Healing lesson from elite sport: Injuries need work, not full rest

Gymnasts tend to have denser bones than swimmers, and walking does little for the spine.

When long jumper Murali Sreeshankar ruptured the patellar tendon in his left knee while training in Palakkad in April 2024, surgeons reattached it with three anchor screws and a wire looped around the kneecap, and early in his recovery, his team already had the knee moving and the muscles around it working.

In 2013, researchers at used carbon released by nuclear weapons tests to date the collagen in human Achilles tendons. (HT Graphic)

“We know that the repair heals better when there is some stress placed on it, rather than none,” said Wayne Lombard, an athlete performance specialist who has worked on Sreeshankar’s comebacks. On July 29 this year, Sreeshankar won silver at the Commonwealth Games in Glasgow with a jump of 8.09m and then went on grab a silver at the Asian Games on September 27 with a jump of 8.07m.

The principle behind that recovery now guides the treatment of far more common complaints, from tennis elbow and heel pain to thinning bone after menopause. When a tendon, bone or muscle is put under strain, its cells respond by building more of it, and most of that building happens during the rest that follows; take the strain away and the cells stop building.

The principle behind that recovery now guides the treatment of far more common complaints, from tennis elbow and heel pain to thinning bone after menopause.

Cells build when strained, and rest is key

The cells in a tendon register each pull and respond by making more collagen, the protein that gives tendon its strength, laying the new fibres along the direction of pull. Bone cells respond to the slight bending of bone under impact by adding new bone. The rebuilding takes different lengths of time: muscles grow measurably within weeks of starting resistance training, bones renew in cycles of three to six months, and the tendon is the slowest of all, because, as Lombard and Samuel Pullinger, head of sport science at the JSW-backed Inspire Institute of Sport, point out, little blood reaches it. Much of the repair happens during sleep, when the body releases growth hormone.

“We know that some of the strongest evidence for it comes with ordinary people rather than athletes as well,” Lombard said. Tennis elbow, an overloaded tendon on the outer side of the elbow that many people develop without ever holding a racquet, shows what the old approach costs. In a 2013 trial of 165 patients published in JAMA, researchers at the University of Queensland found that more than half of those given a steroid injection had a relapse within a year, against about one in eight of those given a placebo injection, even though the steroid had relieved pain far better at four weeks. General practitioners still often prescribe steroid injections, Lombard said, “but exercise is not prescribed.”

The bone responds more to a hard jolt than to a long workout, because what matters is size and speed of the force. Gymnasts tend to have denser bones than swimmers, and walking does little for the spine. In the LIFTMOR trial at Griffith University in Australia, 101 postmenopausal women with low bone mass did supervised heavy lifting and impact training twice a week for eight months, and their spine bone density rose by 2.9%, while a comparison group on a gentle home programme lost 1.2%.

“A massive portion of what we called ‘aging’ was simply the clinical manifestation of advanced disuse syndrome,” Pullinger said. People in their fifties and sixties who start training regain muscle, strength and aerobic fitness, though some losses continue regardless: maximum heart rate, for instance, falls with age at the same pace whether people exercise or not.

Too much, too soon undoes the gain

Hurried use causes the very injuries – tendinopathy, muscle strains and stress fractures – that careful use heals. Lombard sees this most often in sedentary people who attempt a fun run or a hike without preparing for it. Elite athletes also have coaches, physiotherapists and nutritionists tracking their recovery every day, Pullinger pointed out, support that most patients do not have.

In 2013, researchers at the University of Copenhagen used carbon released by nuclear weapons tests in the 1950s and 1960s to date the collagen in human Achilles tendons. They found that the core of the tendon is laid down by the end of adolescence and essentially never renewed, so an adult’s Achilles is built around much the same collagen they had as a teenager. Yet Lombard has seen patients with chronic tendon pain who “often recover well while their scans barely change.” Researchers have not yet established whether that recovery comes from new collagen at the edges of the tendon, from stronger muscle, or from a nervous system that has learned to share the work differently.

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