Is there a deficiency that causes tendonitis?

Three deficiencies that cause tendonitis, and why none of them is in a bottle

Is there a deficiency that causes tendonitis is a question asked by a reader hoping the answer is a vitamin, because a vitamin deficiency is the kind of cause that a tablet corrects, and the honest answer is yes, there are three deficiencies that cause tendonitis, and none of them is a nutrient. The first and by far the largest is a deficiency of capacity. Every tendon tolerates a certain load, set by the density and organisation of its collagen and by the condition of the cells that maintain it, and tendonitis, which in nearly every chronic case is tendinopathy rather than inflammation, is what happens when the load placed on the tendon rises above that tolerance and stays there long enough for the matrix to disorganise, the cells to multiply and change shape, and the tendon to thicken, lose its ordered structure and hurt under load. It happens as often as it does because the tissues of the body adapt to a new load on different clocks. Muscle adapts in weeks, growing stronger within a month of a new programme. A reader's enthusiasm adapts in days, with the second week's sessions heavier than the first's. But tendon adapts over months, its collagen turning over slowly and its stiffness and size rising only after a long period of consistent loading, so the muscle is ready for the new programme long before the tendon that attaches it is, and the gap between a muscle that can now lift the weight and a tendon that cannot yet transmit it is the deficiency that causes nearly every case, which is why tendonitis arrives after the new programme, the new sport, the return from a lay-off or the week of extra sessions, and why the twelve-week look-back on the sudden tendonitis page nearly always finds the change. The second deficiency is of recovery, and it is a deficiency of days. A tendon that is loaded raises its collagen synthesis for around seventy-two hours afterwards, and raises its collagen breakdown too, with breakdown ahead of synthesis for roughly the first twenty-four hours and synthesis ahead for the two days after, so the net gain from a session is collected on days two and three and a tendon loaded heavily again on day one or two is loaded while it is still in deficit, netting less collagen over the week than it loses; a reader who trains the same tendon hard daily, the climber on the fingerboard every evening, the runner adding a sixth day, has a recovery deficiency that no nutrient addresses because the missing ingredient is time. The third deficiency is of energy, and in women also of oestrogen. The consensus statements on relative energy deficiency in sport describe what happens when an athlete or a dieter eats too little for their training load: sex hormones are suppressed, bone turnover falls, recovery is impaired, and the rates of bone stress injury and soft tissue injury rise, with tendon and ligament problems on the list of consequences and the treatment being food rather than any supplement; a reader who has started training more and eating less at the same time has given the tendon both a capacity deficiency and an energy one. And oestrogen loss at menopause lowers tendon collagen synthesis and alters tendon structure, which is why tendon problems, the frozen shoulder, the gluteal tendinopathy, the Achilles, rise in women in their fifties without any change in load, a hormonal deficiency that a doctor rather than a shelf addresses.

The nutrient deficiencies put through the causation test, the correction of the real deficiency, and where collagen sits

The nutrient deficiencies that a reader hoped for are put through the causation test on the vitamin deficiency and tendonitis page, and the honest page gives the verdicts here. Vitamin C deficiency fails. Vitamin C is the cofactor without which the enzymes that stabilise new collagen cannot work, and its severe deficiency is scurvy, a failure of connective tissue everywhere at once, with bleeding gums, bruising, poor wound healing, loose teeth and bleeding into joints, a disease that is rare in the United Kingdom, needs months of near-total absence of fruit and vegetables, and does not look like a sore Achilles after a new running programme; a reader eating any fruit or vegetables is not deficient, and no trial has shown vitamin C above sufficiency prevents or treats tendinopathy. Vitamin D half passes and then fails. Some observational cohorts find lower vitamin D levels in people with rotator cuff tears or tendinopathy, others do not, the association is confounded by age, season and activity, since the people who get tendinopathy and the people with low vitamin D overlap for reasons that have nothing to do with tendons, and there is no randomised trial showing that correcting a low level prevents or treats a tendon problem; a reader in a British winter may well be low, and the correction is worth making for bones and muscle on the national advice, without expecting it to touch a tendon. The nutritional states that do affect tendons are excesses rather than deficiencies, cholesterol in familial hypercholesterolaemia depositing in the Achilles and glucose in diabetes glycating and stiffening collagen, on the tendon problems page, and the drugs that cause tendonitis, fluoroquinolone antibiotics and corticosteroids, are a pharmacist's conversation rather than a deficiency. The correction of the real deficiency is to close the gap between load and capacity from the capacity side: progressive loading, isometric holds for pain and then heavy slow resistance every second or third day, so that the tendon adapts to the load that found it out, with the load reduced for now and raised as capacity returns, on a timescale of months because that is the tendon's clock; the recovery deficiency is corrected by spacing heavy sessions on the same tendon two or three days apart; the energy deficiency by eating for the training, protein at 1.6 to 2 grams per kilogram and enough energy to hold weight; and the hormonal one by a conversation with a doctor about menopause. Collagen's protocol sits beside the loading that corrects the capacity deficiency: 15g gelatin with vitamin C about an hour before loading raised a synthesis marker in healthy men, and 2.5g beside six months of calf strengthening improved Achilles tendinopathy more than placebo beside the same exercise, so the adjunct belongs beside the session and corrects no deficiency of its own, since no reader is deficient in collagen, a protein the fed body makes from any protein eaten. The worked example is that adjunct at habit scale, stated on its true terms: two capsules, 1200mg hydrolysed type 1 marine collagen with 12mg vitamin C at 15% of its reference value plus zinc, 120 for £16.99 at 28p a day, lab tested and UK made, below the 15g protocol dose, carrying vitamin C's collagen formation sentence for cartilage and bones and no tendon claim. Is there a deficiency that causes tendonitis: three, of capacity, recovery and energy or oestrogen, and the shelf addresses none of them.

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