Tendons and Ligaments: What can food do when they go wrong?
Whether you are an elite athlete or just someone who enjoys moving each day, injuries are a pain in the butt (maybe literally!). Many factors play into injury susceptibility and recovery, and nutrition is one of them.
It is a pretty new area of research and there is a lot left to learn. But here are the key emerging themes, translated into practical considerations for your diet as you recover from tendon and ligament injury – whether it be a strain, a sprain, a complete tear, or anything in between.
Before we go into specifics, I urge you to focus first and foremost on consuming a diet rich in a range of whole unprocessed foods, including lots of fruits and veggies!! Apart from anything else, this helps ensure you have the vitamins and minerals you need to maintain your immune system. And the immune system is what drives the repair of your injury. You can check out my recap on the basics of diet in my recent 'Fundamentals' post.
Now, the specifics …
If your injury means your physical activity is reduced, you might think you need to drastically reduce calorie intake. However, repairing your injury takes energy. In fact, your basic energy expenditure can go up by as much as 15-50% in the initial weeks following injury!! So you might not want to reduce your calorie intake by as much as you think. If your body does not have the energy and building blocks it needs, it may take longer to recover and / or recovery may not be as complete. So take care – use changes in bodyweight as a rough proxy of whether you are getting enough calories (if you are losing weight during this time you might want to consider eating more).
Protein is about 80% of the dry weight of tendons and ligaments. Unsurprisingly then, it is mostly protein that is damaged in an injury. And so protein is needed to repair it. A high protein diet may also reduce the amount of muscle loss you suffer if you stop training whilst injured. So, how much? There is evidence to suggest 2.0-2.3g protein per kilogram of bodyweight per day, spread across meals with at least 20g protein every 3-4 hours. This spacing seems to give the greatest acute stimulation of muscle synthesis in the absence of training, although whether this translates into greater preservation of muscle over the long term is not clear.
Also, whilst we are talking about protein synthesis … sorry guys but alcohol impairs it. So although you might want to drown your injury sorrows in a bottle of wine, it is not advised!
Collagen, Vitamin C and Copper
About 60-70% of the protein in tendons and ligaments is collagen. It is what allows the force from your muscles contracting to be turned into actual movement. So it is pretty darn essential!! And it is the primary protein that needs to be remade and restructured to repair an injury.
It turns out that eating collagen appears to stimulate collagen synthesis in the body. Movement also stimulates collagen synthesis. And so if you combine collagen ingestion with the timing of rehab movement of your injured limb it seems that you can stimulate maximal collagen synthesis in the injured tissue to help speed up repair and recovery!! Around 15-20g collagen (or gelatin, which is broken up collagen) appears to be enough, taken around 40 minutes before you start moving the limb (to give it time to digest and actually get to the limb). Tendons and ligaments have limited blood flow. They get their nutrients simply from the general fluid sitting around in the body ... as they tense the fluid moves out and as they relax fluid is drawn in. Like a sponge. This is why the collagen needs to be in the fluid before movement starts … so it is there and waiting to be squeezed in as movement begins!
What do we mean by eating collagen?? You can get it from eating meat with connective tissue and from bone broth (although watch out overdosing on bone broth as it is often high in unwanted heavy metals!), or what might be easier from a dose perspective is to use a collagen powder (analogous to any other protein powder, like whey).
Unfortunately, there is no plant version of collagen, so vegans and some vegetarians may not be able to employ this strategy.
What of the vitamin C and copper in the title of this section?! Well, there are needed for collagen to be made and crosslinked in the tendons and ligaments. Vitamin C cannot be stored in the body and is rapidly used overnight, so if you are taking collagen first thing in the morning before you have any food you might want to consider a collagen powder with a vitamin C supplement. Unlike vitamin C, copper is well stored in the body. So ensuring copper containing foods are included at a recommended level in the diet is usually sufficient.
Two other nutrients of interest …
Creatine monohydrate: 5g per day typically supports muscle preservation and may support tissue repair after injury.
Omega 3: is an interesting one!! Omega 3 helps reduce inflammation. In injury, inflammation can be both a help and a hindrance. Inflammation is essential to getting the cells of the immune system to the damaged tissue for repair. However, it can become damaging if the inflammation goes too far and itself starts to damage tissue. Omega 3 is therefore a ‘maybe’ one … I would chat to an exercise physiologist and sports nutritionist before you start dosing on super high levels after injury!! (same goes for anti-inflammatory tablets like ibuprofen!).
In short, first and foremost eat a range of whole unprocessed foods, including lots of fruit and veggies. In the words of the great sport nutritionist Kevin Tipton “whereas this advice may be considered boring, mundane, and lacking insight, it seems still to be the best course of action”! Try not to lose loads of weight aka take in enough energy, keep protein intake high and evenly spread every 3-4 hours through the day, and consider using collagen and creatine.
To read more:
Baar (2015). Training and nutrition to prevent soft tissue injuries and accelerate return to play. Sports Science Exchange, 28 (142):1-6.
Close et al (2019). Nutrition for the prevention and treatment of injury in track and field athletes. International Journal of Sport Nutrition and Exercise Metabolism, 29:189-197
Shaw et al (2017). Vitamin C enriched gelatin supplementation before intermittent activity augments collagen synthesis. American Journal of Clinical Nutrition, 105:136-143.
Shaw et al (2019). Rehabilitation and nutrition protocols for optimizing return to play from traditional ACL reconstruction in elite rugby union players: a case study. Journal of Sports Sciences, 37 (15):1794-1803
Tipton (2015). Nutritional support for exercise-induced injuries. Sports Medicine, 45 (Supp 1):S93-S104.