Stretching and connective tissue strength

Hello all, I've had issues with medial knee tendonitis (tendinosis actually, or degenerative tendon issues at the pes anserinus or goosefoot) on both sides that started about 4 years ago, witch took almost 3 years to rehab totally (or what I thought was totally) until I did a middle split stretch session a few days ago and felt a twinge in the tendons on both sides. I've since been having a familiar sensation of heat, light pain and irritation around the gracilis/semitendinosus tendon.

I did see a PT for this problem and a chiropractor for ART during the 3 years of rehab, did tons of glute medius and glute maximus activation drills, the PT had me do partial single leg squats too. At some point pain was gone, started skiing again this winter, biked to work every day last summer, so I thought that my connective tissue was in good shape again, but it seems I never did any specific work to strengthen that particular spot, only a more global approach to work on my muscle imbalances. Both PTs I saw never mentioned working to get connective tissue integrity/resistance back up.

Anyway long story short I find myself realising that I can't do the stretch series because of the strain on my medial knee tendons (or I should of gone with lighter stretches and shorter holds but too late for that now). I've rehabed quite a few issues in the past such as epicondylitis, plantar fasciitis but for some reason this one seems to be a bit more elusive and wondered if anyone had had similar issues in the past and could help in finding exercises that could strengthen that particular area.

I know the answer will most likely be go see a PT, but I have in the past, also saw 2 doctors (who only gave me NSAID's). I know the only piece in the puzzle I am missing is the strengthening of that particular area, and maybe not stretching until I have gotten my connective tissue health back. Any help is welcome.

Or on a more general note, has anyone had issues with old injuries, like old muscle sprains and tendonitis, flaring up with stretching? And if so how did you go about being able to stretch?

Thank you all for any advice.

Hi Benjamin,

It's of course hard to comment on your medical specifics over the net but maybe the knee strengthening mobility exercises from the Single leg squat of Foundation 1-2, such as Skiers and the mobility from SLS PE7, begun very lightly, could help. They would address that tendon issue. One thing that I have found help me with that kind of stuff is light joint rotations for moderate to high reps. For your case, that would mean standing one one leg with the other knee pulled up to hip level (leg bent to 90 degrees) and doing leg extensions, flexions, and rotations around the knee joint with that free leg. The idea is to get synovial fluid circulating in the knee, put a very light load on the connective tissue, and have lots of movement. As a bonus, the connective tissue of the supporting leg gets a workout stabilizing you. Just some ideas to get started. You may have to lay off the stretching exercises that cause pain till you resolve this in that area. The only formula I know of is diagnosis, rest, unloaded mobility as described above, lightly loaded mobility as in Foundations, then gradual loading of the area via more specific strength exercises (in your case, side to side squats and cossack squats might be a more specific challenge to that area). Some jumping rope or other ballistic exercise that doesn't challenge the knee's ROM would be another good way to load up that area once it's strong enough to handle the previous exercises. Ballistics/rebounding present a strong challenge to connective tissue so should be entered into carefully, but are beneficial if your body can handle them. Stretching that loads those tendons would be at the very end of program after all this preparation.

@Matthias Schwartz Thanks, you are the first one to try and answer my question. I have since stopped the stretch series also because of some kind of hip impingement. But concerning my medial knee, the pain lasted about 10 days, witch had me scared for a bit, but then it slowly came down. I am now able to do some single leg work (single leg deadlifts, lunges, bulgarian squats and bench pistol squats) without much discomfort after or the following day. I would love to be able to do a bit more work, but the hip pain I had has me being very careful about what I do. After 6-8 weeks of rest for the hip pain I will try and identify what brings about the pain and what doesn't. Mostly I think swivel hips, hip rotations, straddle stretches, frog stretches and cossack squats might all be culprits in my hip impingement pain. I have seen a doctor, had x-rays done but they weren't conclusive. Hip impingement is my self diagnosis, but I will see a PT soon to have a more professional diagnosis.

@Benjamin Renaud, one other technique you might want to explore is using eccentrics for tendon healing/strengthening. And Coach Sommer has written a lot about using heat to heal tendons. There are lot of resources on the net about both topics.

The rationale (unproven so far), that I have seen, behind the success of eccentrics is that it allows you to load the tendon heavily enough to force hypertrophy but with less ballistic input and tendon sheath friction than a concentric contraction. Doing it slowly seems to be essential. Anyway, just another thought. I think, read, and practice a lot about tendon strength so it's an area of interest for me.

Best

20 hours ago, Matthias Schwartz said:

one other technique you might want to explore is using eccentrics for tendon healing/strengthening. And Coach Sommer has written a lot about using heat to heal tendons. There are lot of resources on the net about both topics.

Great advice here. Consult with your PT about this as a possibility. 

@Matthias Schwartz I've read a lot about tendonitis (especially tendinosis or degenerative tendon issues) since this particular issue lasted about 2 years before feeling like it was resolved and eccentrics are what I have used for 2 lateral epicondyles and some patela issues on my right knee. I just had a hard time finding eccentrics for medial knee issues, any idea what I might use? Like I said before, I'm feeling much better now, like I was a few months ago before the stretch series, I just think my pes anserinus tendon isn't as strong as it could be.

@Everett Carroll I had seen a PT for this issue, mostly what I was given as rehab at the time was glute activation (both medius and maximus) witch was essential because I had gluteal amnesia and some planks for core stability. But very little was oriented towards tendon rehab in terms of tendon strength. That part was built up slowly over the course of about a year and a half of various training I did (kettlebells and bodyweight). I just still might need some tendon strength to sustain an hour long stretching session. In the meantime I also developed or uncovered a hip impingement issue for witch I am seeing a PT for in 2 weeks.

Hi @Benjamin Renaud, the eccentrics that I have in mind, that have also helped me with both MCL and medial meniscus irritation are the following.

Again, I can't be aware of underlying issues you might have so my recommendations may not be valid, but these have helped me.

In order of gnarliness (easier first):

1) Air squats. While, done correctly, these don't challenge your medial knee ROM, I think these are great for knee health. They bathe the joint area with blood and synovial fluid and keep those sliding surfaces moving freely.

2) A wobble board has been very good for me. Although it's usually used for ankle rehab, a wobble board is great for lateral knee strengthening. Using a wobble board allows you to put a decent shear load on your knee, but the knee is kept in a relatively safe straight position. These are kind of the opposite of inside squats. Inside squats are high ROM with lower load (as your body is supported by both legs, and also your arms if doing eccentrics), while the wobble board uses all your body weight on one leg but your knee is straight, so your ROM is not challenged. You can use your arms to help support and balance yourself when starting out and you can also do negatives here as well, supporting yourself more with your arms when bringing your weight back to center. The wobble board is great ankle work too. You can do a lot with it. Just start off slow.

3) Inside squats from Foundation 2, SLS PE7. Negatives only, and pull yourself up with your arms while holding onto something. Also keep the ROM and reps very light for the first bunch of workouts. Coach Sommer wrote somewhere (I forget where) about Inside Squats to use 25% of your ROM for 6 weeks to acclimate. Also wait 48 hours between workouts in order to accurately recognize any delayed pain, and to assess and allow for recovery. For me it has been essential to feel better in the affected area the next day and for sure within 48 hours. There should be no soreness after doing tendon exercises. Soreness works for muscles. It is not good when doing tendon exercises. Immediately after doing the exercise you should feel some pleasurable tightness (like you activated the area) and maybe some warmth, but your pain level should not be noticeably more than before the workout.

4) Supported partial straddle split, where you lower and actively support yourself as you go into the beginnings of a straddle split. They key here is to do slow eccentrics only, and don't treat this as a flexibility exercise. Lower eccentrically, then use your arms to pull yourself back out. It may be difficult to do that, so you can use a chair, table, or bench to catch yourself at the bottom of your safe ROM. Treat it as strength training. It is essential to keep the ROM very small, so don't split super wide till you are sure you can handle it. Use your arms to support yourself so you can control the ROM and the load. Keep it easy, just enough to feel some healthy tension on the medial aspect of the knee.

Wildcard - Jumping rope. Single unders and double unders. Not much of a ROM challenge, but in my experience, the ballistic input is a good tendon/ligament/cartilage challenge, and I believe it strengthens those areas. There is probably some evidence out there to support this, but I haven't checked. Coach Sommer has also talked about rebounding being good for joint strength once you can handle it.

I also have a bit of a story related to the wobble board training.

Last fall, right around the time I found GST, one knee was having some minor but noticeable MCL/medial meniscus pain and I went on a Steelhead fishing trip. I spent 4 days wading over slippery cobblestone bottom (rocks in the size range of softballs to volleyballs). I was slipping and sliding over them for 8 hours a day for 4 days. I wasn't sure how my knee was going to handle it but I wasn't having any pain so I didn't let it stop me. At the end of that trip my MCL and knees felt awesome. I had spent a lot of time wading in the river with my legs in a walking stance (not much deep squatting) but with lots of sideways forces on my legs as the river currents pushed on me and I also wobbled and slid around on the edges of rocks. It was a major workout, but for some reason it really helped. I've used the wobble board ever since to replicate those forces, and I think it has merit as a prehab/rehab tool for knees as well as ankles. You can also do this by just balancing on one leg and leaning out to the side to put some sideways force along your leg.

Anyway, just some ideas. I hope something in there may be useful.

Best,

Matt

Thanks Matthias Schwartz, for now inside squats and straddle are out of the question due to unresolved hip pain. So I won't be stretching with the stretch series anyway but will continue to work on knee health.