Taking roughly 70 strokes per minute, for about 60-80 minutes per session, day after day, week after week, sure adds up fast! Over-use injuries are pretty common in our sport, especially the hotspot areas of elbows, wrists and shoulders. Having had my fair share of troubles, I’d love to share how I overcame my last big hurdle… a torn elbow tendon.
ALL OVERUSE INJURIES HAVE AN ORIGIN
The body has an amazing ability to overcome obstacles. When it comes to movement, the body will adapt to any short comings, just to achieve the end result, often at a detrimental cost. My elbow was giving me a hard time, and I was struggling to paddle without severe pain. I was starting to compensate my paddling stroke to cope, and had also stopped doing all upper body strength work to avoid unnecessary load on my elbow.
Even though my elbow was the area of pain, I took a good look at my technique to try and figure out why this was happening, as there had to be an original cause. After a series of movement “screens” and analyzing the data from my Motionize unit, it became obvious that I was not rotating equally, and that the route of my problem lay with my hips/lower back. The adaptation and work around my body came up with, eventually cracked the weakest part of the chain, and I got a bit of pain in my wrist, and eventually it moved into my elbow. The pain got worse, and what started out as a basic “tennis elbow” or lateral epicondylitis, progressed far enough for the tendon to tear.
Now having been down the overuse tendon route before in 2011, which ended up in surgery to reconstruct tendons and remove a trapped nerve in my wrist, which nearly ended my paddling career, I didn’t want to end up in that same boat!
Unfortunately the stubbornness and ability to work through pain that helps put us at the top of our sport, is the same trait that gets us into trouble with injures. I pushed through until Rio, and then took a long break from paddling (which ended up being nearly 6 months). The initial part of the break did nothing for my “tennis elbow”, and after a month of physio with no substantial changes to my pain or function, I changed things up in my rehabilitation.
So what do you do when faced with elbow tendon issues?
Firstly you should get an accurate diagnosis. I ended up seeing a physio for almost 3 weeks with no change in function, so we went and got a scan done, and identified a massive tear in my elbow extensor tendon.
Rest was doing nothing for its healing, and the physio sessions were helping with pain, but ultimately, I needed to aggressively change the structure of the tendon at the injury site. I was getting highly frustrated, and missing paddling terribly!
After chatting with my good friend Rob Hanson, a super sports doc and paddler himself, we decided to go with a more aggressive approach.
Tendons love load. According to Jill Cook – world leading tendon researcher and manual therapist – resting a tendon will cause the tendon tissue to lose structure, with musculotendinous strength dropping within 2 weeks.
I followed a simple routine each and every day for just over 3 months. I purchased a Theraband Flexbar (in green – as red was too easy, and I presumed blue would be too painful!) and did 3 sets of 15 reps every morning. As easy as that sounds, not missing a day was tough. I found it best to either build it into another session I was already doing (running, swimming, or my strength session) and on days off, doing the 3 sets while watching Modern Family helped!
As I got stronger, I increased the load (i.e. sets). After a month and a half, I also started adding some speedier intervals to the routine, as I wanted to simulate paddling. I also worked on range of motion/mobility for my whole body, focusing on that bad lower back, shoulders , elbows and wrists.
HERE IS A QUICK VIDEO OF THE ECCENTRIC WRIST EXERCISE I DID:
The video below gives a great sum up of tendinopothy. There is nothing simple about tendons, and no easy fix. Each person’s situation is different, and the treatment should be individualized.
Here is a great video from Andrew Walker of Physio Works and Wellness, Inc.
As I understand it, the healing process for tendons forms scar tissue via 3 stages, namely Inflammation, Matrix Production, and Remodeling & Maturation. The Inflammation stage is the response to the injury (or overload) and is usually the first week after injury. During the Matrix production phase collagen gets synthesized (which is highly disorganized) and takes place in weeks 1-4 after injury, and then the Remodeling phase starts.
In my case, with all the years of paddling abuse to my wrists and elbows, I had more of a chronic injury situation. I never really had any swelling or visible symptoms usual of a tendinitis. This chronic case of tendon degeneration is called tendinosis, and is thought to be a breakdown of the collagen fibers without the presence of inflammatory cells.
This is like a bad cycle where the body breaks down collagen within the tendon, starts to repair by forming scar tissue, but before full healing occurs, there is another micro-tear. This process repeated over and over again will leave you with chronic tendinosis.
Tendons respond well to load, and if, while the collagen is realigning, we load the tendon eccentrically, we can get the organization of the collagen to be more uniform and aligned with the angle of pull. Think “disorganized” to “organized”.
An eccentric muscle contraction is one whereby the muscle lengthens while contracting (for example -the “down” part of a pull up). In my rehab I tried eliminating the concentric (muscle shortening phase or “up” part), and just kept it eccentric, with regards to the tendons of my wrist and elbow.
Again, every injury is different, acute or chronic, and totally personal. Be sure to get an accurate diagnosis from a reputed therapist and move forwards from there.
WHERE AM I NOW WITH MY ELBOW?
I got back into paddling after about 4 months of following the rehab routine. My pain was totally manageable, just the pain of being unfit was hard to swallow!
I do a maintenance routine of keeping my elbows healthy through some eccentric loading, and mobility work, about 3-5 times per week. I also switched paddles to the Gara Odin with a 40% carbon shaft, which my joints are loving!
The Role of Mechanical Loading in Tendon Development, Maintenance, Injury, and Repair
Marc T. Galloway, MD, 1 Andrea L. Lalley, BS, 2 and Jason T. Shearn, PhD 2
by The Journal of Bone and Joint Surgery, Inc.
Sportsfisio Switzerland Facebook page for the 2017 Bern Symposium “Tendon & Sport”