Here’s What You Need To Know…
1) Inflammation has an important role in recovery but its timing and duration can stall a quick return. The use of NSAID’s, especially within the first week of recovery, has been shown to limit tissue healing and regeneration, and yes, this is backed by science.
2) Enough with the term PRICE for the treatment of injuries. Developing a plan for optimal progressive mechanical loading following an injury can quicken the return to sport as when compared to rest for certain soft tissue injuries, and without the use of ice baths.
3) Progressive loading and active recovery plays a key role in tissue regeneration via hormonal responses, cardiorespiratory functions and the reduction of scar tissue formation.
4) Techniques such as compression through use of ace wraps or Voodoo flossing bands can reduce swelling during acute phases of tissue trauma and can enhance recovery times and recovery from soft-tissue injuries.
5) Joints need help following an injury to relearn proper centration patterns. Joint flossing with wraps such as voodoo bands when applied at the joint space appears to have the potential to provide nervous system input via compression for “pattern assistance”.
7) Using a progressive tissue loading strategy such as tissue tempering can quickly decrease muscle guarding and improve in soft tissue compliance to improve in mobility without the need of applying tension through a joint.
8) The combination of compression, elevation, and active movement are excellent ways of controlling swelling well beyond the initial stages of injury to continue to promote healing and recovery.
9) Remember, 74% of your muscle mass is made of water, use a sound approach to maintaining fluid intake as well as optimizing nutrition to aid in reducing inflammation.
We all get banged up from time to time, and how we invest in our recovery and train around the injury can truly make or break our chances of returning to optimal performance. In the cases of chronic repeat injuries, the frequency of having to take time away from a specific lift can make achieving that goal a far and impossible reality.
Experienced lifters know how to program over-reaching phases into their periodization models so that they don’t over-train but for the mortals learning how to shape their future with steel, these ideas can be far and distant. Let’s take a look at what research and experience is showing us about recovery and how we can implement it into our training models to expedite our return to the iron fortress.
The Importance of Inflammation
Too much of anything, even a good thing can be bad and in this case too much inflammation is not necessarily a good thing and should be controlled.
From the moment we are injured our bodies are quickly mobilizing an army of reactive and proactive agents that aid in healing and speeding up our return to the iron beast.
Our current understanding of soft tissue healing comes from tendon/ligament recovery models and depicts time based predictable phases that in general help explain our body’s attempts at tissue regeneration. The phases are broken down into 3 sequences that do overlap; these are the Inflammatory, repair, and remodeling phases respectively.
Although short in duration (2-4 days) the inflammatory phase is crucial in its own right by its ability to increase local and system wide blood flow. Increased blood flow by means of histamine and bradykinin induce what is known as edema. Edema by definition is a state in which local fluids have increased and spread through membranes to occupy surrounding tissues. This process of edema has wide spread effects at first which may seem detrimental such as inhibiting muscles from contracting and more so activating sensory nerve fibers that input pain but these symptoms are part of a larger process that allows our bodies to prevent further disruption of the damaged tissues.
It is within the swelling that certain leakage points of plasma proteins and other fluids allow for blood to become thicker and thereby act as a signaling agent for out immune systems (white blood cells) to selectively move in and start clearing the debris. This entire process occurs rather quickly and is part of the initial ground work that prepare the right environment for repair to occur.
In most cases people will run from this phase of healing attesting the pain and dysfunction as if it were alien and not “normal” and often the go-to treatment is to address this phase with anti-inflammatory medication.
Let’s be clear, I am no pharmacist just the messenger of research.
Can NSAID Use Limit Recovery?
NSAID’s (Non-Steroidal Anti-Inflammatories) or more commonly an over the counter ibuprofen, or Advil, Aleve (not Tylenol). These NSAID’s are commonly used to decrease pain and swelling but did you know that current research shows that in animal studies of tendon injuries the use of NSAID’s within the first 7 days of injury resulted in inferior mechanical potential strength seen by decreases in the tissue cross-sectional area (Dimmen et al., 2009). In other words the tendons of these lab rats who took a NSAID drugs, had decreased strength and were thus more likely to reinjure. So when is the right time to take NSAIDs?
Well, in a similar study that waiting up to 6 days post-surgery/injury to administer NSAID’s to a group of rats, the results showed in improved tendon healing and regeneration/strength. This finding is consistent with findings of decreased tissue healing with swelling present beyond the initial stage of healing. Hence, the longer the swelling is present for the more scar tissue and poor tissue quality that will form.
In short we can say that allowing the body to optimize the first 6-7 days post injury with pain medication and not an NSAID can aid in improving tissue regeneration and tissue strength; and that the use of NSAID’s in the later stages of remodeling may be beneficial by controlling inflammation that at this point would be detrimental to healing (Virchenko et al., 2004).
Enough With The PRICE Principles To Recovery
If any of you readers have ever played recreational or competitive sports the RICE or PRICE principle is one that has dominated the acute injury model for years. Recent research suggests we call the POLICE on PRICE for being too much of a sissy. POLICE is a new model of approaching early and later treatment of an injury.
The PRICE model which stands for Protect, Rest, Ice, Compression, and Elevation is very conservative in its approach and thereby has been debated in its efficacy in restoring individuals to pre-injury levels due to longer periods of immobilization/rest. This “Hurt vs Harm” conundrum has had the deleterious psychological effects of creating a “default mindset that loading has no place in acute management” (C M Bleakley et al, 2009).
Let’s be clear that the first priority following an injury has to be:
1) Control the local edema or swelling
2) Local and systemic pain modulation
3) Enhance and facilitate the healing process as early as possible
Protection of vulnerable tissues should remain and important goal when necessary but when long periods of protection and unloading occur, adverse changes to tissue biomechanics and morphology become present. Hence, a system wide shift towards using the updated POLICE model would better reflect early activity by addresses the importance of implementing a progressive loading strategy for aid in tissue regeneration.
Progressive loading or optimal loading follows the current science behind new histological studies that demonstrate early mechanical loading following an initial protection phase, prompts cellular responses that promote positive tissue structural changes (Khan KM et al.2009). Consistent findings within animal studies have demonstrated that progressive mechanical loading can actually upregulate certain genetic material such as mRNA to develop key proteins that are essential in the regeneration and healing of soft tissue (insulin-like growth factor-I (IGF-I), TGF-β, bFGF, platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), BMP, and connective tissue growth factor (CTGF) (Chen et al., 2008; Kobayashi et al., 2006; Molloy et al., 2003; Wurgler-Hauri et al., 2007) (Bring DK et al 2009, and Eliasson P et al 2009).
Promoting early loading when indicated can also help to provide better organization to collagen fibers that aid in reducing the building up of scar tissue which can restrict tissue movement or compliance and ultimately decrease joint range of motion.
As one size does not fit all, optimal loading and its dosage should be individualized and strategized to “reflect the unique mechanical stresses placed upon the injured tissue during functional activities, which varies across tissue type and anatomical region.” (C M Bleakley et al, 2009).
The Implementation of POLICE For Expedited Regeneration
The POLICE acronym stands for Protection, Optimal Loading, Ice, Compression, and Elevation.
Following the POLICE model the protection stage emphasizes protecting the injured area from additional injury. Because injuries come in all forms having appropriate knowledge of how to apply splints, pads, and braces in order to immobilize the injured area requires experts. If you are unsure of how bad the damage is and need to have someone take a look at it, don’t hesitate to see your nearest physical therapist.
With the current changes in the health care field you can stop in under “Direct access” (the same as you would for a chiropractor) and get assess. Like in every field know who you are dealing with and get word of mouth recommendations or trusted physician referrals. PT’s are movement specialist and are great at spotting erroneous movement and biomechanical faults.
In short, if the injury is bad enough, lay off. Don’t add insult to injury, this means man up to protecting your body and not your ego. None the less using protection gear can play a role in the early stages of healing when no contraindications are present, such that using crutches for example will allow for some loading to occur in a lower extremity injury.
Ultimately, early protection from further injury allows for your immune system to work and remove foreign debris to initiate efficient healing.
Tip: Know your local clinicians and get screened. Money is tight on everyone’s mind, but investing it into your movement health is just as important as your diet and lifting gear.
Post Injury Optimal Loading Parameters
Optimal loading can intelligently be designed by a movement specialist (i.e PT, ATC, OT, CSCS, ect..) in order to modify ones current level of activity to incorporate training around the injured site and establish a loading strategy to the injured tissues over time.
Current research backs up the idea of mobility vs immobility in certain cases of soft tissue injury such as with ankle sprains (Van den Bekerom et al 2012). Optimal loading is a direct means of replacing the rest phase with an incremental loading strategy and recovery program, aimed at early activity to encourage early recovery (C M Bleakley et al, 2009).
Bearing in mind the uniqueness of the injured tissue or tissues, active or passive range of motion should be discussed to maintain proper tissue compliance and joint mobility if indicated.
Lets start with the early on (1-7 days) phase of tissue healing secondary to injury. In my own experience, movement or range of motion is the first goal then loading. The quote,“First move well. Then move often,” from Gray Cook still holds true.
When passive or early active range of motion is safe and directed to perform, the earlier the better. Let’s briefly shine light on an understanding of gravity vs gravity-eliminated exercises.
Gravity-eliminated exercises define performing a range of movement that is not being resisted by the force of gravity. For example, in treating an upper extremity injury such as a shoulder, performing a gravity-eliminated shoulder flexion movement can be done by using a bent over position or by lying face down in the prone position. Such that gravity will not resist the flexion of the joint rather help by distracting or pulling on the joint to allow and not resist the flexion. Although some positions can’t reduce friction as a force the gravity-eliminated position allows for use vs disuse. You know what they say, use it or lose it!
For lower extremity injuries devices that reduce body weight such as an Alter-G treadmill or a pool (no open wounds to use aqua therapy) can be a tool in the development of a loading strategy.
These early range of motion techniques again when safe and directed to perform are all geared towards increasing blood flow, tissue compliance, and nervous system input which again directly improving healing.
As for the Remodeling or Mid stages of healing (7-21 days) the use of one of the most novel techniques to hit the health and fitness industries in decades, Blood Flow Restriction (BFR) training can be an optimal method of recovery.
Blood Flow Restriction Training
Blood flow restriction training should also be implemented in the early to mid-stages of our loading strategy. Recent research has found positive effects of tissue strength and muscle hypertrophy during BFR training, which allows for low sub max loads to be used during training which can reduce the likelihood of atrophy or muscle wasting during a recovery.
Using BFR with low resistance loads after the initial 7 days to 2 weeks of injury can provide the benefit of heavy loads which at this point would negatively impact healing. BFR succeeds at these adaptations by means of using external compression to induce a low oxygen training environment which stimulate protein synthesis or muscle protein hypertrophy while under working minimal loads.
When we think muscle hypertrophy we should be thinking M&M. That’s M for mechanical tension and M for metabolic stress. These two components are observed during heavy weight training (75-85% 1RM). As we have by now experienced lifting heavy weights doesn’t at first equate to bigger muscles as the body adapts first by improving at the level of the nervous system and later on by strength gains seen with increased muscle recruitment and protein building to a large extent. These protein hypertrophy gains are seen later on in a normal linear lifting model but with the use of BFR training, we can see these changes occurring slightly out of order, with hypertrophy gains seen early on followed by the normal progression of increased nervous system and motor unit recruitment.
Isometrics and Soft Tissue Mobilization
Battening down the hatches around an injured joint to provide increased stability or simply improving joint position awareness by means of increasing muscle motor control is part of the master plan to bullet proof from a repeat injury.
Using a well known effect of a synergistic spiral at the shoulder and hip joint promote increased muscle motor control and joint stability. These techniques can be used with hold times at a submaximal contraction to gain the benefit of isometric strength at that level.
Using submax isometrics at this stage in the game can maintain neuromuscular function and muscle strength while decreasing the risk of disrupting newly forming collagen fibers (building blocks of tissue integrity).
Due to the specificity of the angle being used it is encouraged to use multiple angles of stimulus that are pain free.
Soft tissue mobility is also part of the loading strategy as placing compression or shear forces to a tissue provides stress to the tissue. As with most injuries muscle guarding is present this soft tissue mobilization can also aid in decreasing tightly protected muscles and encouraging other muscles to wake up and work.
Certain types of soft tissue mobilization such as instrument assisted soft tissue mobilization (IASTM), myofascial release, active release techniques, and good old massage, when used appropriately may encourage maintenance of blood flow/lymphatic flow which would aid in decreasing muscle guarding (muscle tone) and decreasing pain which allow for increased joint range of motion (Launder K,et. Al 2014). As well certain self myofascial techniques can be used if indicated. Next, lets move to Repair/Remodeling or Late stages (21 days and beyond).
Eccentric Isometrics & Improving Soft Tissue Compliance
Assuming you stuck to the plan, and healed correctly you are ready to start moving away from BFR training and isometric low load training and really start tapping back into a more linear progression of resistance training.
Eccentric isometrics (EI’s) studied by Dr. Joel Seedman, has focused on the effects of this training technique to promote increased mind muscle connection for greater muscle strength/hypertrophy and in promoting injury prevention by means of improved tissue mobility and joint stability.
EI’s use a form of isometrics known as the “yielding isometric” which depicts the deceleration and control of a weight via a push or pull to given degree, and maintaining that degree without collapse.
This form of training in Dr. Seedman’s work has demonstrated enhanced stability and symmetry between left and right upper/lower limbs when compared to control groups. When you are thinking of recovering from an injury it is often single sided and thus would predispose that side to become weaker and provide less participation in the movement.
Using EI’s can re-train the nervous system by actual feedback through the muscle/tendon organs to aid in proper loading and symmetry. Practice makes perfect and in time the feedback will promote future improved stability and uniformity to strength and hypertrophy.
EI’s also improve tissue mobility by these exact same means of nervous system feedback. Tight over activated muscles and weak under recruited muscles make for a nightmare scenario of motor patterns that are going in all directions but the one we want to stay safe and grow. Loaded stretches and EI’s are almost one in the same as they promote increased tissue hydration and compliance with the added benefit of EI’s in increasing muscle awareness and joint awareness.
IE’s can also promote increased recovery and training frequency by means of promoting proper form and posture. Moving weight around without proper form we all know is a means to an end and having that small tip of form can often be that moment we all attribute to our “turning point”. IE’s again using a nervous system feedback approach, reinforces our form by harnessing the sensory system to give us the internal cues that often after an injury we lack. The efficiency of a movement leads to greater muscle gains, and strength gains by direct means of correct loading patterns and recruitment. This over time can also promote decreased inflammation and decrease repeat injuries.
HOW TO EXECUTE AN ECCENTRIC ISOMETRIC
Pick a push of pull motion and establish the end of the range of motion. This is not where we will stop because at this end we are now hanging on soft tissue and also activating elastic reflexes that do not promote improvements seen with EI’s.
Establish a low point where we just come to being parallel with the floor or slight below it, ensuring we keep the muscle on tension. Here we will perform a strong working muscle contraction and hold for 2-7 seconds.
Hence we move towards just breaking parallel with a controlled movement, we keep the muscle on tension and provide a 2-7 second contraction and hold, and now return to start with a forceful movement.
I have experimented with a set/rep/tempo scheme that follows – 5 sets, 5-8 reps, Tempo: 3-7-0-3
Compression’s Role in Tissue Regeneration and Recovery
Compression is where things get interesting. As explained before, swelling post injury leads to edema formation. Edema, again can infiltrate in and around the injured tissue moving to surrounding tissues essentially braching out and decreasing overall functional mobility.
Because edema makes your blood thicker, imagine it as a space occupier. You only have but so much space for muscle, nerve, veins, ect… to move, glide, slide, and compress against one another. This means that some of the fluid and fascia that separates these tissues has to be pushed away and compressed to make space for the edema, thereby increasing in friction of moving tissues.
Hence, with edema present beyond the early stages of healing the free space is lost and functional mobility suffers as do muscles which are now less efficient at absorbing forces and producing tension for normal movement to occur.
Let’s look at compression used initially and then later on in the repair stages.
The goal of compression is to stop hemorrhage and manage swelling. Hence, compression is applied to limit the amount of excessive fluid accumulation that is caused by the exudation (leaking) of fluid from the damaged capillaries into surrounding tissues. Controlling the amount of inflammatory exudate can reduce the amount and rate of scar tissue formation and can help control the osmotic pressure of the tissue fluid in the injured area.
In short, compression can mechanically reduce the space for any extra swelling to accumulate into which would otherwise leak into surrounding areas and create secondary injuries and pain from a prolonged low oxygen environment. A little bit of hypoxicity never hurt anybody and can actually be good for us as seen during normal muscle contractions.
To review, muscles contract and push fluid away; through repeated contraction waste products accumulate and lower the oxygen in the area (hypoxic). During rest your circulatory system kicks in and moves out the bad to bring in the good.
When compression is applied directly to a joint such as seen with “joint flossing” an interesting yet poorly studied effect inducing a temporary and artificial joint centration occurs. Our current understanding is that with the application of a standard knee sleeve, little to no static alignment changes can be seen at the joint space when compared to osteo-arthritis knee unloader braces via X-ray.
Hence, most of the benefit from wearing a knee sleeve which can be seen with reports of increased perception of knee stability has to do more with the nervous system than anything else.
This phenomenon was observed in a recent published article looking at the immediate effects of wearing a knee sleeve on frontal plane gait mechanics (that’s side stepping for my gym buddies). What the researchers found with their knee sleeve test group was a significant change in frontal plane knee adduction torque and a reduction of loading forces with walking. This means that by using compression at the level of the knee joint the researchers noted improved movement and walking strategies which appeared to have increased the subject groups knee proprioception, “we speculate that the observed effects can be attributed to improved proprioception, which has been associated with knee sleeves before” (Schween R et al, 2015). For this particular study the observed phenomenon makes sense due to well documented knee OA literature that demonstrates a loss of lower extremities proprioception being associated with the destruction and loss of specific proprioception cells at the joint level.
Hence, in my opinion (lack of research in the field) compression at the level of the joint such as performed with voodoo bands may be allowing for the nervous system to use other sensory inputs such as mechano-receptors or cells that are found in the skin, fascia, muscle, joint capsule, and other various structures that provide nervous system feedback, thus increasing joint proprioception.
Voodoo band joint flossing has more backing via real world use than what you will find in the literature. Give it a go and reap the benefits even though some scientist hasn’t proven it, yet.
Review: Compression at the joint space maybe allowing for an intermittent external input into the nervous system to increase awareness of joint position, movement, and pressure.
Tissue Tempering and Ischemic Therapy
Like many accidental discoveries and inventions, the necessity of having something perform better occurs with the pursuit of greatness. Donnie Thompson from Columbia, SC owner operator of The compound and world record power lifter accidentally stumbled across a novel means of increasing in joint mobility through the use of heavy crushing steel rods. The term “Body Tempering” coined by Donnie himself describes the adaptation of skeletal muscle and underlying biological structures to heavy compression that can be performed statically or with tensile/shear forces similar to what is seen in active release techniques (A.R.T), but with faster results when anecdotally compared to large muscle groups.
- Side note: A.R.T. or S.M.R.T both use deep digital tension (finger pressure) to locate and treat a specific tissue or area on the tissue in order to provide a compressive, tensile and shear force to address repetitive strain, cumulative trauma injuries and constant pressure tension lesions. This force of conservative care uses practitioner expertise and client movement in order to restore free and unimpeded motion of sfot tissue, release entrapped nerves, vasculature and lymphatics, and to re-establish optimal texture, resilience and function of soft tissues.
Donnie’s innovative way of tempering the body follows certain well known principles and laws of tissue adaptation. Tissue tempering allows for biological tissue adaptation to occur in general based off of 2 associated observations.
The first observation is by the German anatomist/surgeon Julius Wolff, Wolff’s law. The law simply states that through mechano-transduction (that’s smart for a force created by movement) bones will remodel in response to the imposed stress and become stronger.
The seconds and maybe more direct law is that an American orthopedic surgeon Henry Gassett Davis, which was at the time known best for his work in developing different methods of tissue traction (pulling). The Davis law also simply put states that soft tissue will heal according to the manner in which they are mechanically stressed “Nature never wastes her time and material in maintaining a muscle of ligament at its original length when the distance between their points of origin and insertion is for any considerable time, without interruption, shortened.”(Davis 1867, conservative surgery)
Finally the all too well known S.A.I.D principle (Specific Adaptations to Imposed Demands) describes physiological changes observed over time in the human system.
Tissue tempering stimulates specific changes/adaptations due to its progressive and direct compression to the tissue. As with all forms of mechanical compression and shear a reduction of tissue tightness involving fascia, muscle, veins, organs and nerves have been observed both scientifically and anecdotally. The specific changes seen with tissue tempering can also be extrapolated from recent well documented studies of occlusion training showing increased blood flow and circulating growth factor hormones that stimulate protein synthesis following treatment.
An agreeable yet not documented finding with occlusion training such as tissue tempting is that it may in fact aid in ridding toxins specifically from the fascia, veins and nerve encasement’s by means of increasing vasodilation, NO2 production, and local hyperemia.
The technique, in which Donnie and his team are using though novel in our western training, appear to have certain correlations with decade old eastern culture soft tissue techniques where body weight was applied to certain areas of the body to aid in improving health and performance.
The current loading strategy that is used by Donnie and his crew follow a gradual progression of increased weighted steel rods, emphatically named after a broken family, that follows a frequency of daily instructed use with active movement and 2/wk use with static progressions. Time duration can be up to 5 minutes.
Tissue tempering in my opinion would be best used later on in the remodeling phases of healing as discussed earlier, due to the potential to disrupt certain cell mediators seen only active in the acute and early repair phase. Again, it’s all about balancing the inflammation at the beginning and eliminating it later on.
Lastly, it’s not only what we do but what we eat. Here’s how we can manipulate nutritional intakes to enhance tissue recovery and regeneration.
Microbiome and Controlling Inflammation and Pain
To not make this article any longer than it has to be, lets chat about some requisites to healing. In short much of our body and soft tissue is made up of water. Drink plenty of clear fluids to keep things moving. For the love of goodness, soda doesn’t count. Also recent research in regards to food and inflammation has shown correlations between processing/preservatives and intestinal inflammation, which may and most likely does, decrease your ability to absorb proper micro-nutrients from your diet.
Food also supplies nutrition to the over 15 pounds or millions of bacteria in our gut. These bacteria have recently been noted to manufacture certain key chemicals that our brain uses to establish mood, sleep cycles, pain perception, and even sex drive.
“Let food be thy medicine and medicine be thy food”
Promote and adopt good eating habits and learn about the clean 15 and dirty dozen for starters. Eat clean, eat organic, chew your food, drink plenty of water, understand minerals and vitamins, and for heaven’s sake stop counting calories (this Oreo cookies bag only has 120 calories per serving, oh my gosh!)
It’s important to learn from this first phase of healing, and back track to the point of injury for a self-analysis of what may have occurred. Often times when I ask patients/clients about what they believe lead to their injury, they alone come to the conclusion by means of introspective thought gathering. This isn’t always the case because cumulative injuries are often hard to ascertain in their mechanism when compared to a single overload injury event. None the less finding the culprit can often aid in developing a plan of attack, that should include a firm understanding of the phases of healing and progression/regression models that will remediate and create success.
A Short Side Note On Cryotherapy and Icing Strategies
Ice, the love hate relationship with much heated (get it!) debate on its efficacy has always played a role in recovery. On one end of the treatment world, some groups believe that ice can help to decrease the secondary hypoxic (low oxygen) effects of swelling by lowering the local metabolism of the injured site thereby slowing down the rate of further injury. (This is only slightly true with superficial structures as ice only penetrates a few millimeters into the tissue).
Conversely, on the other side we see a group that thinks ice is a waste of time due to promoting inactivity during its application. Either way ice most likely will be here to stay if not for more than its pain reducing effects by means of increasing nerve conduction latency (slower nerve signals) to promote analgesia (reduced pain) (Kerr 98).
Elevation is another mechanism of improving healing in early stages of recovery by means of using gravity and body position relative to the heart, in order to influence venous and lymphatic drainage. When swelling is too great, compression of lymphatic walls reduce lymphatic flow, and it is within this circulatory system that we find our immune function. This means having to lay down, but by no means does it mean you get to relax.
Using a combination of elevation, compression and active movement can be a power house of effects during the acute stages to help in controlling the swelling and improving in the early stages of healing. None the less in the later stages of recovery, if swelling is still present the trio of mechanical influence can still hold its ground in improving joint ROM, muscle function, decreased pain, and improved functional mobility.
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Bring DK , Reno C , Renstrom P , et al . Joint immobilization reduces the expression of sensory neuropeptide receptors and impairs healing after tendon rupture in a rat model. J Orthop Res 2009 ; 27 : 274 – 80 .
Eliasson P , Andersson T , Aspenberg P . Rat Achilles tendon healing: mechanical loading and gene expression. J Appl Physiol 2009 ; 107 : 399 – 407 .
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Schween R, Gehring D, Gollhofer A. Immediate Effects of an Elastic Knee Sleeve on Frontal Plane Gait Biomechanics in Knee Osteoarthritis. Butler RJ, ed. PLoS ONE. 2015;10(1):e0115782. doi:10.1371/journal.pone.0115782.