). In the long term, these can be significant, but for the complaints discussed here, long-term treatment with injections is not applicable.

Why not an injection?

That does not mean that you cannot have long-term problems from a single injection. Corticosteroids such as Cortisone and cortisol work catabolically. That means they break down proteins and fats in favor of energy in the form of glucose. Research has shown that they yield more results in the short term (one and a half months) than physiotherapy or doing nothing. Due to the cortisone, the inflammation can be combated very quickly, and you soon feel capable of normal training again. However, the proteins that these stress hormones break down for energy are necessary for the maintenance and repair of the volume of the muscles and attachments.

Especially in cases where tendonitis, the inflammation, is accompanied by tendinosis, tendon damage, you need these proteins for repair. You may feel great because the inflammation has disappeared, but the attachment is not yet repaired and thus receives fewer resources to still be able to recover while you think you can go all out in the gym again. It has been shown that although recovery is faster in the short term with an injection, a year later, people who received an injection had many more cases of recurrence than people who received physiotherapy or even did nothing! In the case of physiotherapy, moreover, the cause of the complaints is also looked at.

In the case of an accident, you can do little with this, but sometimes complaints are caused by an incorrect posture or way of moving. A physiotherapist can point this out and work with you on improvement. In the case of an injection, you quickly feel better but continue with the same behavior or posture that caused the problem, and the chance of new complaints is greater.

When to consider an injection?

Suppose you have been training for 4 years for the Olympics in London or you have been bulking for more muscle mass for a year now and are just in your cut phase and competition preparation because you are called Phil Heath and you want to defend your Mr. Olympia title in Las Vegas. In that case, it might be worth it for you to be able to perform at the moment all your efforts were aimed at. If you win a couple of tons in income by winning that prestigious competition and again close a few fat sponsorship deals with supplement manufacturers, then it might be worth the price to you. However, if you are, like most, just a gym rat who always wants to look good and is not training towards a specific moment, then go for the long term and leave that injection.

For a bit of self-respecting bodybuilder, a catabolic agent is, after all, a swear word.