When rest isn’t best - Tendon overuse injuries

Recovery from tendon overuse injuries usually takes months and requires active rehabilitation - not rest.
Ashleigh Flanagan
August 25, 2021

Tendon overuse injuries such as tennis elbow, golf elbow, de-Quervain’s tenosynovitis and yogi butt are prevalent in athletes at all levels. Such injuries can significantly impact function, not just in training but in day to day life. They often lead to people taking significant time off their training to try to recover.

Tendon overuse injuries feel better with rest, but the pain inevitably returns when athletes return to their training after a break. It’s easy to assume that more rest is needed to make a full recovery, but this is rarely the case and can lead to worsening symptoms down the track.

All tendon injuries are overload injuries. This can be acute overload such as a fall onto the side of an ankle or, more commonly, chronic overload, being repeated overload with inadequate recovery. Sometimes athletes will experience a notable incident on top of chronic overload, such as a hamstring tendon popping while doing splits. I call this acute on chronic overload. While loading is essential for the recovery of all tendon injuries, this post focuses on chronic overload injuries.

Tendon overuse injuries are usually the result of doing too much too soon, often after doing not enough for too long.  They tend to occur when starting a new training regime or when increasing training load. However, injury risk increases not just with increased loading but also with reduced tissue capacity. This means stress, poor sleep, inadequate nutrition/hydrations, previous injuries, lack of recovery between training sessions, incomplete rehabilitation, and illness are all risk factors.

Tendons adapt and grow more resilient with increased load, but they need adequate time and recovery for this to occur. While everyone is different, it takes months, not weeks, to get significant structural adaptations to increased load in tendons, which only happens with adequate stimulus and recovery.

When we consider that part of the reason tendon overuse injuries occur is they’re not robust enough to tolerate the load we have been asking them to, it makes sense that extended rest isn’t the solution. After an extended break from training, tendons are even less prepared to tolerate load than before the injury occurred.

Recovery from tendon overuse injuries usually takes months and requires active rehabilitation - not rest. If you want to get back to training how you were, the tendon needs to be better than before the injury, or the symptoms will continue. This is a ticky rehabilitation that requires a balance of increasing the tendon's capacity to tolerate load, while decreasing the overall load to allow it to recover. There are a number of ways to do this, including reducing training frequency, improved recovery strategies and prioritising high load low rep training. The aim is to maintain a loading stimulus on the tendon while ensuring adequate recovery and minimal aggravation of symptoms.

Tendon overload injuries are tricky to manage without expert guidance. So if you are caught in the overuse / over-rest cycle of tendon injury, book in to see us now.


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