Recovery protocol write up

Most of our tendons are made of well-organized bundles of mostly type-1 collagen (the rest composed of types III, VI,. V, XI and XIV) [1] [2].

But not all tendons serve the same function. Experts divide them into two categories: positional tendons, those which hold our limbs in position, and energy-storing tendons, which act like springs. For the sake of this exercise, lets stick with energy-storing tendons, as they are the tendons most injured in sport and power / o-lifting. Our energy storing tendons have a larger amount of type III collagen versus Type I and a collagen turnover half-life of approximately 200 years. [4] This is why recovering from these injuries is so difficult.

Biomechanics / Kinetic Chain

Obviously, there is a myriad of ways to damage this tissue, but one of the major causes of tendon damage is biomechanics issues (poor form), and kinetic chain issues: such as atrophy in the anti-gravity muscles such as quadriceps, calves, glutes. Flexibility and posture issues: poor hamstring, ankle dorsiflexion, and foot posture. [3]

An Ounce Of Prevention…

In saying that, repetitive stress is absolutely a major cause of tendon damage. This occurs through accumulative micro-traumas that aren't given enough time to heal. With something like tendonitis, the body begins to dump type-3 collagen (weak scar tissue) in unorganized bundles atop the injury site. Imagine cutting a bunch of incisions into a piece of paper and then handing that piece of paper to a child and asking them to use that tacky white school glue to patch the holes — that’s sort of what’s happening within the body during tendinopathy. It's a cliche, but if you notice pain in your tendons, stop your training or exercise regimen for 2-3 weeks until the pain is completely gone. If you push through this pain, you may never recover, and that's not some fear-mongering exaggeration. Tendons and ligaments are not muscle. When it comes to connective tissue injuries, an ounce of prevention is worth, like, a thousand pounds of cure.

Eccentric Loading

So, how can we strengthen our connective tissue? Eccentric loading (lowering weights very slowly), and if you really want to give them a boost, don't perform the concentric contraction (lifting the weight back up). For patellar tendinopathy, this would be something like wall-sitting (slow descent) and holding your weight on your injured leg and then standing up from the wall-sit with your healthy leg. If you’re dealing with a chronic tendon injury, this more-or-less teaches or shows the body to once again deposit the collagen in tight and straight bundles. [5]

This is problematic because the athlete needs to load to that perfect balance where they are achieving the necessary resistance/load to incur healing or strengthen the tendon, but not so much resistance/load that they’re aggravating or creating an injury. The general thought is that a weight 70% of your 1RM (10-15 rep max) or greater has shown the best positive adaptations. Again, generally, a 3-4 second eccentric is recommended. [5] [6] [7]

Regarding velocity, you technically can have an explosive concentric if you are using 70% 1RM (MVC). If you’re using below this amount, DO NOT perform your concentric at max effort. Velocity often gets you into this mess, don’t let it keep you there.

Isometric Loading

Although isometric loading hasn’t been shown to be as effective, it can certainly help. 5 x 45 second isometric contractions at 70% MVC has been shown to stimulate positive adaptations. [7]

Recovery Period

24-36 hours. Ideally 36-48 as it's been shown to optimize total collagen synthesis... I know it’s long, but remember, 200 year half-life. [9]

Well Timed Collagen/Gelatin + Vitamin C Supplementation

There is a growing body of evidence and media attention around gelatin/collagen and it's benefit to healing of joint injuries. The proper protocol involves taking 15-20 grams of gelatin/collagen with Vitamin C an hour before exercises/physiotherapy. Essentially, your tendons act like sponges in that they're void of blood without proper loading/exercise. So if you're taking collagen/gelatin and not performing exercises/eccentric loading, it just wont reach the target tissue. I take Progressive Collagen as it has your daily dose of vitamin C in it to assist with the collagen absorption. It's a great product. If you decide to use another collagen product down the line, just take 100mg of Vitamin C along with it to help with absorption.

Edit: Fantastic protocol that pertains to gelatin supplementation and injury prevention from Keith Baar at the University of California Davis and the Gatorade Sports Science Institute.

Avoiding NSAIDs

The negative impact of NSAIDs on healing has been well studied (link 1/2/3). Essentially, NSAIDs provide initial symptomatic pain relief, but they have been linked to poor fracture/tendon healing as our bodies healing process requires significant inflammatory process/markers. NSAIDs blunt the body's production of biochemicals called prostaglandins, that typically flood injury sites. Prostaglandins start processes that contribute to pain, but they also jumpstart our body's natural healing process.

Prostaglandins are made up of two enzymes (COX-1 and COX-2). Celebrex (Celecoxib) and other COX-2 inhibitors selectively inhibit COX-2 while leaving COX-1 untouched. NSAIDs such as Advil are non-selective in that they inhibit COX-1 and COX-2. Recent evidence suggests that COX-2, in particular, is vital for healing [source]. So, it stands to reason that selective COX-2 inhibitors such as Celebrex are particularly detrimental to healing. NSAIDS, while also problematic, also decrease muscle protein metabolism, inhibit tenocytes (the building blocks of your tendons and ligaments) and decrease exercise-induced blood flow. So avoid this class of drug when trying to strengthen your tendons or ligaments or while recovering from an existing injury. (source 1) [source 2]

Understanding that many of your tendons and ligaments receive poor blood flow and that the collagen turnover half-life of this tissue is so long, we really don't want to do anything to adversely affect proper blood flow and tenocyte production. It is even being hypothesized that early use of NSAIDs may be to blame for many cases of tendinopathy as once the bodies proper healing process is disrupted, it's extremely difficult to right it's course. [source]

TLDR

1. Proper biomechanics, strength, and flexibility - can all lead to tendon and ligament damage. Pay attention to proper form, and ensure you have adequate strength and flexibility before asking dramatically more of your body.

2.Prevention - yes, overuse causes ligament and tendon damage. If you feel pain in your tendons, cease training and give yourself a 2-3 week break until pain completely subsides.

3. Eccentric loading - 70% MVC 3-4 second eccentric / 3 sets.

4. Isometric Loading - 5 x 45 second isometric contractions at 70% MVC

5. Recovery Period - At least 24 hours, ideally, at least 36-48 hours

6. Well timed collagen/gelatin + vitamin C - 15-20 grams an hour before loading.

7. Avoid NSAIDs - Especially during initial pain or during a tendon/ligament strengthening and injury prevention protocol. There is a lot of evidence to suggest this class of drug actually degrades and prevent your tendon’s and ligament’s healing and strengthening mechanisms. Don’t reach for the Advil or Celebrex.