5 Nutritional Strategies to Enhance Tendinopathy Rehab

As somebody who has had my fair share of issues with different forms of tendinopathy over the years, I can appreciate that it is a nuanced area. If your training/rehab is not in the right ballpark for encouraging recovery, there’s nothing you can really do from a nutritional perspective that will move the needle. However, there are some nutritional strategies that you can implement that will either speed up the recovery process, or tip things slightly in your favour in terms of how much loading your tendons can handle while still making progress. Here’s 5 of them:

1. Eat an appropriate amount of calories

When we think of muscles, we are typically aware that it is hard to build stronger muscles while in a large calorie deficit. Tendons are similar. It is easier to build stronger tendons while either at maintenance calories or in a calorie surplus.

Often when people have injuries and cannot train properly, there is a temptation to cut calories and switch the focus towards getting leaner. But if the goal of the rehab process is to build up the tolerance of the tendons, in addition to building muscle in certain areas, this could be counterproductive.

With longer term tendinopathy there is typically some form of muscular atrophy that occurs around the site of the affected area, so rectifying that at some stage is likely important. At the other end of the spectrum, you could make an argument for a calorie deficit and getting leaner.

Two examples that come to my mind are:

1. Lower body tendinopathies where you could argue that reducing body weight takes some of the load off the tendon in certain sports.
2. There is research linking higher waist circumference with tendinopathies regardless, and this is potentially linked to inflammatory processes that occur with higher levels of body fat (1).

For most cases however, maintenance calories makes sense. Arguably, a calorie deficit can make sense too under the circumstances described above, but it would likely slow down the actual adaptations of the tendon and reduce the growth of muscle.

2. Strategically Use Collagen/Gelatin + Vitamin C

Collagen supplementation is a little bit more controversial. There’s not a massive amount of research yet, however I also think a lot of people dismiss it too easily. The research we have currently seems mixed. But when you account for a few variables, the research that has been done that meets the below criteria has been positive:

1. Sufficient dosage – 15-25g of collagen (keeping in mind a lot of supplements provide below this amount).
2. Vitamin C – this is required for one of the enzymatic processes of collagen synthesis in the body. Therefore, any fasted study that does not include vitamin C is unlikely to find any benefit. There’s no specific dosage, but >50mg seems like a common theme in research with positive findings.
3. Timing – 40-60 minutes before a rehab session seems to work well because that is roughly how long it takes for the amino acids and collagen peptides to peak in your blood.

A lot of people brush off collagen with statements like “how do we know any of that collagen actually ends up helping the injured area?” We actually do have research indicating that collagen synthesis in the area being targeted is likely increasing in a meaningful way if it is used in this fashion (2).

This is an emerging area of research and I’m super comfortable changing my opinion on it later. But for now, I’m of the opinion that collagen supplementation likely helps, and at worst, doesn’t really do anything. No downside for potential upside. For those who are more optimistic – there is a case study by Keith Baar on an NBA player with patellar tendinopathy that is worth being aware of (3).

In terms of patellar tendinopathy, most people talk about “treating the donut, not the hole.” Basically, implying that the affected area likely will not necessarily heal and get back to being a perfect tendon. The focus is on improving the load tolerance of the healthy tendon around the affected area.

This makes sense because a lot of people get back to pain free performance, but if you gave them an MRI, they would still have the pathology of the tendinopathy. In this case study though, as shown in the MRI below (3), the injured area completely healed. The protocol that was utilised was the collagen supplementation protocol outlined above, in addition to heavy isometrics 2 x per week. This was over the course of 18 months, in combination with a strength and conditioning routine and playing ~50 NBA games each year.

MRI of NBA players knee at baseline, 12 months and 18 months (3). Notice the “hole” near the inferior patella in the first image compared to the last image.

3. Consume sufficient protein

One argument against collagen supplementation that some people have is that after consumption, it mostly breaks down into amino acids. My understanding is that ~10% remain intact as collagen peptides.

The argument is that if your protein intake is high enough, it should cover this. And there is a grain of truth in this. For overall recovery, it is a good idea to keep protein relatively high. It will also help with muscle retention/gain throughout the rehab process too.

Using patellar tendinopathy as an example, there are often deficits in quadriceps strength. If somebody were to consume an inadequate amount of protein throughout the rehab phase, it may prolong how long it takes to address those deficits.

Beyond that, collagen protein is high in certain amino acids, such as glycine, lysine and arginine. These amino acids are not great for muscle protein synthesis. Protein sources that are good for muscle protein synthesis are often low in these amino acids. Basically, collagen protein has a far different ratio of amino acids to almost all other sources.

My advice is to do both. Emphasise protein in general AND also strategically use collagen/gelatin supplementation.

4. Consume enough Omega 3’s

Omega 3 fatty acids may also be beneficial for tendinopathy. They can have a positive impact from an inflammatory perspective.

With omega 3s, I firstly encourage aiming to get them through food. This means focusing on foods like:

• Oily fish
• Walnuts
• Chia seeds
• Flaxseeds

When it comes to research on supplemental forms, one study involving 1.5g of eicosapentaenoic acid (EPA) and 1g of docosahexaenoic acid (DHA) showed slightly better outcomes than placebo for rotator cuff tendinopathy (4). Another study highlighted that patients with rotator cuff tears have lower omega 3 status than those with no rotator cuff issues or tendinopathy (5). This is not specific for tendinopathies, but I still think it is relevant.

Overall, there is not overwhelmingly positive evidence that omega 3s are going to make a world of difference. But there is enough evidence that I would ensure that the patient has either a diet rich in omega 3s, or supplements if necessary.

5. Ensure Vitamin D levels are high enough

Vitamin D is not really talked about much when it comes to tendons. My take is that if you are on the low end of the healthy range or are deficient when you get a blood test, it is worth supplementing. Or alternatively, getting more sun. This is a pretty safe recommendation, because even if it does not help your tendons, it will help other stuff.

A deficiency in vitamin D could be a limiting factor in collagen synthesis and also lead to increased oxidative stress (6). Vitamin D deficiency is relatively common as well, so this is worth considering too.

Summary

One of the difficult aspects of studying tendinopathy in the real world is that if an approach “works” in theory it might not actually make a noticeable difference in practice. If you add a strategy that should theoretically reduce somebodies’ pain by 20%, will that actually happen?

As somebody who has had significant experience with tendinopathy, I appreciate the difficulty of this. If somebody starts feeling 20% less pain, they will likely increase their training volume/intensity in response to this improvement as well. By influencing one variable, you influence multiple variables.

While none of the nutritional strategies mentioned in this blog are more important than nailing exercise rehab fundamentals, pairing these strategies with exercise might help your tendinopathy patients recover quicker than expected.