Harry opened his front door and felt the cool morning air on his face. The sun was just coming up creating a soft glow in the distance. He was anxious to get started. Harry loved to run and it had been a very long time since he injured his heel cord. He stopped running altogether for several months. It seemed as if the pain and stiffness would be a permanent fixture in his life but finally he felt ready. He waited not only until the pain had gone away but an extra two months just to be sure. Today he would run. Run for his health, to lose weight and run for fun.
He did not know he was smiling as he walked down the street and began a slow jog. He was surprised. His muscles felt tight. He moved as if he needed oil in his joints. He could hear the air rush in and out of his lungs. But he was running. Then he noticed a faint but familiar sensation. The heel cord was talking again. He ignored it. “Nah, I’m just not warmed up. It’ll go away,” he thought.
But it did not go away. The message grew in intensity as if the heel cord was shouting “Hey, are you listening to me? I do not like this at all! And if you keep it up, I am going to just shut down the whole system!”
Harry was listening though. He slowed his jog to a walk and turned around to go home. What had started out as such a gloriously bright day turned gloomy and hazy. “When will I ever be able to run?” thought Harry.
Tendinosis lurked silently in Harry’s heel cord only to come out to wreak havoc when he tried to run. Tendinosis is the body’s attempt at repairing weakened and damaged collagen. The result for Harry is a weak, flimsy tendon incapable of withstanding the physical demand of running. It operates in stealth mode only revealing its true nature with physical exertion.
What can be done about tendinosis? From recent scientific studies, it appears the repair is influenced by mechanical load.
A group from the University of North Carolina has demonstrated a relationship between tendon healing and eccentric exercise. The mechanical load produced by eccentric exercise appears to promote DNA and collagen production (Banes AJ, Hu P, Xiao H, et al. Tendon cells of the epitenon and internal tendon compartment communicate mechanical signals through gap junctions and respond differentially to mechanical load and growth factors. In: Gordon SL, Blair SJ, Fine LJ, ed. Repetitive motion disorders of the upper extremity. Rosemount: American Academy of Orthopedic Surgeons, 1995: 231-245.). Harry thought by resting his ailing heel cord he was healing it. Instead, the prolonged inactivity left him pain free but weak.
What should Harry have done? At SportsCenter, the first step in our rebuilding program for Achilles Tendinosis is to find Harry’s pain free threshold to rise up onto his toes. This motion will load the Achilles Tendon. We use a Variable Incline Plane (VIP) such as a Total Gym for the test. Each angle of the VIP is a specific percentage of body weight. By raising or lowering the VIP, we increase or decrease the physical force applied to the tendon. Harry rises onto his toes then lowers the heel slowly down. We adjust the load until we find the amount of force which produces pain. We then lower the force a few pounds to locate his pain free threshold. We now know exactly how much physical load Harry can withstand.
Harry’s training requires both eccentric loads to stimulate collagen production and high volume repetitions to stimulate the sluggish tendon metabolism. For eccentric loads, we generally use 20-30 repetitions, 2-3 sets per drill. Higher volume training includes lower physical loads with 100-200 repetitions per set, 2-3 sets per drill. By the end of the session, Harry should have a low level of pain. The pain indicates the training has stressed the tendon (no transformation without perturbation). The pain will subside within 24-36 hours. He trains 2-3 sessions per week.
Every two weeks, we test Harry’s pain free threshold and adjust his training accordingly. After 2-3 months, Harry should be close to a full body weight force but in some cases the time frame can be as long as a year (dependent upon severity, chronicity and initial pain free threshold). But, to run he needs above body weight force capability. The forces created while running are 4-6 times body weight. To help Harry shorten the rebuilding time, maintain and improve his cardiovascular fitness and give him a glimpse of what is possible, we use a Newton Speed Trainer.
Healing tendon requires physical loading. While stretching, massage, ice and other measures relieve the discomfort, only one thing changes the physical capacity of tendon: controlled loading. Now that you know how to heal the chronic Achilles Tendinosis, can you think of how to apply the same idea to perhaps a rotator cuff tendinosis? Or how about patellar tendinosis? Just remember, tendon is tendon regardless of where it is in the body. Once you know the fundamentals of the healing stimulus, you will be well prepared.
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