Jill Cook Tendon Pain Podcast Review With Professional Recommendations For Athletes

We are trying something a little different here at Peak State Fit by offering a review of the Squat University podcast featuring Jill Cook on the subject of tendon pain. We enlisted licensed physical therapist Raechel Bugner to listen to the above mentioned podcast and offer her professional recommendations based off her experiences treating endurance athletes. I suggest you listen to the podcast first and use Raechel’s tips to apply to your triathlon, cycling or running training program. Of course, consult with your coach and or physician first! Enjoy and let us know what you think!

4 major takeaways from Jill Cook’s interview on Squat University: 

Change In Load

This is probably the single most important thing to remember as an athlete; tendon injuries occur when there is a change in load to the tendon in question. This could mean that the athlete has increased the number of reps they’re completing in a speed workout (on the bike or running), the intensity at which they are completing a workout (a sudden increase in power on the bike or in speed on a run), the reps or weight used during a strength workout, or the overall length of a workout. In my experience, it has been a combination of all of the above that causes tendon injury. The BIGGEST mistake I see patients make is that they ramp up all aspects of their training too quickly following a period of rest. Jill eluded to this as well. If you’ve ever taken time off from training (because of another injury, vacation, or simply because you’re in the off season), you’ve probably felt a bit sluggish and a little less fit when you return to your workouts than you did at the end of your most recent training cycle. it’s not just your cardiovascular system that has lost fitness. Your tendons have lost fitness as well! If you try to jump right back into training where you left off without slowly ramping up and giving your body and tendons time to adapt you’re likely to end up injured. Jill advocates for a week of ramping back into training for every week you’ve taken off. This might seem like a waste of time if your cardio system feels fit, but it’s far less time than you’ll waste if you end up injured.



Degeneration of the tendon does not always trigger pain. There can be long term pathology occurring at the tendon without any pain at all. Jill discussed that the majority of Achilles’ tendon ruptures happen in patients with no history of Achilles’ tendon pain. Degeneration must have occurred in order for the tendon to rupture, but it doesn’t necessarily cause the athlete pain prior to the tendon completely rupturing. Couple this with what we discussed above, introducing load to a tendon needs to happen carefully over time. Just because you are not feeling pain at the Achilles or knee, does not mean the tendon is healthy for you to make large increases in your training volume. More is not always better!

Don’t Stretch It Out

Injured tendons DO NOT want to be stretched much like injured muscles don’t want to be stretched. Think of the injury itself as being due to excessive tension or pull on the tendon. Stretching would further pull at the tendon or at the point where the tendon inserts into the bone (on the heel for the Achilles or on the front of your shin, just below your knee cap for the patellar tendon) causing an increase in tissue damage, irritation, and pain. The first step for all of my patients with tendon injuries (Jill barely brushed over this, but I think it’s extremely important!) is to receive some sort of tissue work and to begin foam rolling or trigger pointing regularly. Seeking a professional (a physical therapist, specialized massage therapist, or soft tissue specialist) to work on “loosening” the muscles from which the tendons are directly attached to (for the Achilles this would be the calf and for the patellar tendon this would be the quad) as well as potentially working the muscle groups that are lengthened in conjunction with the area of pain (this takes a bit more explanation, but think of push off in running. When your leg is behind you, your calf is being stretched and so is your quad. You need length in both of these muscle groups to prevent an over tensioning of either the patellar tendon or the Achilles. All muscles and tendons are covered in fascia (think of this as Plastic wrap around them). There should be fluid that lubricates between fascia and muscles/tendons that allows the two tissues to slide and glide over each other. if this fluid stagnates (this can occur if an athlete doesn’t regularly warm up or foam roll before an athletic activity especially if they spend much of their time sitting behind a desk) it becomes difficult for the muscle fibers and tendons to lengthen and shorten in their typical fashion to accelerate or decelerate movement. This translates to increased tension load (typically to the tendon, but the same mechanism can also cause muscle tears) and eventual injury. Regular foam rolling (nice and slowly) and soft tissue work from professionals trained to work with athletes can help prevent this “stagnation” and ensure that tendons aren’t being over tensioned. In my opinion, if the athlete or therapist simply jump straight to loaded exercises as Jill suggests, without first addressing issues in the soft issue surrounding the tendons (that likely is contributing in someway to the excessive load and injury to the tendon), they are doing the client a large disservice.


Rehab Of Tendon

This is where I start to disagree with some of what Jill discusses regarding the proper rehab of a tendon injury. I will agree that tendons need to be loaded in order to maintain their health, but the way in which she suggests to load each tendon is extremely non-functional, not just for the high level athlete, but for the way in which the tendons and muscles work to accelerate and decelerate motion in day to day life. The most clear example of this is in the way she suggests to rehab a patellar tendonopathy. She mentions using a leg extension machine with heavy loads. Think to yourself: How often do you use your quad to extend your knee from a seated position in front of you? How often do you do this motion with a heavy load? How often do you decelerate or slow down a motion like this? The answer is probably never because it’s not the way your quad functions in life. She also specifically, mentions not using weight bearing exercises to load the tendon because those exercises inevitably bring the hip and ankle joints into play. I would argue that you cannot simply rehab the knee, in isolation, without addressing how the ankle and/or hip joint mobility and muscle strength could be affecting the patellar tendon injury. The knee is a joint that is stuck between two joints, the ankle and the hip. in 99% of the patient’s whom I have treated for knee injuries, the pain in the knee is only a symptom of a dysfunction in the ankle and/or the hip and if you disregard these joints, you will never fully recover. Anytime someone gives out blanketed exercises to use to recover from injury, red flags should go up for the reader or listener. Because no two athletes are the same and their mechanism for injury or pain may be completely different. No two rehab programs are going to be the same. I would advise any athlete who believes they have a tendon injury to seek the help of a physical therapist who specializes in working with, and assessing, high level athletes to receive the personalized care and treatment that they need to fully heal.

Raechel Bugner PT, DPT, FAFS

Guest expert for Peak State Fit