Can weak ligaments be strengthened?

Three weaknesses: lax, hypermobile and deconditioned, and why the word weak hides the difference between them

Can weak ligaments be strengthened is a question that cannot be answered as asked, because the word weak is doing three different jobs in it and the answer to each is different; the honest page separates them first, since a reader who applies the answer for one weakness to another will either train for a change that cannot happen or fail to train for one that can. The first weakness is laxity, and it is what most readers mean. A ligament that was stretched or torn in a sprain heals, if it heals, by scar, and the scar often heals long: the fibres that bridge the gap are laid down with the joint in whatever position it was held in and remodel at the length they find themselves at, so that the healed ligament restrains the joint less than the original did and the joint moves further than it should, which an examiner feels as an ankle that tilts or a knee that opens, and a reader feels as a joint that gives way. The fact that decides what can be done about it is that a healed ligament's fibres do not shorten again. No exercise shortens a ligament, since loading maintains and slowly builds matrix at the length the ligament has rather than pulling it tight, and nothing swallowed shortens one, since supply does not instruct a fibroblast about length; a lax ligament stays lax. The second weakness is hypermobility, which is laxity that was never caused by an injury. A sizeable minority of people, more women than men, are born with connective tissue that stretches further than most, so that their elbows and knees hyperextend, their thumbs bend back to the forearm and their palms reach the floor with straight knees, the manoeuvres that the Beighton scale scores to define generalised joint hypermobility; it is an inherited variation in the collagen and matrix of every ligament in the body, not a deficiency and not a disease in most of the people who have it, and its laxity is not changed by exercise, by supplements or by diet, since the ligaments are built that way and no intervention rebuilds them. For some people hypermobility comes with symptoms, joint pain, subluxations or dislocations, fatigue, easy bruising, and that group is assessed by a rheumatologist for the hypermobility spectrum disorders and the heritable connective tissue disorders, because the management and the other systems involved differ; for most it is a trait to be trained around. The third weakness is deconditioning, and it is the one the word weak fits best in the mechanical sense. A ligament that has spent weeks in a cast or a rigid brace, or months in a joint that was not used, has lost strength in itself: the immobilisation experiments found that several weeks of unloading cut a ligament's stiffness and failure load by around a third and weakened its bone insertion more, because the maintenance of ligament matrix is an active process driven by the strain the cells sense and it stops when the strain stops; the asymmetry that governs this, lost in weeks and regained over months, is on the ligaments get stronger page. Three weaknesses, then, and the question of whether weak ligaments can be strengthened has to be asked of each.

Yes for one and around for two: what strengthens each weakness, the examination that tells them apart, and where collagen's one trial sits

The deconditioned ligament is the one that is strengthened in itself, and the answer for it is a clear yes with a slow clock. The same asymmetry that cut its stiffness when it was unloaded lets it regain stiffness under load, progressively, through the range the ligament restrains, over months rather than weeks, with the ligament's substance recovering first and its bone insertion, the anchor that weakened most, taking a year or more to re-anchor, so that a joint out of a cast is loaded by criteria rather than by how it feels, since it feels ready long before its anchors are. The lax ligament is strengthened around rather than within, and the answer for it is a different yes: the joint it fails to restrain can be made stable even though the ligament stays long, because joint stability is mostly muscle and reflex rather than ligament, and the muscle and reflexes can be trained. For a chronically unstable ankle, the commonest lax-ligament joint, balance and proprioceptive training, single-leg standing progressing to unstable surfaces, eyes closed, with hops and landings, restores the joint position sense and the speed of the peroneal reflex that the original sprain damaged, and it cuts recurrent sprains in randomised trials, with a functional brace or taping during sport as its partner, so that an ankle whose ligament is as lax as it ever was stops giving way; the two ankle timelines, this sprain and the next, are on the ankle ligaments page, and the three senses of fully on the torn ligaments fully heal page. For the few whose ankle still gives way after months of such training, surgery that tightens or reconstructs the ligament is the option that does shorten it, since it is the only thing that does. The hypermobile ligament is strengthened around as well, and here the training is lifelong and general rather than a rehabilitation with an end: strength and control around every hypermobile joint, with particular attention to the shoulders, knees and ankles that sublux or sprain, the avoidance of resting in the hyperextended end-range that the ligaments permit, and a tolerance for the fact that the Beighton score will be the same at the end of the programme as at the start, since the aim is a joint that muscle holds and not a ligament that shortens; symptomatic hypermobility, with pain, dislocations, fatigue or other systems involved, goes to a rheumatologist for the hypermobility spectrum and heritable connective tissue disorder assessment before a programme is built. The examination that tells the three apart takes a physiotherapist minutes, and it is the first job: a history of a sprain or an injury with a joint that has given way since points to laxity; a Beighton score of five or more out of nine, with hyperextending elbows and knees and a thumb that reaches the forearm, points to hypermobility; and a joint that has recently come out of a cast or a long period of disuse points to deconditioning, with combinations common, since a hypermobile person sprains more and a sprained ankle is often immobilised. Collagen's one ligament trial was in the first group: 5g a day for six months given to athletes with chronic ankle instability, lax ligaments long healed, improved a stability questionnaire and cut recurrent sprains against placebo, outcomes that belong to how the joint behaves and that proprioceptive training also delivers, with no measurement of laxity, stiffness or structure, so that it sits beside the training around a lax ankle as an adjunct and says nothing about shortening a ligament, about hypermobility or about reconditioning after a cast. 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 5g trial dose, carrying vitamin C's collagen formation sentence for cartilage and bones and no ligament claim. Can weak ligaments be strengthened: in themselves, yes if deconditioned, by load over months; around, yes if lax or hypermobile, by the muscle and reflexes that take over their job; and the first job is to find out which weakness it is.

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