Resting Tendons - Not The Solution It Seems
The worst advice I see for tendons - (part two of four)
Why resting a sore tendon is one of the worst pieces of advice I see given for clients who want to have big expansive lives. (part two of four)
Most of my clients want to do things with their lives. They want to run with their kids, tramp or hike with their friends, play sport on the weekends and do physical work and exercise during the week.They don’t want to be resting on the couch, inside, being the domesticated version of their wild and feral selves, unable to the things that make their lives feel full. Telling people to rest tendons is a prescription for a life of less activity.
Because of how the human body works resting a sore tendon can be the worst advice for repair and recovery, but it’s one of the most common pieces of advice I hear that my clients have been given. Tendinopathy needs a specific amount of load to recover, and while it can turn up out of nowhere, there is a general pattern of causation. (Hint: it’s doing too much too soon – or applying load that’s greater than the normal capacity of the tendon).
Continuing to rest a tendon means there is no reason for it to change and adapt. There is no requirement for it to become stronger because it is not being challenged.
I see a lot of people with pain caused by tendinopathy – which is essentially a breakdown between the capacity of the tendon to tolerate load and the load – either through super heavy load, repeated moderate load or sustained low load.Sometimes it can seem to turn up out of nowhere. I have had many clients who have rested, returned to activity, felt worse, and slowly found their lives becoming smaller and smaller. So many of my clients have been surprised to hear that more loading allows for more life.
The issue with tendinopathy is that it’s not widely understood in it's modern by general medical professionals, (and while experts agree that load is needed, the advice isn’t always identical) and the advice that’s received from our general care providers is not always the best advice. **This is not to throw shade on our doctors, because they need to know a bit about everything from a headache to an ingrown toenail, and they cannot be expected to know everything about all things.
What is a tendon?
Tendons are the structures that attach muscle to bone. They are the white fibres at the end of the muscle. There are essentially two types of tendons – postural tendons which tend to be broad and flat, and energy storage tendons, which are more circular in shape e.g. the Achilles.
Tendons are made of long strands of collagen, arranged in the direction of force. Between the strands is a fluid called the intracellular matrix.Because the human body is alive, and clever and not a machine, the collagen fibres adapt to the forces that are put through the body, responding to how the body moves, how often and what is required of it. The more we load the tendon, without overloading it, the stronger the tendon becomes. Conversely, the less we move a tendon, the weaker it becomes, allowing for less tolerance to load. In this way, the tendon is related to the strength of the muscle, but the tendon is a much slower adapting tissue than muscle.
What is tendinopathy?
Tendinopathy occurs, in general, as pain noted near the bone when there is load on the muscle or tendon. It also doesn't like being stretched, compressed or leaned on. And it's often stiff when we get up in the morning. It’s caused when the forces through the tendon exceed it’s capacity to continue to remodel. We get micro-sites of breakdown, initially with in the fluid between the collagen fibres, and with longer lasting symptoms, a breakdown in the continuity of the collagen fibres. In later stage tendinopathy, there are small changes in continuity through spots in the tendon. With significant injury, and even later stage progression, there can be tears (small, partial thickness, full thickness, and ruptures). Importantly, this is not an inflammatory process, and this is the reason we can’t medicate our way out of it with anti-inflammatories.
Some of these factors are external, e.g having to drench more sheep than normal can cause pain in the outside of the elbow (tennis elbow or common extensor tendinopathy), and spending a day walking downhill can cause pain in the front of the knee (patella tendinopathy). A blow to a tendon can cause an acute tendinopathy, which can settle, but in some cases it decides to stick around.
Internal factors include general health, changes in our body’s ability to heal as we age, the impact of sleep, protein intake and fuel, hydration, general health, physiological changes e.g. diabetes, thyroid, smoking (though that could be an external factor) etc.
What would you do now?
Now you know the cause of tendinopathy, what do you think the best option for healing is?
What happens when we rest?
Resting a tendon is lovely. It feels better when nothing is being done to it.
However.
However.
Tendons need load to build up the gap between the capacity and the required forces. This means that while people can be told to “rest”, all this really means is that they can’t do what they want to do, the body adapts to doing nothing, the tendon isn’t doing anything, so there is no need for the tendon to change, it gets weaker (the body is cunning) so and then the client can’t do as much as they could before they rested. It’s a vicious circle.
Remodelling:
Because tendinopathy is a breakdown in the capacity of the tendon – we need to build it back up. There are lots of ways to do this, and lots of different theories.
Underlying all these theories is progressive overload – all apply it differently, and all are successful. The plan is that there is a load applied to the tendon, then it is allowed to recover, and then more load is applied, as it is tolerated. This allows the tendon to adapt to the new requirements slowly. In a nutshell, as we load the tendon, the collagen fibres are forced to adapt and become stronger. My plan is based both on evidence and experience - what clients like and get the best results from.
As a note, what I’m seeing in practice is that this is not linear, and some weeks more load is able to be applied and some days, it’s harder to load and more painful. One of my clients recently was making really steady progress with her gluteal tendinopathy exercises and in week 4 wasn’t able to add more to her exercises.Then, like magic, in the middle of week 5, she was able to progress again.
The unfortunate lesson here is that we can’t always trust the information we are provided by even the most well meaning medical professionals. The body ALWAYS needs load, progressively applied, paying attention to how the body is tolerating the changes. Rest isn’t the way forward for changing tissue and progressive loading is the key to nearly every musculoskeletal injury.
How we do it in real life
Settle:Deload:Reload (this is my back to basics plan for all my clients)
When I work with my clients, I start with settling the symptoms, so my client is able to live with less pain – this can make such a difference, because being in less pain AND being able to do the tasks we want to do makes life so much better immediately.This generally takes about four-eight weeks. During this time we begin to deload the area as well, by bringing on muscles that can help, as well as starting to reload (steadily) the affected area.
Sneaky Part:
The first four weeks is a bit of a sneak trick for young players, because it’s pain relieving but doesn’t change the structure of the tendon, we then need to begin to add more load (deload and reload), and increase capacity that way.
Warning: This process is the boring bit as it takes a long time *and to reiterate, it also isn’t linear. Tendon remodelling takes 4 weeks to start feeling good, 4-6 months+ to get back to really good function (including jumping) then it takes another (hides face) 18 months (minimum) especially if the client is in perimenopause. (hides more).
A reminder: you do brush your teeth every day, so it’s not unheard of that you could work for 10-20 minutes three times per week to maintain the tendon, if it might keep you comfortable and in an expansive life, is probably a small price to pay.
For gluteal tendinopathy, I’ve created a pathway for this (and other body parts are coming) – click this link to get on the list. To hear about other body parts as they become available – make sure you are subscribed to the newsletter.
Here are some of the resources I used for this article
Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy | British Journal of Sports Medicine
Continuum model of tendon pathology – where are we now? - PMC
