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com
1
Faculty of Health Sciences
and Medicine, Bond University,
Gold Coast, Queensland,
Australia
2
Institute of Health and
Biomedical Innovation,
Queensland University of
Technology, Kelvin Grove,
Queensland, Australia
3
Centre of Excellence for
Applied Sport Science
Research, Queensland
Academy of Sport, Sunnybank,
Queensland, Australia
4
Department of Physical
Therapies, Australian Institute
of Sport, Canberra, Australian
Capital Territory, Australia
5
Faculty of Medicine, Nursing
and Health Sciences, Monash
University, Frankston, Victoria,
Australia.
Correspondence to
Dr Scott C Wearing, Faculty of
Health Sciences and Medicine,
Bond University, Gold Coast,
QLD 4229, Australia;
swearing@bond.edu.au
Accepted 3 February 2013
Published Online First
23 March 2013
To cite: Wearing SC,
Smeathers JE, Hooper SL,
et al. Br J Sports Med
2014;48:383–387.
Wearing SC, et al. Br J Sports Med 2014;48:383–387. doi:10.1136/bjsports-2012-091707
The time course of in vivo recovery of transverse
strain in high-stress tendons following exercise
Scott C Wearing,1 James E Smeathers,2 Sue L Hooper,3 Simon Locke,3 Craig Purdam,4
Jill L Cook5
ABSTRACT
Objective To evaluate the time course of the recovery
of transverse strain in the Achilles and patellar tendon
following a bout of resistance exercise.
Methods Seventeen healthy adults underwent
sonographic examination of the right patellar (n=9) and
Achilles (n=8) tendons immediately prior to and
following 90 repetitions of weight-bearing quadriceps
and gastrocnemius-resistance exercise performed against
an effective resistance of 175% and 250% body weight,
respectively. Sagittal tendon thickness was determined
20 mm from the enthesis and transverse strain, as
defined by the stretch ratio, was repeatedly monitored
over a 24 h recovery period.
Results Resistance exercise resulted in an immediate
decrease in Achilles (t7=10.6, p<0.01) and patellar
(t8=8.9, p<0.01) tendon thickness, resulting in an
average transverse stretch ratio of 0.86±0.04 and 0.82
±0.05, which was not significantly different between
tendons. The magnitude of the immediate transverse
strain response, however, was reduced with advancing
age (r=0.63, p<0.01). Recovery in transverse strain was
prolonged compared with the duration of loading and
exponential in nature. The average primary recovery time
was not significantly different between the Achilles (6.5
±3.2 h) and patellar (7.1±3.2 h) tendons. Body weight
accounted for 62% and 64% of the variation in recovery
time, respectively.
Conclusions Despite structural and biochemical
differences between the Achilles and patellar tendon, the
mechanisms underlying transverse creep recovery in vivo
appear similar and are highly time dependent. These
novel findings have important implications concerning
the time required for the mechanical recovery of high-
stress tendons following an acute bout of exercise.
INTRODUCTION
Little is known about the adaptive response of
human patellar tendon to loading. Originally con-
sidered metabolically inert, recent studies have
shown acute loading of human tendon results in
increased intratendinous glucose uptake, oxygen
consumption, blood flow and collagen turnover in
peritendinous tissues and the expression of certain
genes, growth factors and mediators of inflamma-
tion.1–6 However, the effect of loading on the
mechanical properties of tendon is less clear. While
most studies have observed that habitually active
individuals possess larger tendons (20–36%) than
their untrained counterparts,7–9 prospective studies
have shown that exercise training either
increases,10–12 decreases13 14 or has no effect on
measures of tendon stiffness and modulus in
vivo.15–17 These studies have, however, typically
Original article
evaluated the effect of exercise training on the ‘elastic’
properties of tendon (ie, stiffness and modulus), and
have largely overlooked the ‘viscous’ component of
tendon behaviour. Like many human tissues, tendons
are known to exhibit viscoelastic behaviour and sus-
tained static or cyclic loading has been shown to
result in increasing strain or creep in tendon.18
With the advent of high-resolution ultrasound
systems, recent in vivo studies have noted an imme-
diate decrease in the thickness of human tendon
after bouts of cyclic resistance exercise and follow-
ing activities involving prolonged walking and
running.19–24 Equating to transverse strains (TSs) of
around 10–20% in vivo, this acute change in thick-
ness has been hypothesised to reflect fluid move-
ment associated with load-induced alignment of the
solid phase of the tendon matrix and is consistent
with creep behaviour reported with ex vivo testing
of animal soft tissues, albeit in a transverse rather
than in an axial direction.18 25–27 While the creep
response in soft tissues has been associated with
reduced muscular activity and electromechanical
delay and has been implicated in the development
of overuse injuries,14 surprisingly little is known
about the time course of the creep recovery of soft
tissues following exercise. Of the few studies under-
taken to date, most have investigated the axial creep
recovery of the intervertebral disc in vitro and have
observed that full recovery of the disc occurs only
when the unloaded recovery time is one to several
orders of magnitude longer than loading.26 28 29
To the best of our knowledge, however, no study
has evaluated the postexercise recovery of human
tendon in vivo. Characterising postload recovery is
not only important for understanding the unloaded
tendon but is also critical to understanding tendon
behaviour under subsequent loadings. The aim of
this study, therefore, was to characterise and
compare the time course of the postexercise recov-
ery in TS in the Achilles and patellar tendon in
vivo. These tendons are thought to function as
elastic-energy-storage springs during locomotion
and in addition to experiencing relatively high
stress levels during activities of daily living are
prone to chronic ‘overuse’ injury and degenerative
change.30 31 We hypothesised that, as with other
human soft tissues, full recovery of the Achilles and
patellar tendons would occur within 24 h following
exercise and that recovery times would not differ
between tendons.
METHODS
Subjects
Seventeen healthy adults were recruited from uni-
versity faculty to participate in this repeated
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Original article

measures study, which received approval from the institutional

review board. Study exclusion criteria included a medical
history of diabetes, inflammatory joint disease, familial hyper-
cholesterolaemia or lower limb tendon pathology. No partici-
pants were excluded. All participants were non-medicated,
non-smokers and recreationally active based on self-report and
presented to the laboratory having abstained from physical activ-
ity in the previous 24 h. Participant numbers were based on pre-
viously published data for human Achilles tendon19 and were
sufficient to detect a 10% difference in the immediate TS
response of the two tendons (α=0.05, β=0.20). Body height
was measured to the nearest millimetre using a stadiometer and
weight was recorded to the nearest gram using clinical scales.
Body mass index (BMI) was calculated by dividing body
weight (kg) by the square of body height (m).

Sonographic imaging
Sonographic examination of the Achilles and patellar tendons
was undertaken by an experienced operator using a 10 MHz
linear array transducer (Echoblaster 128, UAB Telemed, Vilnius,
Lithuania) and standardised protocol. The accuracy and preci-
sion of the ultrasound system was evaluated by undertaking
repeated measurements of a standard calibration phantom
(040GSE, CIRS, Norfolk, Virginia, USA), consisting of a
number of Nylon monofilaments of varying diameters
(0.1–8 mm) and depths embedded within a tissue-mimicking
material (attenuation: 0.5±0.05 dB/cm-MHz). The 95% limits
of agreement for repeated measures of 27 separate calibration
monofilaments were ±100 mm, with a root mean square (RMS)
error of 184 mm.
In accordance with recommendations, longitudinal sonograms
of each tendon were acquired perpendicular to the point of
maximum tendon width to encompass the superior aspect of
the calcaneus and distal Achilles tendon and the inferior aspect
of the patella and proximal patellar tendon (figure 1).32 Sagittal
images of the Achilles tendon were acquired with the participant
prone and the ankle passively positioned at 90°,33 while sagittal
plane images of the patellar tendon were acquired with the par-
ticipants supine with their leg passively positioned at right
angles (90°) to their thigh.32 Sonographic images were taken
immediately prior to and following completion of 90 repetitions
of resistance exercise and repeated during recovery at 3, 6, 12
and 24 h postexercise for the Achilles tendon and at 3, 6 and
24 h postexercise for the patellar tendon.
Exercise protocol
Following pre-exercise sonograms, participants randomly com-
pleted closed kinetic chain resistance exercises involving the
Quadriceps (n=9) or Gastrocnemius (n=8) muscle groups.
Quadriceps exercises consisted of 90 repetitions of double-leg
squat exercises in which participants moved from standing erect, to
a position of 90° of knee flexion and then back again.34 Ankle exer-
cises consisted of 90 repetitions of double-leg calf raises in which
participants moved their foot from full ankle plantarflexion to full
dorsiflexion and then back again with their knee in an extended
position.35 Quadriceps exercises were performed against an effect-
ive resistance of 175% body weight and ankle exercises against an
effective resistance of 250% body weight, so as to induce tensile
loads similar to that experienced during gait.34–36
Data reduction and statistical analysis
Sonographic images were analysed using MATLAB software
(MathWorks Inc, Natick, Massachusetts, USA). Patellar tendon
Figure 1 Tendon thickness was measured from sagittal sonograms at
standard reference sites and with the aid of a greyscale profile. Achilles
tendon thickness was determined 20 mm superior to its calcaneal
(C) insertion (a). Patellar tendon thickness was measured 20 mm distal
to the inferior pole (P) of the patella (b).
thickness was determined at a standard site, 20 mm distal to its
attachment at the inferior pole of the patellar,32 while Achilles
tendon thickness was determined 20 mm proximal to its calca-
neal insertion. The anterior and posterior edges of the tendons
were identified with the aid of a grey-scale profile, and manually
digitised (figure 1). The stretch ratio (λ), the ratio of postexercise
to pre-exercise tendon thickness, was subsequently calculated as
a measure of TS. The stretch ratio is commonly used in the ana-
lysis of materials that exhibit large deformations and approxi-
mates to engineering strain (ɛ) by; ɛ=1−λ. The coefficient of
variation for repeated measures of tendon thickness was 2.3%
and 2.6% for the Achilles and patellar tendons, respectively.
Although biexponential models have been used to describe
the two phase recovery behaviour of collagenous tissues such as
intervertebral disc,26 28 a single-term exponential recovery func-
tion can also be used to successfully model creep recovery in
other human soft tissues.37 Hence, the recovery in TS following
exercise was modelled for each participant using a single-term
exponential function; TS(t) = λo + λe(−βt), where constants λo,
λ and β represent the initial stretch ratio, the range and the rate
of recovery, respectively, and were estimated using non-linear
regression and minimising RMS error. The time for the tendon
to return to 63% of pre-exercise dimensions, the so-called
primary recovery time, was estimated as the inverse of the
β term for each participant.
The Statistical Package for the Social Sciences (SPSS Inc,
Chicago, Illinois, USA) was used for all statistical procedures. As
outcome variables were determined to be normally distributed,
means and SDs have been used as summary statistics.
Between-group differences in body anthropometry were investi-
gated using independent t tests. Differences in tendon thickness
immediately pre-exercise and postexercise were investigated
using paired t tests. Differences in the TS response and recovery

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Table 1 Demographic characteristics of participants completing
Achilles and patellar tendon exercises
Achilles tendon Patellar tendon
N 8 9
Age (years) 39.7 (9.3) 33.3 (11.1)
Height (cm) 176.9 (3.3) 174.9 (7.6)
Weight (kg) 76.8 (8.4) 75.6 (13.8)
BMI (kg/m2) 24.5 (2.1) 24.6 (3.6)
BMI, body mass index.
time between the Achilles and patellar tendons were investigated
using independent t tests. Relationships between variables were
investigated using Pearson product–moment correlations. An α
level of 0.01 was used.
RESULTS
Anthropometric characteristics of participants are summarised
in table 1. There was no statistically significant difference in
average age, height or weight of participants performing the
two exercise protocols.
The average thickness of the Achilles and patellar tendons
prior to exercise was 4.0±0.4 and 3.2±1.2 mm, respectively.
While the Achilles tendon was, on average, 27% thicker than
the patellar tendon at baseline, this difference was not statistic-
ally significant.
Resistance exercise resulted in a significant and immediate
decrease in the sagittal thickness of the Achilles (t7=10.6,
p<0.001) and patellar (t8=8.9, p<0.001) tendons of all partici-
pants, resulting in an average stretch ratio of 0.86±0.04 and
0.82±0.05, respectively. This difference in TS response between
the two tendons was not statistically significant. Similarly,
there was no significant correlation between anthropometric
measures (height, weight and BMI) and transverse stretch ratio
(r=0.22–0.39). However, participant age was moderately corre-
lated with the magnitude of the immediate TS response in the
Achilles and patellar tendons (r=0.63, p<0.01), such that older
age was characterised by a diminished TS response (figure 2).
Although tendon dimensions returned to pre-exercise levels
for both tendons within 24 h, recovery in TS was exponential in
nature (figure 3). The R2 goodness-of-fit for the overall model
was 0.99 for both the Achilles and patellar tendons, with the R2
fit for individual TS–recovery curves exceeding 0.93 in all cases.
Figure 2 Effect of age on the immediate transverse strain of the
Achilles (▪) and patellar (°) tendons in response to exercise.
Wearing SC, et al. Br J Sports Med 2014;48:383–387. doi:10.1136/bjsports-2012-091707
Original article
Figure 3 Recovery curves for the acute transverse strain of the
Achilles (▪) and patellar (°) tendons following resistance exercise.
The average primary recovery time was 6.5±3.2 h for the
Achilles tendon and 7.1±3.2 h for the patellar tendon and was
not significantly different between tendons. Recovery was,
however, dependent on body weight (p<0.01), with greater
body weight associated with prolonged primary recovery in TS
(figure 4). This relationship was also exponential in nature, with
body weight accounting for 62% and 64% of the variation in
primary recovery time of the patellar and Achilles tendons,
respectively.
DISCUSSION
The Achilles and patellar tendons are widely regarded to func-
tion as springs, storing and elastically returning strain energy
during locomotion, which is thought to improve the efficiency
of gait and protect against muscle damage during rapid and
forceful lengthening. Although these tendons are exposed to
high levels of stress during life and are prone to chronic
‘overuse’ injury,31 little is known regarding their acute response
to exercise or the time course of their recovery postexercise.
The findings of the current study indicate that resistance exer-
cise results in an immediate but transient decrease (14–18%) in
the thickness of the Achilles and patellar tendons, that is, recov-
erable within 24 h.
Acute reductions in tendon thickness have been previously,
though not exclusively,38 39 observed following intense or pro-
longed exercise in vivo.19–24 Hypothesised to largely reflect the
Figure 4 Relationship between body weight and the primary recovery
time of the Achilles (▪) and patellar (°) tendons following resistance
exercise.
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Original article
movement of fluid associated with load-induced alignment of
the solid phase of the tendon matrix, the findings of the current
study are consistent with in vitro observations in animal models
in which static and cyclic loading have been shown to result in
reduced tendon thickness, rapid unbinding and extrusion of
intratendinous fluid and visible loss of water and glycosamino-
glycans.40–42 These observations are also consistent with axial
creep behaviour, manifest as an increase in axial length
with cyclic load, reported with mechanical testing of both
animal18 25–27 and human soft tissues in vitro,27 28 and follow-
ing loading of human tendon, ligament and intervertebral disc
in vivo.43–45
Axial creep in tendon has been suggested to alter the poten-
tial of muscle to generate force, via both direct mechanical
and neuromuscular effects, and thereby increase the risk of
injury.46 47 Although the mechanisms underpinning the creep
response of soft tissues are poorly understood, Vresilovic et al48
proposed that, for the intervertebral disc, the magnitude of
dynamic creep was dependent on the quantity of fluid within
the fluid-flow pathway, and demonstrated marked changes in
creep of the disc with manipulation of tissue hydration. While
comparable effects of hydration have been observed on the
relaxation behaviour of tendon in vitro,49 in the current study
exercise induced a similar magnitude of TS in both the Achilles
(1−λ, 0.14) and patellar (1−λ, 0.18) tendons, suggesting that the
pathway and unbound fluid content of the two tendons are likely
comparable. In support, Maynard et al50 demonstrated that the
water content of the rabbit Achilles tendon (59% wet weight)
did not differ from that of the patellar tendon (63% wet
weight), despite obvious differences in the ultrastructure of the two
tendons and subtle differences in cellular properties and respon-
siveness, collagen crimp, interstitial space and glycosaminoglycan
concentration.51–54
A novel finding of the current study was that the magnitude
of the TS response of the two tendons following exercise was
moderately correlated with age. Older age was associated with a
reduced TS response. Based on the regression equation, each
decade of life was associated with a ≈2.5% reduction in the TS
response of the Achilles and patellar tendons. Changes in
the composition of tendon, including increased collagen cross
linking, altered fibril morphology, decreased glycosaminoglycan
concentration and lower water content are known to occur with
aging.55–58 Given that load-induced fluid movement has been
hypothesised to play a key role in tendon homeostasis and that
tendinopathy is characterised by a reduced TS response to exer-
cise,59 60 it is possible that diminished load-induced fluid move-
ment with aging, as evidenced by a lower TS response to
exercise, may in part account for the impaired ability of tendon
in the elderly to adapt to training and the greater incidence of
tendon degeneration and rupture with advancing age.61 62
However, age accounted for only 40% of the variation in the
TS response of tendon to exercise, suggesting that other, as yet
unidentified, factors also influence the transverse creep response
of tendon to exercise.
Recovery of TS, as defined by the stretch ratio, in the Achilles
and patellar tendons in the current study followed an exponen-
tial pattern and was several orders of magnitude longer (hours)
than the duration of the exercise (minutes). The average time
for primary recovery of the Achilles and patellar tendons follow-
ing exercise was 6.5±3.2 h and 7.1±3.2 h, respectively. This
finding is consistent with in vitro studies on the axial creep of
skin and disc tissues,28 63 and similarly slow recovery rates,
albeit in axial strain, have been reported in vivo for other bio-
logical tissues following mechanical loading in animal models.
4 of 6
Gedalia et al64 observed that feline lumbar structures recovered
by only 37% with rest lasting more than twice the duration of
creep loading (2 h). Similarly, Solomonow et al26 observed that
50 min of cyclic load induced axial creep in the feline lumbar
spine that required more than 7 h to recover (>90%).
The primary recovery time of the Achilles and patellar
tendons in the current study was, in part, dependent on the par-
ticipant’s body weight. Greater mass was associated with a pro-
longed primary recovery in transverse tendon strain (figure 4).
Although delayed physiological recovery in markers of skeletal
muscle metabolism and perfusion have been observed following
exercise in the obese,65 in vitro studies on the mechanical
behaviour of the human vertebral disc have also demonstrated
that the creep recovery is influenced by the magnitude and dur-
ation of the applied load.28 In the current study, exercises were
performed against a percentage of body weight. Consequently,
it is unknown if the relationship between body weight and the
recovery of transverse strain in the Achilles and patellar tendons
reflects physiological processes associated with greater mass or
merely greater mechanical loading of the tendon during exer-
cise. Further research, specifically evaluating the creep recovery
of tendon to a varied strain stimulus seems warranted.
The present experimental setup did not allow for a mechanistic
explanation for the observed recovery in TS following exercise.
However, previous in vivo studies in humans have shown that a
single bout of loading initiates a cascade of physiological events
postexercise, including increased intratendinous blood volume
and glucose uptake and the expression of certain genes, growth
factors and mediators of inflammation.1 5 6 66 Although markers
of collagen metabolism peak after the primary recovery times
noted in this study,67 the time course of postexercise circulatory
and inflammatory responses appear similar to the recovery in
transverse tendon strain. For instance, intratendinous blood
volume in the Achilles tendon has been shown to increase imme-
diately following a series of isometric muscle contractions and
remain elevated for at least 20 min after exercise.66 Similarly,
cyclic loading of ligament and tendon in animal models has been
shown to increase the mRNA expression of inflammatory media-
tors immediately postexercise,68 which return to basal levels in
paratendonous tissues within 6–12 h of exercise.69 70 It is pos-
sible, therefore, that a reactive hyperaemia and/or inflammatory
processes may collectively or individually drive imbibition of
fluid in tendon and thereby the recovery of tendon dimensions.
As such, tendon recovery may reflect active rather than passive
processes. However, the time constants for the overall recovery
of the patellar and Achilles tendons in the current study (≈6–7 h)
are comparable to those reported for recovery of axial strain of
the intervertebral disc when studied in vitro (≈8 h),28 suggesting
that recovery in transverse tendon strain in vivo may be governed
by passive osmotic and ionic forces.
This study evaluated the recovery of transverse tendon strain
following resistance exercise protocols that involved periodic
concentric and eccentric modes of muscle contraction. While
there is some evidence that aerobic exercise may elicit greater
tendon hypertrophy than resistance exercise over a 12-week
period,62 the time course of tendon recovery observed in the
current study may not be transferable to other types and modes
of exercise. There is evidence, for instance, that both the mode
(eccentric/concentric) and duration of muscle contraction may
influence blood flow and the magnitude of creep in tendon.19 66
Nonetheless, the findings of the current study demonstrate that
short periods of resistance exercise, involving cyclic concentric
and eccentric contraction, induce substantial TSs in healthy
human Achilles and patellar tendons. While the time course of
Wearing SC, et al. Br J Sports Med 2014;48:383–387. doi:10.1136/bjsports-2012-091707
 Downloaded from http://bjsm.bmj.com/ on January 25, 2015 - Published by group.bmj.com
the recovery of tendon dimensions is considerably longer than
the loading duration, with a primary recovery time of around
7 h, the optimal schedule of activity and rest ratios in these
high-stress elastic-storage tendons is still unknown, and requires
attention in light of the knowledge gained through this study.
CONCLUSION
In vivo recovery of TS in the Achilles and patellar tendons fol-
lowing resistance exercise of the quadriceps and gastrocnemius
muscle groups is considerably longer than the loading duration,
with primary recovery in both tendons requiring around 7 h.
These findings suggest that, despite their structural differences,
the mechanisms underlying Achilles and patellar tendon
mechanics in vivo are similar and highly time-dependent.
Although further work is required, these findings highlight, for
the first time, the duration of recovery required for high-stress
tendons to return to pre-exercise dimensions following an acute
bout of exercise.
What are the new findings?
▸ Despite marked differences in tendon ultrastructure, acute
mechanical loading of the Achilles and patellar tendon via
resistance exercise results in an immediate though similar
decrease in tendon thickness in vivo.
▸ Although the acute response to exercise was moderated by
age in both tendons, the time course of the recovery of
transverse strain (TS) in the Achilles and patellar tendons
was considerably longer than the loading duration.
▸ Primary recovery requires approximate 7 h for both tendons,
but is influenced in part by bodyweight. Complete recovery
requires 24 h.
How might it impact clinical practice in the near future?
▸ Decreases in tendon thickness following exercise reflect
load-induced collagen alignment and convective fluid
movement in tendon, which likely plays an important role in
tendon homeostasis and adaptation. This is the first study to
document the acute TS response and recovery in both the
Achilles and patellar tendons following exercise. Despite
structural differences between tendons, short periods of
resistance exercise induced similar TSs in healthy human
Achilles and patellar tendon. These required considerable
time to recover. Primary recovery (63%) required about 7 h
in healthy tendons, while full recovery required 24 h. While
this information could be used clinically to guide physical
activity to rest ratios in healthy adults, optimal ratios of
activity to rest in high-stress tendons remains unknown, and
requires further attention in light of the knowledge gained
through this study.
Acknowledgements The authors would like to thank the research assistant on
this study, Dr Nicole Grigg, for her assistance with data collection.
Contributors SCW is responsible for the overall content of the manuscript as
guarantor and made substantial contributions to the project conception and design,
data and statistical analysis and interpretation of data; drafting, revision and the
final approval of the manuscript. JES contributed to the study conception and
design, analysis and interpretation of data, revision and the final approval of the
Wearing SC, et al. Br J Sports Med 2014;48:383–387. doi:10.1136/bjsports-2012-091707
Original article
manuscript. SLH contributed to the study design, analysis and interpretation of data,
revision and the final approval of the manuscript. SL contributed to the study
design, analysis and interpretation of data, revision and the final approval of the
manuscript. CP contributed to study conception and design, analysis and
interpretation of data, revision and the final approval of the manuscript. JLC
contributed to the study conception and design, analysis and interpretation of data,
revision and the final approval of the manuscript.
Funding This research was funded by an Australian Research Council Linkage Grant
(LP_0989716).
Competing interests SCW is funded through a Smart Futures Fellowship,
Department of Employment, Economic Development and Innovation, Queensland
Government.
Patient consent Obtained.
Ethics approval The study was approved by the regional ethics committee. QUT
UHREC (Approval Number: 1000000857).
Provenance and peer review Not commissioned; externally peer reviewed.
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 Downloaded from http://bjsm.bmj.com/ on January 25, 2015 - Published by group.bmj.com

The time course of in vivo recovery of

transverse strain in high-stress tendons
following exercise
Scott C Wearing, James E Smeathers, Sue L Hooper, Simon Locke,
Craig Purdam and Jill L Cook

Br J Sports Med 2014 48: 383-387 originally published online March 23,
2013
doi: 10.1136/bjsports-2012-091707

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