Articles Nutrition/Training Overuse Tendon Injuries in the Bodybuilder: Symptoms, Diagnosis, and Treatment
Overuse injuries. We've all encountered them. In fact, let's face it: it's a basic part of training if we're going to take it to the top and give it our all. Or is it?
There is not a single person who devotes themselves to pumping iron who hasn't had a nagging overuse injury that caused them to modify their training regimen. Whether it is a shoulder, elbow, wrist, hip, or whatever; it's something that we all desperately try to avoid. But for those who currently suffer, or have suffered from an overuse injury, what can be done about it, and what exact is overuse?
Overuse injuries include stress fractures, exercise-induced compartment syndrome, and tendinitis. Most commonly, bodybuilders suffer from tendinitis.
Any injury to the body (whether it's due to weightlifting, running, or any sort of trauma) starts off with inflammation which eventually causes pain. The body then begins to heal and repair itself in a manner similar to the way in which muscles grow from weight-training (breakdown and building-up). However, tendons that are inflamed and painful lead to tendinitis. Tendon injuries often require patience and careful rehabilitation because tendons heal more slowly than muscles do.
Many overuse injuries are caused by tendinitis. It is critical that the athlete be aware of these symptoms and not ignore them. If ignored, the body may be unable to fully repair the damaged tissue. This can lead to partial or complete tendon tears (which may mean having to get an operation). Studies have shown that tendon strain up to 6% is physiologic; strain in the 6% to 8% range contributes to overuse injuries; and strain of greater than 8% may lead to complete rupture of the tendon.
Tendons have a relatively poor blood supply just before they insert into the bone. This poor blood supply predisposes the tendon to further breakdown and degeneration which is called tendinosis (the suffix "osis" implies a condition of chronic degeneration without inflammation). If left untreated, tendinitis usually leads to tendinosis. The scar-like tissue from tendinosis is never as strong as normal tissue and therefore is most susceptible to tearing and rupture. Varying degrees of calcification in areas of degeneration exist in tendons that have undergone tendinosis (Figure 1).
Chronically damaged tendons from overuse injuries have disorganized fiber structure and degenerative collagen repair mechanisms. Many of the collagen fibers are thin and wispy, and are usually separated from each other when compared to normal tendons. Micro-tearing and separation between collagen fibers are also observed.
Diagnosis
The first step in treating and preventing an overuse tendon injury is understanding what caused it. Always listen to your body. Warning signs of tendon overuse injuries include tenderness to the touch, stinging, aching, and burning.
Diagnosing an overuse tendon injury is relatively straight forward since certain movements in the gym will cause pain or weakness if you've got it. If you're unsure, a visit to your physician may help. Tests that your physician may order in helping diagnose your condition include MRI and/or ultrasound (especially if a tendon rupture is expected).
A classification system developed by Blazina is helpful for physicians in grading overuse tendon injuries:
Grade I: pain only after activity
Grade II: pain during activity but does not affect athletic performance
Grade III: pain during activity and does affect athletic performance
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(1) Achilles tendon with area of tendinosis. Note the characteristic dull and thickened appearance. (2) Normal adjacent tendon fibers. Courtesy of footsurgeryatlas.com |
Warming-Up
Warming-up is essential. Sure, we could start with 225lbs on the bench or 315lbs on the squat and consider that a warm-up. But try doing that in your 30's and 40's and you'll soon notice that what once worked in high school may not be such a good idea any longer. There are many great powerlifters and bodybuilders who simply warm-up with the bar alone. Stretching and wearing warm-ups throughout training is always a good idea (even though it may mean that others won't be able to see your sexy muscles flexing...)!
Treatment
The best treatment for an overuse injury is prevention. Whether that means an adequate warm-up by keeping the muscles and tendons warm during a training session, or by keeping the poundages light until your muscles are ready to get pumped, may be the difference between continuing training versus having to slow things down (or at the very worst, refrain from training completely until the pain is resolved).
Initial treatment mainly consists of rest and physical therapy. Very few controlled studies have been done in regards as to which treatment modality is best. Unfortunately, the treatments that are currently available don't speed the healing process very well. Below are some of the more common ones used:
Non-Operative Methods:
1. Rest & Cryotherapy
Resting and icing the affected area (aka cryotherapy) can help reduce swelling and pain from a tendon overuse injury. Icing before and after a workout can help ameliorate symptoms of tendinosis. Studies have shown that it usually takes tendons over 100 days to make new collagen, so being patient and not rushing through the healing process helps avoid any further injuries. However, you need to keep in mind that atrophy and stiffness can result from prolonged disuse. So waiting a few weeks shouldn't be of any harm before gradually re-starting any strengthening exercise program depending on how severe the tendon overuse injury is.
2. Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs serve to decrease swelling and manage pain and can be effective in the initial process of tendon injury (tendinitis). However, using NSAIDs should not be a routine practice (i.e. longer than 2 -3 weeks) due to potentially other systemic effects on the body. NSAIDs use can be of limited benefit once a tendon overuse injury becomes a chronic process (tendinosis).
3. Ultrasound, Laser Treatment, Electrical Stimulation
Although not enough research has been conducted to prove these various treatment modalities, some patients swear by them and others claim that they don't help at all. Ultrasound therapy can sometimes help manage and reduce swelling and fluid build-up around tendons. Usually your physical therapist can help you decide if one of these these options is right for you.
4. Physical therapy
Physical therapy and supervised exercise to strengthen the injured area can be of great value. Eccentric contractions, or 'negatives', have been shown to greatly benefit patients who have tendinosis (especially in the achilles and patellar tendons). Studies have shown that loading a tendon helps the collagen fibers grow in proper orientation with improved parallel alignment and can assist with healing. Your physician can prescribe you a physical therapy program after examining you if needed.
5. Injections
Other modalities to treat tendon overuse injury include injections. Corticosteroids (i.e. cortisone injections) significantly reduce inflammation although carry certain risks such as infection and further weakening of the tendon with possible rupture. As discussed earlier, tendon overuse injuries usually develop into a chronic degenerative process resulting in tendinosis. Since there is very little inflammation in tendinosis, cortisone injections may be of limited value. However, if diagnosed early (i.e. within a few weeks), a cortisone shot may help reduce symptoms of a tendon overuse injury since inflammation is highest during this early period.
Another injection that has been used recently in regards to treating tendinosis is that of platelet-rich plasma (PRP). PRP injections have shown some promise in regards to tendon healing; however, further studies are currently being conducted since this is a relatively recent treatment option for overuse tendon injuries.
6. Braces
Some patients find that wearing a brace can help them get through an overuse injury. Braces are mainly used to support joints from unstable or weak ligaments and tendons; therefore, using them for a tendon overuse injury is debatable. Braces, however, can serve as a reminder during a workout that you have an injury. Just don't depend on them too frequently as your joints can become accustomed to wearing them and you could start losing some strength and flexibility.
7. Supplements
Nothing definitive in the medical literature in regards to nutritional or chemical supplementation (i.e. anabolic steroids; growth hormone) has been shown to help overcome or prevent overuse tendon injuries. It stands to reason of course that a healthy bodybuilding diet and lifestyle with adequate amino acid intake and rest can only help the healing response. Since the cells of the damaged tendon are already damaged, adding more supplementation may just produce more damaged collagen fibers from the damaged cells, although this has not been proven either.
Operative treatment modalities
As much as I enjoy helping patients by performing surgery if needed, many orthopaedic surgeons (including myself) view an operation as the last and final treatment option for tendon overuse injuries. Always make sure to give your body plenty of time to heal on its own before you and your physician decide upon surgery. Surgery can be of great benefit but can always carry inherent risks (such as those with administering injections). Keep in mind that once surgery is performed you will still have to continue to undergo further physical therapy and rehab exercises.
Surgery is usually reserved for Grade III lesions that are also identified on MRI after non-surgical methods have been exhausted.
Surgery includes mainly two types of operations:
1) The 'excise and stimulate' group
This is where significant scar tissue from tendinosis that has been built up causing the problem can be surgically removed. Also, sometimes cutting open the sheath around the tendon (called the paratenon) can remove the pressure around the tendon and reduce symptoms as well.
2) The 'stimulate a healing response' group
Carefully introducing a needle by percutaneous puncture through the area of tendinosis can cause a healing response. This also can be used in conjunction with or without multiple longitudinal incisions along the tendon.
The goal of both types of surgeries is to induce a healing response in the diseased tendon by inflicting an acute traumatic event which is thought to help in repairing the degenerative tissue.
More research is needed to find effective treatments for tendon overuse injuries as we are currently unsure how to reverse the damage once it occurs. Still no treatment has been proven to reverse microtears that occur with tendinosis. Fortunately in most situations, tendon overuse injuries usually improve with time, physical therapy, and rest.
So whatever your fitness goals are, always keep in mind that the human body needs to be thoroughly cared for: before, during, and after training. Using common sense and proper lifting technique in the gym can help avoid these injuries. Doing so will help keep your tendons, ligaments, muscles, and bones healthy for many years and can help you avoid setbacks from nagging overuse tendon injuries.
Note: The above information is meant as a guideline and is not intended to diagnose or treat any particular condition. Please consult with your physician if you have questions or are undergoing symptoms of tendinosis.
(1) Achilles tendon with area of tendinosis. Note the characteristic dull and thickened appearance. (2) Normal adjacent tendon fibers. Note the capillaries and overall better quality and definition when compared to the area of tendinosis. (3) Paratenon covering the tendon
Courtesy of footsurgeryatlas.com
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