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Rest is not Always Best

I can’t tell you how many times I see runners in the clinic who say something to the effect of “I took an extra day off” or “I took a week off” after developing some sort of pain or symptoms on the run, and there is ensuing confusion as to why this didn’t fix the problem or that the pain isn’t better. Relative rest is certainly an important first step in recovery for an injury (or potential injury), but it is pivotal to both address the underlying cause as well as strengthen the injured area. While this applies to most injuries, today we are going to focus on muscle and tendon issues specifically.

Injury occurs when tissue breakdown exceeds tissue repair. If we think of training, whether it be running, cycling, swimming, lifting weights, etc., as a stressor that causes breakdown, there needs to be adequate time in between training sessions to allow for recovery. Most of us are familiar with this concept because it is how our training programs are designed. The best coaches will tell you: the real magic of training occurs when you’re resting, not during training.

Excessive stress on a muscle-tendon unit can occur for a variety of reasons, including but not limited to: biomechanics, life stress, poor sleep, poor nutrition, equipment, training surfaces, and relative muscle weakness. To stay healthy, the body must be able to handle the load that it is being asked to do.

If rest isn’t the answer, then what is a runner to do when tendon injury strikes? Here are the tenants of tendon injury to follow so that you can get back on the roads as quickly and safely as possible:

1. Relative Rest

The first step is to decrease/manage pain and offload the injured area. This will look different depending on location of injury, but it can include activity modification and cross training as well as kinesiotape, shoe modifications, manual therapy, and mobility work. This concept of “relative rest” is present throughout the healing process, but it gradually progresses as the body can handle more without a flare up in symptoms. This is an important stage to identify the underlying cause of the injury, so that any activities or biomechanical factors can be changed before returning to training.

2. Progressive load

Tendon injuries are characterized by a disruption of connective tissue and collagen fibers, such that the fibers that are usually parallel to one another become disorganized, potentially resulting in swelling or a “bump” on the tendon. The muscle-tendon unit needs the appropriate stimulus to return to full strength following injury. This is why you may have heard of eccentric exercises for Achilles, proximal hamstring, or rotator cuff tendinitis. Eccentric exercises (exercises where the lowering portion of an exercise is emphasized) are the preferred choice for loading the tendon because they load it in a way that facilitates collagen remodeling and reorganization. The dosage of these exercises is very important, as it has to be sufficient to challenge the tendon, but not excessive to further delay healing. This is where guidance by a Physical Therapist is helpful, as they can help monitor your symptoms and advise how to progress. Most studies done on eccentric protocols operate on a 12-16 week program, indicating that long-term consistency in performing these exercises is key to success. And don’t stop doing them once you feel better!

3. Specific load

Once the tendon is no longer painful and has increased in resilience, we need to get it ready to handle the specific type of load that comes with running. Tendons are like springs: they absorb and release energy to produce forward motion. So, in order to perform this very important and specific job, we need to train it as such. Plyometrics, or “jumping” exercises, help to train the stretch-recoil system our tendons need to utilize with running. Jump roping is a great place to start, eventually progressing to double leg box jumps and single leg hops/box jumps.

4. Return to sport

Everyone’s rehab is going to look different, as some athletes may be able to monitor symptoms and run a decent portion of their normal running volume as they are recovering from injury, while others might have to significantly cut back training. A general rule is a continual and gradual progress in pain/symptoms without any major setbacks in severity or duration of symptoms. The expectation should not be linear progress, but rather a positive upward trend in improvement.

So there you have it: the “stop, drop, and roll” of tendon recovery-- rest, address, appropriately stress. Don’t worry, I’m not going to try to make that phrase go viral.

Keep going, you got this!

Dr. Kacy Seynders, PT, DPT


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