Connective Tissue Injury and Prevention: Connecting the Dots

Connective tissue makes up one of the most important aspects of our musculoskeletal system, as it is critical to our overall movement quality and injury prevention. Unlike our muscles (which are very quick to adapt), connective tissues (such as our tendons, ligaments, and fascia) are a bit slower to change, and require more time and intentional effort to strengthen. This is why runners tend to build up mileage slowly, ensuring that the entirety of the musculoskeletal system is ready to move forward and preparing for what’s to come.

This episode is going to briefly overview the general make-up of our connective tissues and explore how we can help prevent injury.

What are our ‘connective tissues?’

Connective tissue is a fairly broad term, encompassing a lot of the… well.. connecting tissues in our body, such as the tissue that connects bones to each other, or the muscles to our bones.

Tendons: Tendons connect muscles to bones, which help us transmit the forces created by our contracting muscles through the joint. For example, the Achilles tendon helps transmit power from our calves when running.

Ligaments: Ligaments connect bone to bone, often providing stability throughout a joint. Examples here include the ACL, MCL, PCL, and LCL in our knees.

Fascia: Fascia is a network of fibrous tissue that is layered around muscles and organs.

Most of these tissues are made up of collagen and elastin, which provides strength and elasticity. However, they tend to have fewer arteries and veins than other areas of our body. This makes them fairly resistant to fatigue, but also slower to adapt and recover after injury. Because of this, connective tissue injuries tend to last weeks to months, so prevention is key!

Tendon Injuries

Tendon injuries are one of the most common pains experiences by athletes. Chronic and repetitive use can be straining for our tendons, leading to potential tendinitis, microtears, partial tears, and rupture if not treated.

The best way to avoid such injuries is to ensure that you are staying active throughout your life, which protects the tendons from growing stiffer or more fragile as you age (1). Additionally, progressive strengthening programs, slow increases in work load, and stretching can help ensure your tendons are well-prepared for your next race, event, or training block (2).

When injured, eccentric exercises have been shown to help reduce pain and enhance recovery. Eccentric exercises are exercises that lengthen our muscles, such as standing on a step and lowering the ankle below the stair during calf raises. In fact, in one (small) study on Achilles tendinopathy, all participants who performed heavy-load eccentric exercise returned to baseline activities and performance in 12 weeks. Conversely, none of the conventional group (rest, anti-inflammatories, orthotics) recovered over that time (3). Now, eccentric exercise is viewed as a key part of Achilles rehab, demonstrating the importance of physical therapy.

Ligaments

Ligament injuries can be incredibly disrupting, as they can sideline an athlete for an entire season. Ligamentous injuries can happen for a variety of reasons, involving both internal and external factors. Many cases stem from an impact on a joint (such as getting hit or landing from a jump) with the joint in a suboptimal position. Because of this, muscle imbalance - such as relying too much on your quadriceps, while neglecting your hamstrings - is thought to increase the risk of an athlete sustaining such an injury (4).

Making sure to focus on strengthening a variety of your muscles, can ensure you are maintaining relative muscle balance. (Never skip leg day!) Research also shows that plyometric exercises can go a long way in recruiting these muscles, so that they are activated during exercise and play.

Plyometric exercises are made up of quick eccentric (lengthening) movements followed by rapid concentric (shortening) movements. The quick-paced, alternating acceleration and deceleration is thought to build better neuromuscular power and is considered the ‘missing link’ between muscle strength and muscle performance (5). An example of this type of exercise may be ‘squat jumping’ which is jumping in the air starting and ending in a squatting position.

Fascia

The fascia make-up one of the most often overlooked, and (for that reason) least understood aspects of the musculoskeletal system. Nevertheless, it is clear the fascia play an important role in our sensation of muscle soreness, bodily aches and pains, and even our autonomic nervous system (6).

Current research suggests that self-myofascial release (activities that release the fascia surrounding our muscles) can help reduce muscle soreness, promote blood flow, and improve short term flexibility. Examples of this include foam rolling or massaging the area.

While the jury is still out on whether it plays a major role in long-term flexibility, the benefits of reducing muscle soreness and inflammation and improving short-term flexibility can help athletes increase their activity and workload efficiently and safely.

Conclusions

Just as you focus on specific muscle groups when you go to the gym, my hope is that you also consider these connective tissues as part of your training regimen. Adding exercises that help maintain your tendon and joint strength can help improve your performance and reduce the likelihood of injury. Remember, prevention is the best medicine.

Disclaimer: This if you are experiencing joint pains or injury, this article is not medical advice. The best thing for you to do, in order to recover quickly and efficiently, is to be evaluated personally by a medical professional.

Sources and Further Readings:

1. Hess GW. Achilles Tendon Rupture: A Review of Etiology, Population, Anatomy, Risk Factors, and Injury Prevention. Foot Ankle Spec. 2010 Feb 1;3(1):29–32.

2. von Rickenbach KJ, Borgstrom H, Tenforde A, Borg-Stein J, McInnis KC. Achilles Tendinopathy: Evaluation, Rehabilitation, and Prevention. Curr Sports Med Rep. 2021 Jun;20(6):327.

3. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-Load Eccentric Calf Muscle Training For the Treatment of                     Chronic Achilles Tendinosis. Am J Sports Med. 1998 May 1;26(3):360–6.

4. Hewett TE, Ford KR, Hoogenboom BJ, Myer GD. UNDERSTANDING AND PREVENTING ACL INJURIES: CURRENT BIOMECHANICAL AND EPIDEMIOLOGIC CONSIDERATIONS - UPDATE 2010. North Am J Sports Phys Ther NAJSPT. 2010 Dec;5(4):234.

5. Davies G, Riemann BL, Manske R. CURRENT CONCEPTS OF PLYOMETRIC EXERCISE. Int J Sports Phys Ther. 2015 Nov;10(6):760.

6. Beardsley C, Škarabot J. Effects of self-myofascial release: A systematic review. J Bodyw Mov Ther. 2015 Oct 1;19(4):747–58.