Updated: Apr 19, 2022
I know someone who does a lot of Crossfit and got "golfer's elbow" from doing gymnastics ring training (It's almost never from golf!). Almost a year later it was still bothering him. It would feel better then act up as soon as he started doing a lot of pulling exercises on the rings. Soon he gave up most ring exercises, it was just too frustrating. He didn't want PT from me because he had "been there, done that" already. I have had similar episodes before I learned more about how to train connective tissue. I gave up playing drums a couple decades ago because my finger and wrist flexor tendons that run up my forearms hurt every time I picked up the sticks. Incidentally, do you know what they call a guy who hangs out with musicians? A drummer.
Learn To Speak Tendon
Tendons are different than muscles so we should treat them differently. Like a muscle, they respond to tension, but they respond a little differently.
Keith Baar, a researcher at UC Davis puts it really well when he says, "A tendon is like a 13 year old kid. It'll listen for 10 minutes and then it won't pay attention anymore."
According to Dr. Baar:
10 minutes of activity will stimulate the cells that produce the collagen matrix of a tendon. You can keep exercising more than 10 minutes but the tendon cells won't 'wake up' any more
The cells stay active for the next few hours and settle down after 6-8 hours
An individual who wants maximum tendon training effect could do 10 minute bouts of exercise at 6am, noon, and 6pm, thus 'waking up' the cells to produce more cellular matrix three times in one day!
Learn To Feed Tendons
I've been taking collagen protein and wondering the whole time if it was helping my joints. Now Dr. Baar has helped me feel better about it.
Taking 15g collagen (gelatin, peptides, it doesn't seem to matter) an hour before you exercise appears to be the sweet spot
Do this an hour before each of your 3 tendon training sessions for maximum effect
How To Train Your Dragon, I Mean Tendon
So you've taken your collagen, it's an hour later and you're ready for some tendon training! What you do next will depend on whether or not your tendon is injured. We'll focus on training an injured tendon first. Let's pretend it's the distal biceps tendon, the one that attaches at the elbow.
Isometric muscle contraction is what to use. This is where the muscle contracts, but the elbow angle doesn't change, in other words the arm doesn't move
Lengthened positions are thought to be more effective. So the elbow would only be slightly bent, lengthening the biceps muscle
Only a 40% muscle contraction is needed to be effective. One could push their hand into a wall or under a desk so the only thing keeping the arm from straightening out is the biceps contraction
Maintain the isometric contraction for 30 seconds. This is enough time for the tendon itself to begin to creep, or stretch. This stretch under muscular tension is what we want!
Let the arm rest for 20-30 seconds
Repeat until the 10 minutes has elapsed
So that was one session. If done at 6am, the next session would be noon, and the next would be 6pm. That means that in one day the tendon has not only been stimulated with the tension it needs to heal three times, but it is in a nutrient rich environment each time. Again that 30 seconds of sustained tension is crucial for an injured tendon. There is a phenomenon called "stress shielding" with quicker movements where the healthy parts of the tendon absorb the force without stretching, and the tension never reaches the injured tissue that needs the tension as stimulation to signal healing.
As the tendon becomes more tolerant of tension, increase the tension of the isometrics. Given enough time the above exercise could be progressed all the way up to very high level exercise like a planche! (Don't hold your breath though, this would likely take years)
This Stuff Works!
I had a nagging hamstring injury that I got in June. It wasn't that bad, but it hung around as hamstring strains commonly do. Ask any sprinter, soccer player, wide receiver who has had one, they can alter a season and sometimes a career. I started applying Dr. Baar's protocol to my hamstring injury and made more progress in 3 weeks than in the prior 6 months!
What About Healthy Tendons?
Good news here if you're not a fan of isometrics. It appears from the evidence that any kind of contraction, be it isometric, concentric, or eccentric can make a healthy tendon stronger. You just have to train it through the full range of motion. That means squatting down all the way until your thighs cover your lower leg completely if you want healthy quad and patellar tendons. That means doing RDLs and back extensions in addition to classic deadlift for your hip extensor tendons.
More wisdom from Dr. Baar:
The balance between muscle strength and tendon stiffness is important
Light, explosive, plyometric exercise like sprinting, jumping, bounding will increase tendon stiffness over time more than muscular strength
Heavy, slow exercise like 3 second up, 3 second down single leg calf raises in the weight room will increase muscular strength while making the tendon more elastic because it gets that slow stretch (creep) over the course of a heavy, slow set
If the tendon is stiffer than the muscle is strong, an athlete is vulnerable to mid-belly muscle strains
If the muscle is stronger than the tendon is stiff, an athlete is vulnerable to tendon injuries
It's All About That Balance
No surprise to those who believe in common sense, maintaining tendon health is a lot about the balance of opposing elements. Be strong but flexible through your whole natural range of motion. Give your body the stimulus it needs to adapt but also give it the recovery time to adapt. This balanced approach is the foundation of treatment at Neighborhood Physical Therapy and the most powerful way I know to promote lifelong athletic enjoyment.
Orion Kooistra, DTP, OCS