International Journal of Sport Nutrition and Exercise Metabolism, 2019, 29, 189-197
https://doi.org/10.1123/ijsnem.2018-0290© 2019 Human Kinetics, Inc.

SCHOLARLY REVIEW

Nutrition for the Prevention and Treatment of Injuries
in Track and Field Athletes
Graeme L. Close

Craig Sale

Liverpool John Moores University

Nottingham Trent University

Keith Baar

Stephane Bermon

University of California

Université Côte d’Azur

Injuries are an inevitable consequence of athletic performance with most athletes sustaining one or more during their athletic
careers. As many as one in 12 athletes incur an injury during international competitions, many of which result in time lost fromtraining and competition. Injuries to skeletal muscle account for over 40% of all injuries, with the lower leg being thepredominant site of injury. Other common injuries include fractures, especially stress fractures in athletes with low energy
availability, and injuries to tendons and ligaments, especially those involved in high-impact sports, such as jumping. Given thehigh prevalence of injury, it is not surprising that there has been a great deal of interest in factors that may reduce the risk of injury,
or decrease the recovery time if an injury should occur: One of the main variables explored is nutrition. This review investigates
the evidence around various nutrition strategies, including macro- and micronutrients, as well as total energy intake, to reduce therisk of injury and improve recovery time, focusing upon injuries to skeletal muscle, bone, tendons, and ligaments.
Keywords: athletics, collagen, epidemiology, protein
In athletics, the epidemiology of injuries occurring before or
during an international elite competition has been extensively
described (Edouard et al., 2015, 2016; Feddermann-Demont
et al., 2014). Unfortunately, there is less accurate information
available when it comes to injuries occurring during training(out of competition) periods and/or in subelite or recreational
athletes. In elite track and ﬁeld athletes, there were approximately
81 injuries per 1,000 athletes registered to a World Championship(Feddermann-Demont et al., 2014), in other words, approximately
one in 12 registered athletes will incur injury during International
Athletics Championships. This is important since approximately
half of these injuries will result in a time loss and absence fromsports, including both training and competing (FeddermannDemont et al., 2014). Among these injuries, skeletal muscle isthe principal type, accounting for 40.9% of all recorded injuries(Edouard et al., 2016), with 58% of these injuries resulting in timeloss during the International Athletics Championships between
2007 and 2015. Hamstring injury is by far the most frequent injury(approximately 17%), and it is more frequent (relative risk: 1.94) inmale athletes than in female athletes. These hamstring injuries are
more frequently described in sprinters, whereas overuse injuries of

Close is with the Research Institute for Sport and Exercise Sciences, Liverpool
John Moores University, Liverpool, United Kingdom. Sale is with Musculoskeletal
Physiology Research Group, Sport, Health and Performance Enhancement
Research Centre, School of Science and Technology, Nottingham Trent University,
Nottingham, United Kingdom. Baar is with the Dept. of Neurobiology, Physiology,
and Behavior, University of California, Davis, CA; and Dept. of Physiology and
Membrane Biology, University of California, Davis, CA. Bermon is with LAMHESS, Université Côte d’Azur, Nice, France; and Health and Science Dept.,
International Association of Athletics Federations, Monaco, Principality of Monaco.
Close (g.l.close@ljmu.ac.uk) is corresponding author.

the lower legs are more frequently reported in middle-long distancerunners and race walkers. Elite female athletes experience more(relative risk: 3.1) stress fracture injuries than male athletes(Edouard et al., 2015), and this is explained by a higher incidenceof Relative Energy Deﬁciency in Sport Syndrome (Mountjoy et al.,2014) and the associated reduced calcium absorption, ﬁxation, andbone mineral density in this population.
Preparticipation predictors for Championships injury andillness have been identiﬁed (Timpka et al., 2017). For instance,
athletes who reported an illness symptom causing anxiety before
the competition were ﬁve times more likely to sustain an injury
during the championships. Moreover, intensive training camps or
tapering periods are often associated with increased stress andaltered appetite response and decreased food intakes (both quantitative and qualitative aspects) in power-trained athletes. Theseﬁndings attest to the important role that anxiety, stress, and theirconsequences play on the athlete’s nutritional status and in thedevelopment of an injury during a major competition. Therefore,
providing stress management and nutritional interventions as
potential preparticipation interventions may reduce the onset ofan acute injury is relevant.
Although injuries could be classed as a very likely outcome ofsport, it is important to recognize that appropriate nutritional
strategies have the ability to reduce the risk of injuries as wellas enhance the recovery if an injury should occur. All athletesshould engage with a properly qualiﬁed nutritionist who will
promote a “food ﬁrst approach” to prevent and treat injuries.
Although the main preventative nutritional strategy will be toensure adequate total energy intake and appropriate dietary intake,there are some supplements that have the potential to help. This
review will focus on nutritional strategies to assist with the mostcommon injuries, that is, skeletal muscle, bone, tendon, andligament. We include a review of the extant literature that has
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Close et al.

looked at nutrition to prevent injuries and increase repair, as well as
considering the change in energy requirements during the injury
period.

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Nutrition to Prevent and Treat Muscle
Injuries
There is limited direct research on nutrition to prevent/treat muscle
injuries, with most research originating from laboratory-induced
muscle damage to study delayed onset muscle soreness (Owens
et al., 2019). Although such studies provide insights into potential
nutritional strategies, it must be stressed that there are substantial
differences between delayed onset muscle soreness and a major
muscle tear, both in terms of the structural damage, as well as thelevel of immobilization and unloading that may occur. However,given that there are no published placebo-controlled, randomized
control trials on nutrition to prevent or treat muscle injuries
following a “true” muscle injury in elite athletes, the laboratoryinduced muscle damage literature currently provides the best
evidence base to help guide practice, while, of course, taking
into consideration the limitations of this approach. From a nutrition
perspective, it is important to consider the potential of nutrition toassist in injury prevention and prevent the loss of lean mass during
immobilization, and to consider the change in energy requirements
during the injury period along with any strategies that may promotemuscle repair.
Given the crucial role of dietary protein in muscle protein
turnover, it is not surprising that much attention has been given to
dietary protein in the prevention of muscle injuries. It is acceptedthat the provision of dietary proteins enhances the adaptive processes to both resistance- and endurance-based exercise (Phillips &Van Loon, 2011), and it is, therefore, attractive to hypothesize that
increasing dietary protein may alleviate markers of muscle damage.
However, the evidence to support this hypothesis is, at best,equivocal, with some studies reporting a beneﬁt (Buckley et al.,2010; Cockburn et al., 2010; Nosaka et al., 2006), whereas others
show no beneﬁt (Blacker et al., 2010; Wojcik et al., 2001), albeit inlaboratory-induced muscle damage studies. In a recent systemic
review, the balance of the evidence suggested that protein supplements taken acutely, despite increases in protein synthesis andanabolic intracellular signaling, provide no measurable reductions
in exercise-induced muscle damage and enhanced recovery ofmuscle function (Pasiakos et al., 2014). This lack of an effectmay be explained by the differing time courses between an acutemuscle injury and muscle protein turnover, with adaptations tomuscle protein turnover being a relatively slow process (Tipton
et al., 2003) compared with the rapid changes that occur following
an injury. It can, therefore, be concluded that, given sufﬁcientdietary protein is provided in the general diet of an athlete,additional protein intake will not prevent muscle injury or reduce
postexercise muscle soreness. However, to date, this hypothesis
has not been fully explored in elite athletes following a true injury
and, therefore, case study data may help to provide further insights.
Although additional protein may not prevent a muscle injury,
increased dietary protein may be beneﬁcial after an injury both interms of attenuating muscle atrophy and promoting repair. Limb
immobilization reduces resting muscle protein synthesis as well as
induces an anabolic resistance to dietary protein (Wall et al., 2013),
although, again, it must be stressed that such studies are laboratory
based and not following a true injury. This anabolic resistance canbe attenuated (although not prevented) through increased dietaryamino acid ingestion (Glover et al., 2008). It is beyond the scope of
this manuscript to fully discuss what is appropriate protein intake
for athletes and, for this, the reader is directed to several excellent
reviews (e.g., Morton et al., 2018; Phillips, 2012; Stokes et al.,2018; Tipton & Phillips, 2013). Contrary to popular belief, athletes
engaged in whole-body resistance training are likely to beneﬁt from
more than the often cited 20 g of protein per meal, with recent
research suggesting 40 g of protein may be a more optimum
feeding strategy (Macnaughton et al., 2016). Protein intake shouldbe equally distributed throughout the day, something that manyelite athletes fail to achieve (Gillen et al., 2017), with many athletes
consuming the majority of their protein in their evening meal, withless consumed at breakfast and lunch. In terms of an absoluteamount of protein per day, increasing protein to 2.3 g/kg body mass
reduces the loss of lean body mass (LBM) during reduced calorie
intake (Mettler et al., 2010), a strategy that could also prove usefulfor the injured athlete. Taken together, despite the limitations of thecurrent literature base, injured athletes may beneﬁt from increasing
their protein intake to overcome the immobilization-induced anabolic resistance as well as helping to attenuate the associated lossesof lean muscle mass documented in injured athletes (Milsom
et al., 2014).
After a muscle injury, it is likely that athletic activities are
reduced, if not stopped completely, to allow the muscle to recover,although some training in the noninjured limbs will likely continue.
This reduction in activity results in reduced energy expenditure,
which consequently requires a reduction in energy intake to prevent
unwanted gains in body fat. Given that many athletes periodize
their carbohydrate intake, that is, increase their carbohydrate intake
during hard training days while limiting them during light training
or rest days, it seems appropriate that during inactivity, carbohydrate intake may need to be reduced (Impey et al., 2018). It should
be stressed, however, that the magnitude of the reduction in energy
intake may not be as drastic as expected given that the healing
process has been shown to result in substantial increases in energy
expenditure (Frankenﬁeld, 2006), whereas the energetic cost ofusing crutches is much greater than that of walking (Waters et al.,1987). Moreover, it is common practice for athletes to perform
some form of exercise in the noninjured limb(s) while injured tomaintain strength and ﬁtness. It is, therefore, crucial that athletes do
not reduce nutrition, that is, under fuel at the recovery stage throughbeing too focused upon not gaining body fat; thus, careful planningis needed to manage the magnitude of energy restriction during thiscrucial recovery period. One thing that is generally accepted is that,when reducing energy intake, macronutrients should not be cut
evenly as maintaining a high-protein intake will be essential toattenuate loss of lean muscle mass.
Poor attention has been paid to dietary lipids in the preventionof musculoskeletal injuries. In this context, mainly omega-3 polyunsaturated fatty acids (n-3 PUFA) have been studied because of
their anti-inﬂammatory properties. Many studies have investigatedthe effects of n-3 PUFA supplementation on the loss of muscle
function and inﬂammation following exercise-induced muscle
damage, with the balance of the literature suggesting some degreeof beneﬁt (e.g., DiLorenzo et al., 2014; Marques et al., 2015).
These supplements should be taken for a minimum of 2 weeks with
5 g/day of ﬁsh oil capsules (providing 3,500-mg eicosapentaenoic
acid and 900-mg docosahexaenoic acid) to permit detectable
increases in muscle n-3 PUFA lipid composition (McGloryet al., 2014). This level of n-3 PUFA supplementation is far inexcess of what would be consumed in a typical diet and muchgreater than most suggested supplement regimes. Given that it is

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Nutrition to Prevent and Treat Athletic Injuries

not possible to predict when an injury may occur, it could besuggested that athletes should take n-3 PUFA supplements on aregular basis; however, the long-term daily dose requires further
investigation. Again, however, relying on ﬁndings from theexercise-induced muscle damage model to rule on a beneﬁt of
n-3 PUFA in macroscopic muscle injury prevention or recovery is
speculative at this stage.
There are a number of other nutrients that have some rationale
for supplementation to reduce the magnitude of muscle tissue
injury and/or promote healing. Many of these nutrition strategies
are claimed to work through either acting as an antioxidant or
through a reduction in inﬂammation. In reality, unless there is adietary deﬁciency, the vast majority of nutritional interventions
have limited research to support such claims. Some of the mostfrequently studied and supplemented micronutrients to help withskeletal muscle injury are summarized in Table 1.
Finally, consideration must be given to the balance between
muscle recovery and muscle adaptation. There is growing evidence
that nutritional strategies that may assist with muscle recovery,such as anti-inﬂammatory and antioxidant strategies, may attenuate
skeletal muscle adaptions (Owens et al., 2019). It would, therefore,
be prudent to differentiate between an injury that requires time lostfrom the sport and typical exercise-induced muscle soreness whenit comes to implementing a nutritional recovery strategy. Where
adaptation comes before recovery, for example, in a preseason
training phase, the best nutritional advice may simply to follow a
regular diet and allow adaptations to occur naturally.

Nutrition to Prevent and Treat Bone Injuries
Stress fractures are common bone injuries suffered by athletes thathave a different etiology than contact fractures, which also have afrequent occurrence, particularly in contact sports. Stress fractures
are overuse injuries of the bone that are caused by the rhythmic
and repeated application of mechanical loading in a subthresholdmanner (McBryde, 1985). Given this, athletes involved in highTable 1

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volume, high-intensity training, where the individual is bodyweight loaded, are particularly susceptible to developing a stressfracture (Fredericson et al., 2007), and training time lost can besigniﬁcant (Ranson et al., 2010). The pathophysiology of stressfracture injuries is complex and not completely understood(Bennell et al., 1999), but some studies have suggested thatnutritional inadequacies could be considered a risk factor (Moranet al., 2012). That said, there is little direct information relating
to the role of diet and nutrition in either the prevention or recovery
from bone injuries, such as stress fractures. As such, the completion of this article requires some extrapolation from the information relating to the effects of diet and nutrition on bone health ingeneral.
Palacios (2006) provides a brief summary of some of the key
nutrients for bone health, which include an adequate supply of
calcium, protein, magnesium, phosphorus, vitamin D, potassium,and ﬂuoride to directly support bone formation. Other nutrients
important to support bone tissue include manganese, copper,
boron, iron, zinc, vitamin A, vitamin K, vitamin C, and the B
vitamins. Silicon might also be added to this list of key nutrients forbone health. Given this, the consumption of dairy, fruits, andvegetables (particularly of the green leafy kind) are likely to be
useful sources of the main nutrients that support bone health.
Of the more speciﬁc issues for the athlete, undoubtedly thebiggest factor is the avoidance of low energy availability, which isessential to avoid negative consequences for bone (Papageorgiou
et al., 2018a, 2018b). Ihle and Loucks (2004) were among the ﬁrst
to demonstrate this, showing that bone formation was reduced at anenergy availability (EA) of 30 kcal·kg LBM−1·day−1. More severe
reductions in energy availability to 10 kcal·kg LBM−1·day−1 had
the effect of both reducing bone formation and increasing bone
resorption, likely initiating a dual negative effect on the bone. This
seems like a serious problem, particularly if continued over time,
given that some amenorrheic athletes have been reported to haveenergy availabilities of ∼16 kcal·kg LBM−1·day−1 (Thong et al.,2000). Two studies from our own research group have used thislevel of energy availability and shown that 5 days of low EA

Nutritional Strategies Claimed to Help With Skeletal Muscle Injuries in Athletes

Micronutrient

Rationale for supplement

Suggested dose

Key research

Vitamin D

It is well established that many athletes are vitamin D deﬁcient due
to a lack of sunlight exposure. Emerging evidence suggests thatvitamin D deﬁciencies can impair muscle regeneration following
damaging exercise both in vitro and in vivo.

Owens et al. (2015,2018)

Vitamins C and E

It has been claimed that increased free radical production increases
the magnitude of muscle damage following exercise and, therefore,
supplements with vitamins C and E could increase recovery time.
Literature, however, indicates that vitamins C and E have limited
ability to attenuate muscle damage or promote recovery.
It is claimed that polyphenols may attenuate muscle damage caused
by inﬂammation and increase free radical production. Montmorency
cherries (Prunus cerasus) are suggested to help improve rate ofmuscle function recovery after damage as well as reduce muscle
soreness and inﬂammation, especially in athletes consuming a low
polyphenol diet.
Creatine monohydrate is one of the most widely used supplements to
support gains in strength and lean mass. Supplementation has beenshown to attenuate loss of upper arm muscle mass and strength
during limb immobilization, as well as increase muscle hypertrophy
following lower leg immobilization.

2,000–4,000 IU D3 taken daily
during the winter months toensure serum 25(OH)D is greaterthan 75 nmol/L with sensible sun
exposure in the summer.
No need for additional
supplementation.

Polyphenols

Creatine

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Close et al. (2005);
Cobley et al. (2015);
Owens et al. (2019)

A diet rich in polyphenols (fruitand vegetables) may be the best
strategy to augment recovery
from damaging exercise rather
than speciﬁc supplementation.

Bell et al. (2015);
Peeling et al. (2018)

20 g/day for 5 days followed by
5 g/day thereafter.

Hespel et al. (2001);
Johnston et al.
(2009)

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(15 kcal·kg LBM−1·day−1) decreased bone formation and increasedbone resorption in women, but not in men (although some men wereaffected; Papageorgiou et al., 2017). In athletes, this poses
the question of whether the effect of low energy availability onbone is a result of dietary restriction or high exercise energy
expenditures. Recently, the effects of 3 days low energy availability(at 15 kcal·kg LBM−1·day−1) achieved by diet or exercise on boneturnover markers in active, eumenorrheic women were examined(Papageorgiou et al., 2018b). Low EA achieved through inadequate
dietary energy intake resulted in decreased bone formation but nochange in bone resorption, whereas low EA achieved throughexercise did not signiﬁcantly inﬂuence bone metabolism, highlighting the importance of adequate dietary intakes for the athlete.
Evidence of the impact of low energy availability on bonehealth, particularly in female athletes, comes from the many studies
relating to both the Female Athlete Triad (Nattiv et al., 2007) and
Relative Energy Deﬁciency in Sport Syndromes (Mountjoy et al.,2014), with the latter also suggesting that this might also be an issue
for male athletes. A thorough review of these syndromes is beyond
the scope of the current article; however, those interested areadvised to make use of the existing literature base on this topic.
Maintaining an energy availability of 45 kcal·kg LBM−1·day−1 overtime is likely to be important in optimizing bone health in theathlete and, potentially, in helping to protect the bone against thedevelopment of bone injuries. That said, this is likely to be an
unrealistic target for many athlete groups, particularly the endurance athlete (e.g., road cyclist, marathon runner or triathlete),
whose energy expenditure during training is likely to be high,with a training schedule that limits the amount of time available for
fueling. This target may also be difﬁcult to achieve in youth athletes
who have limited time to fuel given the combined demands ofschool and training. In addition, a calorie deﬁcit is often considered
to drive the endurance phenotype in these athletes, meaning thatwork is needed to identify the threshold of energy availability
above which there are little or no negative implications for thebone. However, a recent case study on an elite female endurance
athlete over a 9-year period demonstrated that it is possible to trainslightly over optimal race weight and maintain sufﬁcient energy
availability for most of the year, and then reduce calorie intake toachieve race weight at speciﬁc times in the year (Stellingwerff,
2018). This may be the ideal strategy to allow athletes to race attheir ideal weight, train at times with low energy availability todrive the endurance phenotype, but not be in a dangerously low
energy availability all year round.
Moran et al. (2012) collected dietary intake data from military
recruits at the start and end of basic training using food frequency
questionnaires and compared the dietary intakes of the recruits who
suffered a stress fracture (n = 12) with those who did not (n = 62).
The development of stress fractures was associated with preexisting dietary deﬁciencies, not only in vitamin D and calcium, but also
in carbohydrate intake. Although a small-scale association study,
these data provide some indication of potential dietary risk factors
for stress fracture injury. Miller et al. (2016) also demonstrated anincreased risk of stress fracture in athletes with low vitamin D
status, as assessed by circulating 25(OH)D3. Similarly, othergroups have shown a link between calcium intake and bothbone mineral density (Myburgh et al., 1990) and stress fracturerisk (Nieves et al., 2010) in athletes. Conversely, improving
vitamin D and calcium status with 800 IU/day vitamin D and
2,000 mg of calcium supplementation has been shown to reduce therisk of developing a stress fracture in military recruits (Lappe et al.,2008). Despite these initially encouraging ﬁndings, there remain

relatively few prospective studies evaluating the optimal calcium
and vitamin D intake in athletes relating to either (a) stress fracture
prevention or (b) bone healing. For a more comprehensive reviewof this area, readers are directed toward a recent review by Fischer
et al. (2018).
One further consideration that might need to be made withregard to the calcium intake of endurance athletes (and possibly
weight classiﬁcation athletes practicing dehydration strategies tomake weight) is the amount of dermal calcium loss over time.
Although the amount of dermal calcium lost with short-term
exercise is unlikely to be that important in some endurance athletes
performing prolonged exercise bouts or multiple sessions per day(e.g., triathletes), this could become an issue. Under these circumstances, athletes should consider either a high-calcium preexercise
meal containing ∼1,300 mg of calcium (Haakonssen et al., 2015) ora 1,000-mg calcium supplement (Barry et al., 2011), both of whichhave been shown to limit disturbances to calcium homeostasis and,potentially, the bone metabolic response to subsequent exercise.
Athletes are generally advised to consume more protein than
the recommended daily allowance of 0.8 g·kg BM−1·day−1, withmany athletes consuming 2–3 times this amount. Protein is a key
constituent of the bone’s structure, making up a substantial proportion of its mass and volume (Zimmermann et al., 2015). As
such, it would seem logical to propose that dietary protein intake isimportant for bone health, but the role of protein (particularly
animal protein sources) in bone health has been questioned, withsome suggesting that it could be detrimental because of the acidic
load that it creates; termed the “acid-ash hypothesis” (Barzel &Massey, 1998). More recently, however, several reviews (Rizzoli
et al., 2018) and meta-analyses (Shams-White et al., 2017, 2018)
have opposed this view and have shown that there are no negative,
and some beneﬁcial, consequences of a high-protein intake forbone health, particularly when consuming adequate calcium.
Maintaining an appropriate dietary intake is important for
maintaining ﬁtness and health and/or in regaining ﬁtness after
injury in athletes. Conversely, inadequacies in dietary intake havea negative effect on physical performance, which might, in turn,contribute to an increased risk of injury. This is as likely to be thecase for the bone as it is for other tissues of importance to theathlete, like muscles, tendons, and ligaments. Despite this, there isa relative dearth of information relating to the effects of dietaryintake on bone health in athletes and, particularly, around the
optimal diet to support recovery from bone injury. In the main,
however, it is likely that the nutritional needs for bone healthin the athlete are not likely to be substantially different from thoseof the general population, albeit with an additional need tominimize low energy availability states and consider the potentially elevated calcium, vitamin D, and protein requirements ofmany athletes.

Nutrition to Prevent and Treat Tendon
and Ligament Injuries
Tendinopathy is one of the most common musculoskeletal issues inhigh-jerk sports. Jerk, the rate of change of acceleration, is thephysical property that coaches and athletes think of as plyometricload. Where the plyometric load is high across a tendon, such as forthe patellar tendon in hurdlers and in the plant leg of jumpers andthrowers, tendinopathy rates are high: approximately 30% and 45%
for elite athletes, respectively (Lian et al., 2005). In support of therole of jerk in the development of tendinopathy, in distance

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runners, where jerk across the patellar tendon is lower, patellar
tendinopathy rates are similarly lower <15%, whereas Achilles
tendinopathy rates rise to ∼55% (Knobloch et al., 2008).
Given that the volume of high-jerk movements increases in elite
athletes, interventions to prevent or treat tendinopathies would havea signiﬁcant impact on elite performance. The goal of any intervention to treat tendinopathy is to increase the content of directionallyoriented collagen and the density of cross-links within the protein
to increase the tensile strength of the tendon. The most common
intervention to treat tendinopathy is loading. The realization that
tendons are dynamic tissues that respond to load began when theKjaer laboratory demonstrated an increase in tendon collagen synthesis, in the form of increased collagen propeptides in the peritendinous space 72 hr after exercise (Langberg et al., 1999). They
followed this up using stable isotope infusion to show that tendon
collagen synthesis doubled within the ﬁrst 24 hr after exercise(Miller et al., 2007). Therefore, loading can increase collagensynthesis, and this may contribute to the beneﬁcial effects of loadingon tendinopathy. Recently, combining loading with nutritional
interventions has been proposed to further improve collagen synthesis (Shaw et al., 2017) and promote tendon and ligament healing(Baar, 2018), and this possibility will be discussed below.

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Vitamin C
Nutrition has been recognized as being essential for collagensynthesis and tendon health for over 200 years. In the ﬁrst
controlled nutritional trial ever recorded (1747 AD), the Scot
James Lind fed 12 sailors with scurvy one of six different interventions: no treatment, quart of cider, “twenty-ﬁve gulls” of vitriol,
six spoonfuls of vinegar, half a pint of seawater, or two oranges andone lemon (Lind, 1757). The two sailors given the oranges andlemon recovered within 6 days; however, the relationship between
the citrus fruit and scurvy continued to be debated for over
150 years. In 1959, Jerome Gross showed that guinea pigs on avitamin C deﬁcient diet did not synthesize collagen at a detectablelevel (Gross, 1959), making the molecular connection between
vitamin C and scurvy. The requirement for vitamin C in thesynthesis of collagen comes from its role in the regulation of prolylhydroxylase activity (Mussini et al., 1967), an enzyme required forcollagen cross-linking and export from the endoplasmic reticulum.
As vitamin C is consumed in the hydroxylation reaction, andhumans lack the L-gulono-γ-lactone oxidase enzyme required forthe last step in the synthesis of vitamin C (Drouin et al., 2011), we
need to consume 46 mg/day to maintain normal collagen synthesis.
Even though a basal level of vitamin C is required for collagensynthesis, whether exceeding this value results in a concomitant
increase in collagen synthesis has yet to be determined. Therefore,
currently, there is no evidence that increasing vitamin C intake will
increase collagen synthesis and prevent tendon injuries.

CopperSimilar to vitamin C, copper is also required for enzymatic crosslinking of collagen through its role as a cofactor for the enzyme
lysyl oxidase (Kagan & Li, 2003). Like vitamin C, copper
deﬁciency leads to impaired mechanical function of collagencontaining tissues, such as bone (Jonas et al., 1993), leading toan increase in fractures in people with copper deﬁciency (Paterson,1988). However, the beneﬁcial effects of copper are only seen in
the transition from deﬁciency to sufﬁciency (Opsahl et al., 1982).
There is no further increase in collagen function with increasing193

doses of copper. Therefore, the goal for copper intake should
approximate the RDA of ∼1 mg·kg−1·day−1.

GlycineFibrillar collagens are a repeating tripeptide of glycine-X-proline/hydroxyproline, where X represents any amino acid other thanglycine and proline. This sequence allows collagen to form the tighttriple helix that gives the protein its mechanical strength. Becauseof the importance of glycine, some researchers have hypothesizedthat increasing dietary glycine would have a beneﬁcial effect on
tendon healing. Vieira et al. (2015a) showed that 21 days after acollagenase injury to the Achilles tendon, rats on a diet containing
5% glycine demonstrated increased collagen and glycosaminoglycan content as well as mechanical strength. The authors repeatedthe results in a follow-up study (Vieira et al., 2015b), suggestingthat glycine may aide in the recovery of tendon function after
injury. However, consuming a diet where 5% of the calories comefrom glycine is not realistic in an athletic population.

Gelatin/Hydrolyzed Collagen
Another potential source of the amino acids found in collagenis gelatin or hydrolyzed collagen. Gelatin is created by boilingthe skin, bones, tendons, and ligaments of cattle, pigs, and ﬁsh.
Boiling releases large molecular weight (>100 kDa) proteins thatshow limited solubility in water and form a gel after heating. Further
chemical or enzymatic hydrolysis of gelatin breaks the protein into
smaller peptides that are soluble in water and no longer form a gel.
Because both gelatin and hydrolyzed collagen are derived fromcollagen, they are rich in glycine, proline, hydroxylysine, andhydroxyproline (Shaw et al., 2017). As would be expected from a
dietary intervention that increases collagen synthesis, consumption of
10 g of hydrolyzed collagen in a randomized, double-blinded,
placebo-controlled study in athletes decreased knee pain from standing and walking (Clark et al., 2008). The decrease in knee pain could
be the result of an improvement in collagen synthesis of the cartilage
within the knee since cartilage thickness, measured using gadolinium
labeled magnetic resonance imaging, increases with long-term consumption of 10 g of hydrolyzed collagen (McAlindon et al., 2011).
The role of gelatin consumption in collagen synthesis was directly
tested by Shaw et al. (2017). In this randomized, double-blinded,
placebo-controlled, crossover-designed study, subjects who consumed 15 g of gelatin showed twice the collagen synthesis, measured
through serum propeptide levels, as either a placebo or a 5-g group.
Furthermore, when serum from subjects fed either gelatin or collagenis added to engineered ligaments, the engineered ligaments demonstrate more than twofold greater mechanics and collagen content(Avey and Baar unpublished; Figure 1). Even though bathing theengineered ligaments in serum rich in procollagen amino acids
provides a beneﬁcial effect, this is a far cry from what would beseen in people. However, these data suggest that consuming gelatinor hydrolyzed collagen may increase collagen synthesis and potentially decrease injury rate in athletes.

Other Nutrients
There is a myriad of other nutrients that are purported to improve
tendon/ligament function, including turmeric/curcumin, taurine,
arginine, bromelain, or boswellic acid. These and other nutraceuticals have recently been reviewed by Fusini et al. (2016). Interestingly, many of these nutrients are thought to decreaseinﬂammation, and the role of inﬂammation in tendinopathy in

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Figure 1 — Effect of serum isolated from an athlete before (open bars) or 1 hr after (gray bars) consuming 15 g of either gelatin or hydrolyzed collagenand vitamin C on both (a) modulus (stiffness) and (b) percent collagen.

elite athletes remains controversial (Peeling et al., 2018). Therefore, future work is needed to validate these purported nutraceuticals in the prevention or treatment of tendon or ligament injuries.

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Conclusions

with the fact that the time course and pathology of the same injuries
are often very different), it is important that high-quality casestudies are now published in elite athletes to help to develop an
evidence base for interventions.
Acknowledgments

Although injuries are going to happen in athletes, there are several
nutrition solutions that can be implemented to reduce the risk anddecrease recovery time. To reduce the risk of injury, it is crucial that
athletes do not have chronic low energy availability, as this is amajor risk factor for bone injuries. Cycling energy intake throughout the year to allow race weight to be achieved, while achieving
adequate energy availability away from competitions, may be themost effective strategy. It is also crucial for bone, muscle, tendon,and ligament health to ensure that there are no dietary deﬁciencies,
especially low protein intake or inadequate vitamin C, D, copper,
n-3 PUFA, or calcium. This highlights the importance of athletes
having access to qualiﬁed nutrition support to help them achieve
their goals without compromising health. If an injury does occur,
one of the key considerations during the injury is to ensure
excessive lean muscle mass is not lost and that sufﬁcient energy
is consumed to allow repair, without signiﬁcantly increasing bodyfat. It is crucial to understand the change in energy demands and, atthe same time, ensure sufﬁcient protein is consumed for repair,especially since the muscle could become anabolic resistant. In
terms of tendon health, there is a growing interest in the role ofgelatin to increase collagen synthesis. Studies are now showing thatgelatin supplementation can improve cartilage thickness anddecrease knee pain, and may reduce the risk of injury or accelerate
return to play, providing both a prophylactic and therapeutic
treatment for tendon, ligament, and, potentially, bone health. It
should ﬁnally be emphasized that, where possible, all of thesenutritional solutions should be explored in a “food ﬁrst” manner,
rather than a reliance on supplements (Peeling et al., 2018). Where
supplementation is deemed necessary (e.g., diagnosed vitamin D
deﬁciencies), athletes should seek appropriate advice from qualiﬁed staff with up-to-date knowledge of supplement contamination
and anti-doping regulations. Last but not least, more human-based
research is needed, ideally in elite athlete populations, on thepossible beneﬁts of some macro- and micronutrients in the prevention or boosted recovery of injured athletes. Given that placebocontrolled, randomized control trials are exceptionally difﬁcult toperform in elite athletes (no athlete would want to be in a placebogroup if there is a potential of beneﬁt of an intervention, combined

All authors contributed equally to the manuscript, with each author writing
speciﬁc sections and all authors editing the ﬁnal manuscript prior to ﬁnal
submission. They also declare no conﬂicts of interest related to thismanuscript.

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