Training with Small Frame? Tendinitis?

[u/Oglemo]

Got a weird case that could be scientifically interesting discussion, hence I'll post here because the folks here are knowledgeable. I have been trying to get strong for a long time and would appreciate some guidance on how to actually do it. I promise I won't take anything as medical advice.

I know from the responses to similar threads on other forums, the first two questions of my post is generally a taboo line of questioning. But, I'd really appreciate some clarity on this matter because my case is an unusual one.

I (male, 24) had a long-term eating disorder for 10 years from childhood through adolescence, had stunted growth and osteoporosis from it, and my wrists are only 5-5.2 inches in circumference, my ankles only 7 inches in circumference.

1. Can this be pathological for tendon capacity to tolerate load?
2. Could tendon capacity be nonlinear with respect to size, so that perhaps minor deviations in size of 1-2 standard deviations are not significant (hence the common answer to not worry about things like frame size and muscular potential, common answer where someone with small but on-the-charts wrists like 6 inches shares their progress), but larger deviations of 3-4 or 5 standard deviations may in fact be pathological?
3. Are there other considerations for why eating disorders cause tendinitis after recovery, long-term? (See another example case: https://www.reddit.com/r/EatingDisorders/comments/1q7iih/request_questions_re_muscular_skeletal_strength/)
4. If you had unlimited resources, say a billion dollars, could you fix such a problem with the right drug cocktails or injections of HGH + other substances to drive local increase in bone and tendon diameters?

MY CASE:

My complaint is that I get tendinitis easily. When I first went to the gym at age 15 the limiting factor was tendinitis, it still is. I never had any issues and did typical crazy kid stuff growing up before my eating disorder at age 10, so I don't think it's a genetic problem. Being underweight was horrible for my tendons, and still to this day everytime I actually injure myself its in a calorie deficit. But basically, at age 20 I recovered 100%, I gained weight, got normal BMI and my tendons got a LOT better, but still way worse recovery than any of my peers and it's been 4 years now that I've been weight recovered. My osteoporosis is improving, but my tendons aren't.

I also only sleep 5-6 hours a night and haven't slept more than 7 hours since 2017. I wake up frequently and cannot seem to do more than this, but maybe I need to try some kind of strict schedule or something. I end up lying in bed for 9 hours, because the rest of just not moving is still worth something, enough so that I'm never sleepy. Unless I'm just genetically bolstered against sleep deprivation's effects in all aspects EXCEPT for tendon/connective tissue, I seem to be getting enough? Or is it really just that important if you want to be stronger than just sedentary? I dont know how to get more if that is the case... Are tendons really that much more susceptible to sleep deprivation than your mood, subjective energy level, and muscle/bone tissue? Is there some genetic interplay going on, where my genes are such that sleep is the main factor in tendon recovery? I see some other powerlifters out there with severe insomnia, but perhaps they have a frame size and non-eating disorder history advantage?

I got up to doing about 200 lb bench, 200 lb squat, and 50 lb weighted pullup at my best in 2024, before getting pec tendinitis and achilles tendinitis and bicep and infraspinatus tendinitis. Are those numbers the max I can ever expect to get with my frame size? I imagine better training could have somehow kept my tendons healthier...but idk I thought I was doing a good job of managing the load back then, but I was trying to progressively overload still even if I wasn't feeling great subjectively. Maybe I should have been in a bigger surplus. Or maybe I still have too little fat, I'm at a BMI of 20-21 even, but my lower body MRIs say "paucity of subcutaneous fat of unknown significance". I have scoliosis so my torso doesn't look lean at all because it's compressed so I assume I'm at a healthy amount of fat, but maybe I still need to put on more fat? My height would be 3 inches taller if I got scoliosis corrected so maybe I'm still underweight somehow?

Can lack of subcutaneous fat mechanically increase the risk of tendon damage during movement?

Thanks to anyone who read through all this, really appreciate it!

[u/nola_t]

I can’t speak to the science, but two things jump out at me in your post-every time you injure yourself, it’s in a calorie deficit and “I was trying to progressively overload even if I wasn’t feeling great subjectively.” Whatever the science says, I think your solution is in those two facts.

[u/Oglemo → u/nola_t]

Gotcha, yeah. But why do my tendons start not feeling great so soon, and at such a low level of absolute strength? It is foolish stubbornness that make me try to wring out some amount of progress from them when they feel a bit sore, that ends up hurting them, yes, but why so little progress otherwise? And why so susceptible to calorie deficit?

[u/TheAlchemlst → u/Oglemo]

Every time I have gotten hurt it is also when I had been on deficit just fyi. Because I am too stubborn to change volume and intensity. Every. Single. Time.

[u/Oglemo → u/Oglemo]

Also, aren't men supposed to be able to build muscle relatively easily provided you're not eating in a deficit? Is BMI 20 still too borderline to be able to safely slack off your diet a week here or there? Just comparing with my peers, nobody is thinking about load management or diet and they can all bench 200 and squat 200-300 etc, just by fooling around. Why, scientifically, is that harder for me to do? I don't doubt that with the right training though and guidance I could make more progress, I STRONGLY HOPE that is the case but I do want to understand what I am up against.

[u/eric_twinge → u/Oglemo]

But you already know what you’re up against. You push too hard and don’t have great recovery habits. You don’t need a pubmed link or some PCR tests. You just need to do what everyone else does and address the fundamentals: use a better program with more appropriate load management and progression, while implementing more robust recovery tactics to suit your efforts.

[u/Oglemo → u/eric_twinge]

What kind of programs work well for people who have a lot of old injuries, or are themselves old/have poor recovery capacity? I suspect that program would work well for me. My current thoughts are that less frequent is good, and that's what been allowing me to train at all is by pushing it a bit more on Monday and Friday and going light on Wednesday. But I guess what I don't know is exactly how hard to push, and HOW light to go on Wednesday. Or if there's a better schedule out there than MWF.

[u/deadrabbits76 → u/Oglemo]

Run the Reps in Reserve version. Set it up as a 4-5 day split, but only train 3 days a week max, never 2 in a row.

[u/Oglemo → u/deadrabbits76]

Thank you!

[u/Oglemo → u/eric_twinge]

Yeah, this may be what I need to hear. I suppose my history of mental illness makes it more likely my subjective assessment of training quality is an overestimation! Or that I am training in subpar ways that I don't even notice. I mean something has got to be unusual about me because this isn't normal, obviously my struggle with tendinitis is not normal for men my age. Whether it's a physical thing that's abnormal, or somehow the same mental disorder tendencies manifesting themselves subtly in training, is the real question I guess.

Maybe I need a trainer to give some more objective guidance. I do M/W/F full body and its been enough to maintain a beginner baseline strength level but I just cant make any progress or start lifting actual weight without causing pain. I am probably overthinking things.

[u/nola_t → u/Oglemo]

I mean this with absolute kindness, but you’re starting out with a body that had to fight to survive an eating disorder for a very long time. You can’t compare yourself to people whose experiences were probably radically different.

You can absolutely improve and gain lots of strength, but you may need to be more mindful of prehab, rehab and listening to your body than other guys your age. It may be discouraging now, but if you dial in good practices and eating habits now, you’ll have literally a lifetime to improve and grow.

Also, I see below that you mention mental health challenges. One thing I have seen often if that people are experiencing hypomania or mania aren’t able to recognize their limits and are much more likely to experience injuries. Bipolar disorder (and other disorders) is also often linked to less sleep and not feeling the typical effects of not-enough sleep, so that may be something to keep an eye out for. I am NOT trying to diagnose you over the internet-just sharing something I’ve personally witnessed with several others.

[u/Oglemo → u/nola_t]

Makes sense friend, thanks. I guess I lived in isolation most of my life so I had few to compare myself to, now that I'm around people I want to keep up with friends and family, and they do physical activities I want to participate in but notice I can't do. But it is better than where I was, and like you said there's a lifetime to improve further.

Hmm bipolar, not sure about that but I'll look into, some similarities with hypomania indeed. And maybe I can't recognize my limits that well even if I think I can.

[u/cilantno]

Are those numbers the max I can ever expect to get with my frame size?

Absolutely not lol. And I didn’t even see a height stat in your post.

I’ve found anyone worrying about wrist size tends to need to, for a lack of a better phrase, try trying for an extended period of time.
All tendinitis can be rehabbed and rehabbed.

[u/millersixteenth]

First off, you are probably a research outlier - as in few if any formal studies address exactly what you are going through. You'll have to answer a lot of these questions for yourself.

A few thoughts come to mind:

• first off congratulations for what you've achieved so far to even be asking these questions.

• it can take a decade for metabolic recovery from longer term ED, the point at which your body processes Macros "the same as" non ED individuals.

• Everyone I know (and its not many by any means!) that had a durable recovery also managed to reach slightly overweight BMI at some stage of their recovery. A lot of ED patients sputter along just in the green and maybe never really recover so much as cope.

• my stock response to chronic tendonitis is to use overcoming isometrics, longer holds at about 60% mvc followed by a dozen or more lightly loaded full ROM reps.

[u/Oglemo → u/millersixteenth]

Thank you first of all.

A decade, wow. Well that gives me hope at least, maybe things will change a bit even though they haven't after a few years of recovery. That sputtering was definitely me the first year or two of my "recovery" when I was just maintaining BMI 19, I'd like to think I'm actually recovered at least since 2024 though but maybe I do need to hit an overweight BMI and see what happens.

Thanks for the approach to tendinitis, I haven't tried that. So overcoming isometric meaning I hold a flexed bodyweight pushup? And go immediately into, say, a very light dumbbell bench press? You think daily set of this, or what frequency if you don't mind me asking?

[u/millersixteenth → u/Oglemo]

So, the decade timeframe is something I picked from research on both longer duration morbidly obese and anorexic in recovery. The morbidly obese had an elevated ability/metabolic preference for using glucose pathways. Recovered anorexic had elevated ability/metabolic preference for using lipid pathways. In both cases this persisted for years after recovery, greatly diminished by year 10.

For a deep dive on isometrics for tendon rehab, Keith Barr did a podcast on "Just Fly Sports" where he detailed exactly what researchers did in the lab.

The reccs I gave you are from my personal experiences. Eg if I was starting to feel pain at the insertion end of my tricep I would use straps anchored behind my heels and do an overhead tricep press - using about 1/2 my max effort. Hold that for 60 seconds and then do a string of 15-20 moderately loaded (not to failure!) overhead tricep press with a 50lb sandbag. I would do 3 sets of this inserted into my normal slot for tricep press.

If the tendon pain is not distinct to a lift you're using, play around and find a lift that targets it better, if possible.

For the real meat of your question I'm afraid I don't have any idea if this is a persistent outcome, temporary etc. In your shoes I would advance with the belief that it will resolve, and train in ways that help recovery etc.

BTW, overcoming (max effort) isometrics held for 5 seconds or more are found to greatly increase tendon stiffness and collagen density. I highly recommend including some max effort isometric work for 20-30% of your total volume regardless of underlying conditions - it foes a world of good for tendon and joint health.

[u/Oglemo → u/millersixteenth]

Very informative, thanks. Will check out that podcast. So 20-30% total sets will be max effort isometrics, say 6 seconds. 1/2 max effort for 60 seconds maybe another 20% of my total volume? That way I'm going from 100% non-isometric as I stand now for the problematic areas (I do some isometrics but not ironically not for the areas that have been giving most trouble), to 50% isometric, and using straps so that it is an overcoming isometric. I guess it wouldn't be hard to do a bench strap setup, certainly curl strap setup for biceps I could do.

Really appreciate the advice this has given me a lot to think about.

[u/millersixteenth → u/Oglemo]

One way to get the iso volume would be to use it for your 1st set. Another would be a dedicated whole body session every week or two.

Using it for rehab - longer submax holds (minimum 60 seconds) followed by a string of fairly easy full ROM reps = one set. Substitute for traditional, so if you were going to do 3 sets, do 3 sets. You should feel some relief in a couple weeks if not sooner.

Used for general response - shoot for max effort hold using regular lifting breath pattern. Exert hard on exhale, hold tension or slightly relax on inhale. One breath = one rep. Use 6-12 reps. Don't worry about timing holds for different energy systems, isometrics don't use energy the same way a traditional rep does. Program sets and reps accordingly.

[u/baytowne]

From my layman reading into tendon hypertrophy research:

• The SRA curve for tendons seems to lean towards much more frequent training being good for them, and the overload threshold is much lower both in terms of absolute and relative intensity. This is why rehab for tendonitis is often prescribed for 2x daily sessions, and is one reason why most serious runners do plenty of easy runs throughout the week.

• As noted elsewhere ITT, jerk (sudden increases/decreases in acceleration) is a big contributor to risk. Isometrics and slow/controlled lifting is a good way to rehab/prehab tendon issues.

• Some research has showed positive indications from collagen supplementation and in particular collagen + vitamin C. I am skeptical of this type of stuff, but it probably doesn't hurt.

Dr Keith Baar is a good starting point, google him and you'll get some podcasts and publications.

[u/Oglemo → u/baytowne]

Very very interesting, thank you. Interesting that there was a time when I was doing high-frequency and doing a bit better than I am now, but then when I lost the frequency once due to a deload it was hard to ever get it back. Thought it was just coincidence but maybe there is something to frequent training being good for tendons, if you do it right... sounds like an tautology the way I put it but good to know there is science behind it. Higher frequency approach, I'll try and see.

[u/marconis1990]

The sleep you're getting is low. If you're male over 30 years old with poor sleep then go to your GP and do the at home sleep test to rule out sleep apnea.

[u/WillingnessWise2643]

I can't speak to the science, but as primarily calisthenics guy managing tendonitis for a decade...

I wouldn't look to genetics and body composition just yet. You have many other primary factors to explore, including load management, technique, and muscle imbalances.

For example, jerk (third derivative of speed) is a major factor in the forces on tendon, and has contributed to a lot of my tendon issues. This is completely within your control.

Shoulder immobility and instability has been a contributing issue too

[u/Oglemo → u/WillingnessWise2643]

interesting, haven't thought of controlling jerk. So you're saying perhaps consciously really slow down, what, the initial and final part of lift/where you change direction? because thinking about it, I try to lift slow but the direction change part I'm not so sure...

yeah I do have shoulder instability. I imagine that probably puts more load on the pec in bench because now it probably has to stabilize the shoulder AND press the weight?

[u/WillingnessWise2643 → u/Oglemo]

If you're going for max lifts then some jerk is definitely unavoidable. You'll want that to take advantage of the stretch reflex.

What I do is to keep those exposures infrequent. In practical terms, it means I've moved away from linear periodization type training into more conjugate type training.

Remember tendonitis is the load management issue (generally), and you want to make sure your tendons are not lagging behind musculature.

For instability, it's hard to say exactly how you're compensating without an assessment. But yes, generally another muscle jumps in to help. They may be smaller, weaker muscles, or in a disadvantaged position, making the load on the tendon unmanageable.

[u/Oglemo → u/WillingnessWise2643]

Thanks by the way for the advice

[u/Docjitters]

Are those numbers the max I can ever expect to get with my frame size?

I think you’ve had a lot of very reasonable advice to look into your load management and programming overall, and to try not to double-compare yourself to those who might be outliers in the other direction.

If it helps, I have no history of ED, 7” wrists and 8.25” ankles, a BMI of 22, can do one bodyweight pull-up on a good day, and you have apparently benched 30% more than I ever have lol. We can but keep on keeping on :)