Simple Exercises That Can Repair Tendons, Isometrics vs. Eccentrics, and More — Dr. Keith Baar

Summary

In the latest episode featuring Dr. Keith Baar, hosted by Tim Ferriss, the discussion delves into tendon rehabilitation, the science of isometrics versus eccentrics, and cutting-edge research in muscular health. Dr. Baar, a leading expert in tendon physiology, debunks common myths surrounding tendon recovery and shares the latest scientific insights. The conversation covers a range of topics, from the impact of diet on tendon health to practical exercises that can aid in tendon recovery. This episode is a treasure trove for anyone interested in optimizing tendon health and athletic performance.

Highlights

• Dr. Baar explains why traditional ankle boots may not be the best for healing sprained ankles, as they can promote scarring. 🚷
• Discusses the benefits of isometric exercises over eccentric ones due to better force distribution. 🔄
• Outlines a 10-minute isometric routine that can improve tendon recovery with minimal wear. 💯
• Introduces novel research showing early loading post-surgery can help heal tendons faster. 🚀
• Shares insights on how proper collagen supplementation supports tendon health. 🦴

Key Takeaways

• Stress shielding with boots post-injury may worsen tendon health instead of helping it. 🚫
• Isometric exercises are often more effective than eccentric loading for tendon repair. 💪
• Optimal tendon exercise involves 10 minutes of loading with rest intervals to maximize benefits. ⏲️
• Collagen and vitamin C supplementation can aid tendon recovery, but source matters. 🍊
• Early post-surgery loading can significantly accelerate recovery times. 🕒

Overview

Dr. Keith Baar, in conversation with Tim Ferriss, dismantles long-held beliefs about tendon recovery using innovative research as evidence. One key revelation is the potential harm caused by common medical practices like immobilizing injured tendons in boots, which can inadvertently lead to scarring. Instead, Dr. Baar proposes the use of isometric exercises, which differently load tendons to promote more effective healing.

The episode delves into various methodologies, including the importance of eccentric versus isometric loading. While traditional approaches have favored eccentric exercises, Dr. Baar’s research supports the efficacy of isometrics, providing a more balanced force distribution across tendons. He highlights the minimal time investment of just 10 minutes for effective isometric workouts, noting that these routines could be performed twice a day for optimum benefits.

Further, Dr. Baar emphasizes the role of nutrition in tendon health, recommending collagen and vitamin C to complement exercise. He explains how these nutrients can uniquely support tendon recovery when timed correctly with exercise. The conversation also touches on the broader implications of these findings for athletes and the general public, aiming to reshape conventional recovery paradigms with science-backed strategies.

Chapters

• 00:00 - 03:00: Introduction and Discussion on Tendon Repair Methods The chapter discusses methods of tendon repair, specifically focusing on the common medical practice of using a boot for an ankle sprain. It explains that while boots are designed to relieve stress from the injured tissue, they may inadvertently contribute to scar formation by shielding the tissue from necessary tension. This highlights a potential drawback in the traditional approach to treating tendon injuries.
• 03:00 - 10:00: The Role of Isometric Exercises The chapter "The Role of Isometric Exercises" reflects on the historical development of immobilization methods dating back 4,500 years to Egyptian hieroglyphs. The discussion emphasizes the outdatedness of such ancient treatments in other fields like oncology and suggests the need for advancements in orthopedic care, similar to progress in cancer treatments.
• 10:00 - 15:00: Adaptations and Benefits of Isometric Holds The chapter introduces the topic of isometric holds by beginning with a casual conversation between the speaker and a person named Keith. The speaker expresses gratitude for the opportunity to discuss the topic, indicating enthusiasm and anticipation for a fruitful conversation. Additionally, the speaker mentions having just received focus shockwave treatments from a reputable doctor, which delayed the start time of the discussion. This sets the stage for further exploration into the topic of isometric holds, their adaptations, and benefits.
• 15:00 - 25:00: Comparison Between Isometric and Eccentric Training The chapter begins with an apology for starting late and transitions into a discussion about the origins of the conversation. The speaker reveals their first encounter with the other person's work, which was surprisingly recent given their interest in the same field. The context for this encounter was a tweet, possibly posted on social media platform X, that inquired about remedies for tennis elbow.
• 25:00 - 35:00: Recommendations for Tendon Injury Protocols The chapter titled 'Recommendations for Tendon Injury Protocols' discusses the connection between a YouTube video by high-level climber Emil Abrahamson, who conducted a hangboard training twice a day for 30 days, and a study or review related to minimizing tendon injury and maximizing return to play. The transcript focuses on applying these findings in a rock climbing context.
• 35:00 - 45:00: The Impact of Pharmaceuticals and Supplements on Tendon Health The chapter explores the relationship between pharmaceuticals and supplements and their impact on tendon health, using a case study of a high-level climber who undertook a 30-day regimen involving reduced weight hangs. The exercise routine is briefly described: 10 minutes daily, focusing on a hangboard with 70% bodyweight support. This regimen aimed to highlight the interaction between tendon strength improvements and possible pharmaceutical or supplemental influences.
• 45:00 - 55:00: Orthobiologics and Their Efficacy In this chapter, the discussion revolves around the impressive improvements observed in an individual's climbing performance, specifically related to hang times. The subject was able to increase his maximum hang time dramatically by employing a strategic training regime involving adding weight and maintaining tension for specific durations. Despite not using technical language, the narrative highlights the remarkable achievements and how it strongly impacted the subject's perceptions.
• 55:00 - 65:00: Collagen Synthesis and Nutrition for Tendon Health The chapter begins by questioning the physiological adaptations that enable improved physical performance, particularly in the context of strength. The narrative suggests that understanding these fundamental changes is crucial for recognizing the essence of strength itself. It emphasizes that strength is commonly associated with lifting heavy weights, an activity known to lead to increased muscular strength. The discussion likely continues to explore the biological and nutritional aspects of collagen synthesis and its impact on tendon health, although this specific transcript does not delve into those details directly.
• 65:00 - 75:00: Discussion on Ketogenic Diet and Its Effects The chapter titled 'Discussion on Ketogenic Diet and Its Effects' begins by describing the physical demands on certain athletes, such as climbers, who engage in heavy lifting and dynamic movements. These activities often lead to breakdowns in finger tendons and their pulleys. The discussion points to the ongoing research in strengthening these muscle groups, a task the speaker has been involved with for years.
• 75:00 - 85:00: Gender Differences in Tendon and Ligament Health The chapter discusses the traditional belief that muscle strength is directly proportional to the muscle's cross-sectional area, implying that bigger muscles are stronger. It also mentions a discovery related to a small molecule in cells that helps muscles grow bigger during resistance exercise. However, the transcript does not provide the name of the molecule.
• 85:00 - 95:00: Protein Intake and Muscle Health This chapter discusses the role of the mTOR complex in muscle health, particularly in relation to protein intake. It involves the author's personal experience working with elite athletes at the English Institute of Sport's Cycling Center, where the emphasis is on building muscle mass while considering the need to carry the additional weight during competitions.
• 95:00 - 98:00: Conclusion and Final Thoughts In the conclusion, the author reflects on the surprising realization that athletes can become stronger without necessarily increasing in size, and sometimes even becoming smaller. This revelation challenges previous scientific understanding regarding muscle growth and strength. The key insight is that while muscle 'motors' generate force, the real mechanism involves the efficient transmission of that force from muscles, which involves more than just size, emphasizing technique, and possibly neural efficiency.

Simple Exercises That Can Repair Tendons, Isometrics vs. Eccentrics, and More — Dr. Keith Baar Transcription

• 00:00 - 00:30 if you go and you sprain your ankle and you go to the doctor very good doctor very well-meaning they're going to give you a boot and what is a boot so I told you that a scar forms when we get stress shielding what a boot is it is a mechanical stress shielder what it's designed to do is to take the stress off the tissue you've injured if I've told you that the thing that's going to cause that tissue to get a scar is that you take off the tension what I've just done is I've made the problem worse
• 00:30 - 01:00 yeah I always tell people that the first recorded immobilizer for an ankle or a leg is from Egyptian hieroglyphs where they showed pictures 4,500 years ago if I took you and you said you had cancer you would not want a treatment that was developed 4,500 years ago you would hope that something new has been developed in the last 4,500 years that is where we are for our Orthopedic situations
• 01:00 - 01:30 [Music] all right let's start off Keith just by saying thank you for the time hey thank you this is going to be great this this should be really fun Should be a good time I have a lot of questions and the start time for this was delayed because I was getting focus shock wve treatments with a doctor I think is very credible
• 01:30 - 02:00 and that is why we're starting late which Segways very nicely into our conversation and I wanted to give the Genesis story because I came across your work for the first time shockingly it's astonishing to me I didn't come across you earlier because I put a tweet online not sure what the noun is for something like that on X at this point asking about remedies related to tennis elbow specifically and it was within the
• 02:00 - 02:30 context of rock climbing and someone put up a video from YouTube by Emil abrahamson I'm probably pronouncing that incorrectly who is a highlevel climber great YouTube Creator and teacher who put up a video called something like doing hangboard training twice a day for 30 days and that is where he referenced a study of yours or may have been a review I'm not sure exactly but minimizing injury and maximizing return to to play lessons
• 02:30 - 03:00 from engineered ligaments and I just want to give people the punchline to this because and then I'll shut up and let the expert talk he is a highlevel climber he climbs v5s bouldering he is incredibly good and after 30 days of doing 10 minutes a day roughly of hangboard not even full hangs let's just say 70% body weight so his feed are on the floor kind of like a nice stretch for 10 seconds on 50 seconds off
• 03:00 - 03:30 right so so 100 seconds of tension per session he I think added 60% weight to his maximum hangs so this is weight attached around the waist he went from something like a05 second one-handed hang on a tiny little ledge I'm not using technical climbing language here to 13 seconds and so on and so forth and it just blew his mind completely so let's
• 03:30 - 04:00 just start with asking what is happening here what are the adaptations that are allowing something like that to happen and then we'll kick off from there it's a great place to start because we think it actually shows something fundamental about strength because what we do is I'm in our strength physiology facility here and and we normally think of strength as yeah we're going to lift weights we're going to do something really really heavy and because that's going to make us stronger we know that when we lift heav weights we get stronger and the
• 04:00 - 04:30 reality is that there are certain especially certain athletes like climbers where they're doing all kinds of heavy lifts they're doing all kinds of heavy work they're doing all kinds of really Dynamic moves and what happens what breaks down is they break down in their finger tendons and they break down in the little pulleys within the tendons and we had come to this because for years I had been working on how to make muscles bigger Ander stronger and I
• 04:30 - 05:00 always said okay bigger and stronger because the definition in my old textbooks would say that the strength of a muscle is related to the cross-sectional area it's proportional to the cross-sectional area of the muscle and so I was like okay to get stronger you need to be bigger so I actually was really fortunate to be to be part of the team where we discovered that the small molecule in our cells that actually allows our cells to get bigger when we do resistance exercise what is the name of that just brief so
• 05:00 - 05:30 it's mtor so it's mtor complex one it's the mechanistic target of rap so i' had been doing this I had a laboratory my first laboratory was in Scotland and I was invited down by the English Institute of sport to come to to their Cycling Center and they were like okay this is great we need to we have these incredible athletes who are winning all kinds of gold medals and we wanted to get stronger and so I go in there with my spiel about bigger muscles and all of this and they're like yeah but we got to carry that muscle mass and I've got five years of data that shows me I'm getting
• 05:30 - 06:00 these athletes stronger without making them any bigger and in many cases making them smaller and I'm like oh well so much for all the science that I've been doing for a long time but then I had to figure out okay so how is this working or how are they getting people who are stronger without them getting bigger and so what it came down to is if we have the little Motors in our muscles that are going to produce the force what we then have to do is we have to transmit that force and that Force has to be transmitted from our muscle where we're
• 06:00 - 06:30 producing it to our bone where the movement is going to occur and that's going to go through tendons it's going to go through connective tissue it's going to go through all of these proteins that are that we call colloquially force transfer proteins and so that was the first thing that we were thinking of and then what we what we were doing is we would make these little engineered ligaments and so the goal at the beginning is hey I'm going to make ligaments you're going to rupture your ACL you're going to send me like a a sample that will'll take in the doctor's office isolate the cells I'm
• 06:30 - 07:00 going to make you an ACL in the dish in my laboratory I'm going to send it back to you so that you don't have to take your hamstring or the middle third of your patella and we can replace that ruptured ACL that's the idea but we have to get them stronger so we started looking at okay we know exercise makes these tenons stronger but what about the exercise and what we found is it didn't matter whether we stretched them 20% or 5% or 2% the signals to get bigger and stronger were the same but then we started doing for different Tim lanes and it started the signal would go up
• 07:00 - 07:30 and then it would go away really quick and so the way that I explain it now is that your tenin ligament your bone all of your connective tissue cells are a lot like my 17-year-old daughter she's going to listen to me for maybe five minutes maybe 10 minutes and then she's going to just tune me out so I need to get all the information in in that 5 to 10 minutes so if you're going to go and you're going to climb for example like ail would do all the time he's going to spend three four five hours at the wall doing different things the tendons
• 07:30 - 08:00 stopped getting the signal to adapt at 10 minutes everything on top of that was just wear and tear that could you know slightly cause problems and so what that meant to us is that there's this minimal effective dose so if I give you 10 minutes of loading that is optimized for those connective tissues whether it's tendon ligament cartilage or bone I can get you to get all of the signal from that whole exercise Bo in 10 minutes and so that was the first part the second
• 08:00 - 08:30 part was how long does it take before I can get more signal to go through that system think of it like your toilet I flush my toilet it's going to flush but if you know when my daughter was younger she would oh that was fun let me do that again it wouldn't flush for a while she needed to let the bowl refill let the tank refill so I could flush it so that's called the refractory period how long do I have to wait before that next session and what we found is about eight hours six to eight hours later and
• 08:30 - 09:00 amazingly that was almost exactly the same thing that other researchers had found for bone that as little as as few as 40 stimuli with eight hours of rest was maximal for bone we found that 10 minutes of activity whether you did walking or running or just holds 10 minutes worth so 10 seconds on 50 seconds off 100 seconds total over that 10 minutes that's all the signal your your cells need you wait eight hours you can do it again and so A's brother had lots of injuries so he did it twice a
• 09:00 - 09:30 day his hands are healthy now he can climb Amil because he's a huge strong boulderer Who does these Dynamic loads he had a really big effect of doing those isometric holds because he was getting all of the stimulus to make the muscle stronger the brain power to stimulate the right muscles to have him to be able to contract that what he was missing was he was getting too much wear and tear on the tendons on the force transfer stuff so when we just got him to do those 10-minute
• 09:30 - 10:00 sessions his force transfer capacity went way up and now his grip strength went way up and one of the best videos that he has is he becomes a competitor in the world's strongest grip competition oh it's an amazing video it's so good and so these guys are twice his size and he's grabbing all these things about the same as the the people who are twice his size and it's it's awesome because 's smaller than me he's a great guy and but it's like okay so you're getting to the where you have some of the strongest
• 10:00 - 10:30 grip in the world and all you're doing is these little things you're doing your Dynamic climbing and you're combining that with these isometric holds and so what we're improving is that ability to transmit the force between the muscle that's making it and the bone that's trying to help us do the movement okay so let me dive into a few aspects of that with clarifying questions just so we can keep folks who need Scooby Snacks engaged with just some prescriptive stuff
• 10:30 - 11:00 but before I get to that let me just ask you and we can come back to this because I'm sure it's a large topic we could uncork but in 2016 I interviewed David sabatini on mour and then navdeep chandelle on met foran and we did it in Easter Island or on Easter Island so rapanui after which Rapa is named and we had a great conversation and you mentioned earlier I suppose and I don't know if
• 11:00 - 11:30 this is correct me if I'm getting this wrong but the the M torque one pathway as being key for sort of resistance exercise induced hypertrophy muscle growth right does that mean that taking something that has maybe more of a systemic effect like Romy a lot of people in Silicon Valley and elsewhere take Rapa for hoped for longevity purposes since they've seen that demonstrated in some species are you making sacrifices on the hypertrophy side hypothetic or or do you
• 11:30 - 12:00 expect not much of an interference there the short answer is that at the doses that they're taking for longevity you have a minimal effect on the adaptation of skeletal muscle but you're still going to have a somewhat negative effect so for most people that's not enough of a negative effect to see a difference if you were trying to do highlevel competition or build your muscles to the biggest possibility that would prevent that some degree it's the same kind of
• 12:00 - 12:30 thing that endurance exercise can do because endurance exercise like met forming can can activate Pathways that counteract mtor complex one and so you've got this balance and a lot of times what we're doing is is people will Target mtor not because for longevity the thing that they're trying to do is they're trying to decrease systemic inflammation because just like our muscles our inflammatory cells need mtor AC ity in order to respond to the stress
• 12:30 - 13:00 our muscles need mtor activity to respond to the stress of lifting heavy weights and to allow us to incorporate more of what we eat in our meals more of the protein that we eat in our meals into our muscles to store that protein or those amino acids as muscle proteins our immune cells they are doing similar things they need Amor activity in order to respond to an immune Challenge and so you do see the same thing with people who are taking wrap of mice and is that
• 13:00 - 13:30 they do have a little bit of an imuno compromised situation and it's the similar kind of you know muscle compromis situation is what we'd say got it and I would say folks talk to your doctor number one and number two watch your dosing and look up the original applications of rap ay before you start gobbling it like Tic Tacs all right I want to come back to the meat and potatoes what you were just saying before and ask specifically because I've seen a lot of
• 13:30 - 14:00 pain relief from imitating the ABR hangs even though these are the 70 80% body weight feet still on the floor hangs that Emil demonstrates in his videos it may not even be for my current problem but just for people listening who may have say golfer elbow so people have pain on the medial epicondilite as I do in the video Emil is doing 10 seconds on 50 seconds off for 10 minutes digging around online
• 14:00 - 14:30 there are other people who claim can't believe everything you read they're like as per Keith bar I am doing 30 second hangs semiflexed with two minutes in between for four repetitions so one is a question on what you think the optimal load duration and rest intervals are for take your pick could be golfers or tennis elbow and then secondly is why
• 14:30 - 15:00 isometrics because for instance 15 ft away from me I have a a flex bar this is a device that looks kind of like a churro and you use it to apply eccentrics right and you hear a lot about Ecentric loading for say tennis elbow so those are the two questions kind of how you would prescribe like the loading protocol in terms of duration number of intervals Etc and then why isometrics versus say Ecentric
• 15:00 - 15:30 this is the money question this is like what I love about what I'm doing right now so let's start with why the Ecentric okay and can you explain to people just like if you're doing a bicep curl folks and you're lowering the weight after curling it up that is The Eccentric or negative portion of that movement but you may be able to give more color for that no it's perfect so when I'm curling up that's my concentric move when I'm holding it still that's the isometric component and when I'm I'm lowering it
• 15:30 - 16:00 that's the Ecentric component all right so when I'm completely healthy and when everything is working perfectly with my tendon it doesn't really matter what I'm doing as much the reason that I say that is that your tendons like any other tissue in our body it's not a homogeneous tissue but what it is is a mechanical tissue and what that means is I'm passing load through it and so if
• 16:00 - 16:30 there's strong parts and there's weak Parts the load is going to go more through the strong Parts because they're stiffer and so when I load quickly load goes through the strong Parts when I have an isometric hold the strong part gets tired and the load then is put onto the rest of the T that's if the isometric is long enough or just by virtue of being isometric by virtue of being isometric but then the longer the isometric the more evenly the signal is given to all of the cells
• 16:30 - 17:00 within got it think of it like this The Rock and I are doing a tug-of war together against somebody over there okay so at the start it doesn't matter if I'm there or not because the rock is going to be like putting in 900% of of what we're going to put into that that rope I'm just standing there because for contrast right yeah but then what happens is the rock doesn't do much endurance work that's how he gets so big so he's going to tire really quickly and
• 17:00 - 17:30 as he tires suddenly I'm having to put more load on the on the rope in order for us to maintain that position we all had a sadistic gym teacher who said okay go to the wall there put your back against the wall go down and sit so that your legs are 90 de and 90 degrees at the hip and the knee yeah walls sits yeah and you did a walls sit and you're sitting there like I am not moving why the hell are my legs burning like the world is on fire the reason is that as I
• 17:30 - 18:00 hold that position my tendons start to relax and as my tendon starts to relax in order for me to stay there my muscle has to contract more and so what I get is I get creep in my tendon now that's really important because you know if you take a paper piece of paper and you just load it and I don't know if you do you do do the video so I'll do this demonstration and just describe what you're doing as you're doing it I will yeah so if I take a piece of paper just like our tendons piece of paper is made up of fibers and
• 18:00 - 18:30 in this case it's paper fibers or wood fibers in my tendon it's made up of collagen so if I load that dynamically I'm loading all of the all of the fibers within them now if I tear this and I the people who are just listening just take a piece of paper tear it and then just you have a little Edge there now if load goes through that what's going to happen is it's going to tear across but if I just go back and I dynamically load doesn't go through there it doesn't tear
• 18:30 - 19:00 because there's no load going through this there's a beautiful set of papers done by this wonderful old Japanese Professor named Hayashi and what he did is he took a metal wire and he put it from the patella into the tibal plateau of a rabbit he just tightened it so that there was no load going through the patellar tendon and within two weeks he had all of the indications that the tendon was scarred perfectly healthy tendon but it had tons more cells it had
• 19:00 - 19:30 smaller collagen molecules and they were not directionally oriented those are the definitions of a scar so if you have a scar that's because you didn't get load through it and so all I have to do in order to get load through this area is I just have to put a small amount of weight and just be patient right and just just for people who aren't seeing it you're pulling from top to bottom I'm pulling on the top and the bottom yeah and now eventually the paper will tear right at the point where we put that original injury the reason for that is
• 19:30 - 20:00 because what happens is normally when our tendons are kind of ready to go or kind of just sitting there we've got the weak spots and we've got the strong spots the strong spots are shielding the weak spots from the stress it's what we call stress shielding and so all of the load is going through the strong bits this is why your favorite athlete doesn't rupture their Achilles tendon on the first or second thing they do it after warming up they do a bunch of
• 20:00 - 20:30 loading they then they go and do that load where they put their foot in the ground and now it's going to rupture because what's happened is you've kind of fatigued out the strong part and it can't Shield the weak part anymore and then just like my piece of paper it tears so quick interjection if I may so the isometric allows you to recruit you instead of just the rock right using your exactly metaphor from earlier but Ecentric movements do not allow you to do that the standard of care for tenant
• 20:30 - 21:00 injuries has been for the last 25 years Ecentric loading MH it's actually a really funny story because the guy who developed the protocol this Sky Henderson who was this Scandinavian guy and he knew from his experience as a scientist that it's easier to heal a tendon once it ruptures than when you have a tendonopathy it's shorter the time period you get more complete healing so what he was trying to do is he had an Achilles tenant injury yeah he had Achilles tenant opposite and so what he was trying to do is he's trying to
• 21:00 - 21:30 rupture it and he thought the best way that I can get the most load through this is if I put all the weight I can and I just try and hold it there and slowly go down what he found out is that it actually fixed his Achilles tendon and this is where we got this whole system this is like what they used to do with race horses so that was the Genesis but if he wanted to rip it all he had to do is take that big heavy weight and move super fast yeah because now you have the what we call jerk and so for
• 21:30 - 22:00 our tendons again jerk is not just that person that you hate in the world it's actually a physical property so where I am that's my location the rate of change of my location that's my velocity the rate of change of my velocity that's my acceleration everybody's good up till now the rate of change of my acceleration that's jerk so when I'm accelerating one way so I'm going to do a snatch and I'm going to accelerate up the bar gravity is accelerating down so when I hit that bar and I get that catch
• 22:00 - 22:30 that catch is jerk that's why that's where we get the most injury the reason I get tennis elbow I'm swinging a tennis racket in One Direction the ball is going the other direction I get a small amount of jerk that goes through the tendon the reason I get golfers elbow on the inside is I'm swinging through I'm going to hit and it doesn't usually happen on grass because there's not too much resistance it happens much more on the synthetic surfaces now I get that jerk in the opposite direction now I get pain on the inside the elbow but it's the same thing with jumpers jumpers get
• 22:30 - 23:00 jumpers knee because they're doing these Dynamic modes jerk is the thing that's going to induce injury jerk is that rate of change of acceleration MH so now the reason that Ecentric were working is because it wasn't about Ecentric it had nothing to do with that because Michael Care's beautiful work if you do really heavy strength training it has the exact same effect as Ecentric the reason is when I lift a weight That's Heavy I have to go slowly the core of the Ecentric training was to do a
• 23:00 - 23:30 slow Ecentric it had nothing to do with the Ecentric it had nothing to do with the conent it was the tempo it had to do with the velocity and so when we realized that the velocity was the key then we said okay what is it about velocity so if we keep velocity at zero now what we should see is we should see the biggest bang for a buck and so all we had to do is make the velocity of the movement zero and suddenly we got loaded through the whole tendon that's fascinating so the whole Ecentric thing
• 23:30 - 24:00 which has become kind of scripture in a lot of places just like rice which we might talk about right the rest ice compression elevation which we'll talk about at some point hopefully if we have time it was a false positive in a sense right or they thought it worked because of the Ecentric nature of the movement but it wasn't that at all it was the reduction of velocity exactly and maximal reduction of velocity is isometric yeah and and so if you're trying to hold the weight while you're
• 24:00 - 24:30 doing that slow Ecentric load yeah the weight is good but from our engineered ligaments it didn't matter whether we did a big movement or a little movement or a heavy movement or What mattered was we got load through the cells so the cells could sense the load and that we did it and we could stop at about 10 minutes and those were the two things that that made the difference do you see any difference I don't know if you were testing this in the lab but back to the original question about intervals or duration of stressor
• 24:30 - 25:00 right 10 seconds on 50 seconds off for 10 minutes straight versus like 30 seconds on two minutes off 30 seconds on two minutes off absolutely have you been able to draw any not necessarily conclusions but inferences hypotheses worth testing as to what might be better we actually do have really good data there what we know is it when when the tenant is pretty much healthy we can do shorter duration isometrics so we can do 1 to 10c
• 25:00 - 25:30 isometrics when we've got pretty good health that'll get us our maximal signal without a problem if I'm recovering from an injury and the more mature the injury the more problematic it is now the system that shielded the injury is much better at shielding so now I need longer for that to relax so what it's a kin to The Rock has done a little bit of aerobic exercise now so he's going to hold on a little bit tighter for a little bit longer so I need to go for a longer period if I've been training my
• 25:30 - 26:00 big partner to do those longer duration things so if they have been having to Shield the injury for longer now it takes me a longer isometric to get to the point where I can get that load evenly across the tissue what would be the minimal effective duration for a longstanding injury let's just say tennis elbow What would a reasonable duration look like so the reason that
• 26:00 - 26:30 we've gone with 30 seconds is we can do this we can take out the tendons from animals we can pull them in our machine and we can watch the stress or the force that we need to hold it at that distance apart go down and it goes down exponentially and by about 30 seconds is about 85% of the way to the bottom and if you wait out to two minutes you only get about 15% more diminishing returns exactly at 10 seconds you're still coming down a fairly steep curve but you're getting some stress relax ation but by 30 seconds you've turned the
• 26:30 - 27:00 corner and you're basically getting diminishing returns from there and so that's why for the for the injured tendons we're going at that 30 second hole and then when you've got somebody like ail who's who's doing pretty well now we can go with a shorter hole the other thing when we're talking about the climbers is the tendons aren't as big so I don't need as long on my flexor tendon and my finger as I do on my patella tendon or my achilles Tenon right ailles is my biggest tenant in my body it's
• 27:00 - 27:30 going to take longer for the strong parts to relax than if I am looking at my flexor tenants so let me tell you what I'm doing and then I want you to critique it if that's okay absolutely this whole conversation is a pretext for me fixing my elbow so let me tell you what's going on totally good that's only half set in justest many many many years ago this is like 20 plus years ago did a lot of Jiu-Jitsu and had my arm hyperextended a number of times yep and like many men younger vintages felt
• 27:30 - 28:00 I was invincible so I would ice it wrap it and just go straight back to the gym like an idiot now that has come back to haunt me and I love climbing I'm not particularly great at it but what happens is I take a long break usually a few years then I come back I start climbing everything is great until I get to about 511a where I start having these harder for me crimps right and at that point my elbow goes absolutely berserk
• 28:00 - 28:30 in that lateral epicondyle itself but let let's put that aside for now I also have quite a bit of pain kind of lower tricep near the elbow but then I take a long break I go back and the process repeats itself yeah then I got very excited about fixing this with isometrics and I thought to myself okay and we may not have time to dig into this but I do have questions about collagen and vitamin C so I've been
• 28:30 - 29:00 taking hydrolized collagen peptide powder we can talk about whether that checks the box or not with vitamin C about an hour prior to doing isometrics and then I've been varying because the internet has different things to credit you with and I don't know which are correct one is I I don't have proper tools here but I'm using a basically a cast iron pan and you can for people listening you can imagine I'm holding this in my right hand the pan is
• 29:00 - 29:30 pointing straight up my elbow is by my side and then I'm rotating so that the top of my hand is up and holding it in that there's probably a better technical term but kind of internally rotated position holding that for 30 seconds and then taking two minute rest another 30 seconds and doing four total rounds of that I've done that I've also experimented with having my arm flat on a table and then pushing down on the top
• 29:30 - 30:00 of the hand so it's effectively like holding a reverse curl you might think of and have played around with that what should I do to fine-tune that what are your thoughts so this is one of the reasons that one of my post and I are actually starting a small company we just spun out a company because yeah look at that what we always doing is we're trying to figure out how can I do this with a bunch of stuff that's not well suited for it and so what we're doing is we're designing devices and then we're instrumenting them so that
• 30:00 - 30:30 you can see how much load you're putting through it and you can then understand like okay I'm going to do this repetition here's my strength curve okay there's my 30 seconds okay until those things are out basically what we would say is you're trying to do exactly what you're saying there first of all when you have injury what we're trying to do is we're trying to keep the kind of the pain on the scale of 1 to 10 we're going to try and keep it at two or below MH because what we want to get is we want to get load through there without
• 30:30 - 31:00 getting too much load we don't need a ton of load remember so that's what the Abrahams are good with and there you can start even with 40% of body weigh M and it's independent of the load and so as long as you can get load through the through the tissue that's fine so if you have a really big damaged thing basically your cast iron pan might be a little too much and so you might be overdoing it a bit and getting a little bit more of the signal to the wear which is what we're looking at so what's your ratio of signal to wear and we're trying
• 31:00 - 31:30 to maximize the signal with minimizing the wear and tear yep and so what we would do is the other way to do it is to just take a a tennis racket and find like a like a door jam or something and just put it underneath and just do the opposite I see right and then you can do that in both directions or a golf club I've seen demos with that as well exactly or under a kitchen island like I have in front of me here yeah I got it so so you'd basically be pushing against it as an isometric yeah and so that's
• 31:30 - 32:00 called an overcoming isometric because you're starting to you're trying to overcome something and the important thing there and the reason that I like what's called an overcoming think of it like a leg extension when you're starting with your knees both bent you haven't touched the little pad down there to start extending your legs now I put my my feet against the pad and I'm going to extend out I have to try and over overcome the weight if I put the whole stack of weight down there it's an
• 32:00 - 32:30 overcoming isometri the reason that we like these overcoming isometrics versus what you're doing a little bit with the pan lowering the pan which is called a yielding isometric yielding isometric okay a yielding isometric is you basically the way of thinking of it is going back to the leg extension I'm kicking out with two legs and then I'm taking the weight onto one leg okay Y and I'm holding it with the one leg so those yielding isometrics we're going to get a lot more load but again that's not
• 32:30 - 33:00 necessarily the key component that where we want to start with we want to build to that but at the beginning we need to make sure that we're controlling the load what I like about the overcoming isometrics is I can have you now instead of going like hold the pan and you have to immediately hold it and you get jerk yeah totally at that immediate part now what I can do is I can minimize jerk and so what I'm going to do with the overcoming isometric is I'm going to say I want you to develop force over over 3 seconds so I want you to start nice and
• 33:00 - 33:30 light just feel the feel the pad on that leg extension and I want you to slowly try and extend your leg until you get to your maximum force and then I want you to hold it there for 30 seconds and then I want you to slowly let it off and now what I've done is I've decreased that wear and tear component as low as I can and I've maximizing my signal component because I'm going to do that 30 seconds I'm going to do a two-minute rest and I'm going to do four of those and now that's going to give me 8 minutes so 10
• 33:30 - 34:00 minutes of work 10 minutes of activity on that one tendon I'm looking for and that's going to give me all of my signal and a very very small amount of wear and tear because I've minimized jerk I've gotten the signal into the cells and basically that signal is just like oh look there's load and the load's coming from that direction because the reason you get a scar is it doesn't feel the load it doesn't know where the load is so puts collagen all in all kinds of different directions when the load comes
• 34:00 - 34:30 through now it goes oh we just have to make it this way and it makes all the collagen in One Direction now you can fill in your scar because now you can synthesize collagen in a directionally way that's going to meld up with the the whole tissue from the beginning and now we can regenerate that tissue pry complete got it okay so bunch of follow-ups so it sounds like if you had a clinic and you're just Private Practice meeting people giving them prescriptions that you would probably bias with people who have chronic
• 34:30 - 35:00 injuries at least overcoming isometrics versus yielding isometrics is that a fear statement I would okay now the yielding what I've actually done now that I'm looking at the pan it is not cast iron it's a lighter stainless steel but I've been part of what I like about the yielding is I've been adding at first I added a bowl to it to add some resistance and then I added a cup inside the bowl it's not the most elegant solution but but it's been working in the sense that I can add progressive resistance I may be overthinking this on
• 35:00 - 35:30 the overcoming isometric let's say I have a tennis racket my sort of elbows by my side tennis racket facing up I turn my palm down stick it under and we'll hopefully add some videos for this so people can see what we're talking about and then I start kind of uh rotating up externally rotating externally rotating but it's not moving so it's under the the kitchen ledge how do I think about the sort of rate of perceived exertion should be like a two out of 10 three out of 10 effort if I
• 35:30 - 36:00 don't have pain so I don't have a lot of pain when I'm performing these exercises should it be eight out of 10 and by 30 seconds I'm like wow this would be getting close to like my thinking around concentric failure how would you think about answering that when it comes to the overcoming isometric so first of all this is again one of the reasons why we're developing the company is is so that when you're doing an overcoming isometric you need to have something that tells you what's the load you've
• 36:00 - 36:30 got right and what's the load today versus tomorrow so if I'm trying to do one of these moves or if I'm trying to go against a resistance so if you have a rotator cuff and I have I have a cord or a belt there and I'm G to pull I have no way of knowing what kind of load I'm putting through unless it's instrumented yep that's where we're adding instrumentation so that I can go into a physical therapist instead of giving me a little cord where I go back and forth back and forth back and forth and it does absolutely nothing because it's a small Dynamic move it mobilizes it warms
• 36:30 - 37:00 up that little area but it doesn't actually fix the tendon but now if I go and I do the isometric if I'm instrumented I can tell you what you did yesterday what you did today so I can get that Progressive so so that's great because we do want to progress but for those people who will not have access to those things in the meantime absolutely yeah so what we cue on when we're doing the the ABR hangs for example M we say I want you to feel tension through that tendon system I want you to feel tension
• 37:00 - 37:30 in the forearm and that's enough I don't have to feel like oh it's like you know 80% at Max if I'm relatively healthy tension through there is going to be enough for me to get it if I need to get a little bit more stimulus through there because I've got a longer term injury yeah that's me or I've got a stronger injury so now what I'm going to do is either I'm going to go for longer or I'm going to go at a heavier load or I'm going to push harder on my asymmetric I don't have to go to 80 90% for that I
• 37:30 - 38:00 can do it at say 50% so that my leg isn't shaking if I'm doing a leg based one or my elbow I don't feel like I'm shaking to hold it in that position it's just that it's at the end of it it's a challenge and it's not necessarily that I'm crushing myself we get into this whole thing this is like this Macho business with lifting weights is oh no pain no gain there's no reality to that okay so I took a photograph of this card
• 38:00 - 38:30 at a coffee shop that I put up recently which was it said work medium play medium we're not as young as we used to be which I thought was perfect for my my new mosop Randi around my training yeah but you can still train at high loads you can still train at high forces if that's something that you really enjoy yeah like when I get on the machines back there I'm lifting a lot of weight again I'll use a machine because it's got two things that I really like one is that I don't have to worry about the
• 38:30 - 39:00 small muscles because we always injure the small muscles y because I'm trying to do a movement I'm trying to get big muscles but if I'm doing something that requires the small muscles to stabilize if those are underdeveloped I'll never be able to get my big muscles and I'll get a small stimulus on my small muscles it's not ideal and the other thing that's really good about having a machine if the machine is welld designed it has a strength curve so free weight doesn't have a strength curve so if I'm doing a squat with a free weight at the bottom where I'm my weakest because my
• 39:00 - 39:30 muscle is the longest and the length tension curve tells me I'm weaker in this position the weight is exactly the same as when I'm in my strongest yeah so what the machines that are really good are going to do is when I'm strongest it's going to be heavier when I'm weaker it's going to be lighter and so those two things allow me to work really really well to load the muscle in a very safe way and I've done lots of NFL Consulting and I always go into the room and I always see the rookies and the first second year players are over in
• 39:30 - 40:00 the squat racks doing all kinds of dynamic movements all those All Pro veterans they're all over in the machines because they know that those machines are going to keep them healthy those machines are going to get them that $30 million contract yeah you might get a half a step Faster by being over there but for the veteran they know that if they're available for 16 games of the year they're going to get their next contract because they're going to perform at a high level for sure so so that's just kind of as we go through the
• 40:00 - 40:30 strength component the big difference for me when I'm looking at the muscular scale system as a whole is when I've got somebody into control I can now regulate the jerk better and so I can regulate that in such a way is that I am not going to get as many injuries in a weight room when I'm trying to improve myself or when I'm trying to get stronger and I'm going to be a stronger athlete when I go out and do my activities daily living whether that's that I'm going to go compete play you know play Inner murals or or go out and
• 40:30 - 41:00 play you know over 40 soccer whatever it is that I want to do now I'm going to be stronger when I'm doing that I'm G to have better balance I'm going to have all of those better things that are going to allow me to perform at a higher level I'm going to give people just a couple of teasers you have an incredible breadth of variety in your research it's it's kind of mindboggling to me I'm just going to give people a teaser we don't have to dive into it right now you can't believe everything you read on the internet but I believe you were involved in some research on ketogenic diets
• 41:00 - 41:30 found that I think it was a one-month ketogenic diet in middle-aged mice I feel like a middle-aged Mouse sometimes increased muscle mitochondrial content significantly though not in the brain or liver so we could talk a lot about keto yeah I am going to stick with the isometrics though for a second here I have just a few two on exercise examples right so we talked about the tennis elbow a little bit and the overcoming isometric would say a tennis racket
• 41:30 - 42:00 under the kitchen counter is that the only movement that you would prescribe to someone like me for tennis elbow or are there other varieties of movements isometrics that you would throw into the mix that's question number one so the thing for your extensors so the extensors of the of the forearm they're going to be rotational and they're going to be extensors so you have to do both so you want to do one that's it's an extensor you can do an isometric and again you can do it at any point along the chain so if the muscle is in a Long
• 42:00 - 42:30 position that helps a little bit got it again thinking it as an overcoming isometric the muscle and the tendon are longer so I can get a little bit more relaxation there so let me describe the visual for folks so the extensors are on the top of the forearm think about doing like reverse wrist curls and you just had the wrist cocked down yep so it's at the bottom of the wrist curl where I'm about to start doing my reverse wrist curl now I just pull it up a little bit with a weight that I couldn't really lift the hway but now I can do that and I can hold it in that fist below my
• 42:30 - 43:00 forearm position and I can try and extend my my fist up and that's going to get me that extension component and then I'm going to need that rotational component which we talked about with the tennis rack got it the biggest one for most people and the thing that drives my students crazy now is that every class almost every class I have them doing isometric lunges or isometric squats and isometric lunge
• 43:00 - 43:30 I'll have them go down hover the knee above you know and I do it for okay whoever beats me gets an extra point an extra credit point and we sit there and and it's like a you two-minute thing but by the end of two minutes there's maybe one or two of us left and they okay that's enough times but the reason I'm doing it is because now I get my quad tendon and my Patell tendon and if I move forward and I shift forward and my knee is over my toe I'm getting a good stretch on my achilles tenant or I'm getting good load through my achilles tenant and I've also got it on my
• 43:30 - 44:00 backside so that the knee that's in the low position now I've got quad Tenon and Bellar Tenon there and I've got a little bit on the planter fascia on that foot so now in that one move I'm getting pretty much all the tendons in my lower leg I'll switch and do the other leg and then I'll do like a a side lunge those types of things for most of us who are getting older like to run wor we're sitting there and we've got so now what I want to get is I need to get my KN and
• 44:00 - 44:30 my achilles those are the two things that are the primary thing for most people those isometric squats are amazing for it and that's the split squat yeah so it's like a Bulgarian split squat so one foot in front of the other just a long stride go down 30 seconds would be the minimum effective dose you can build up to that so you start with 10 or whatever you can do and then you build up and you get into that 10 to 30 seconds if you've got existing injuries we're going to go more like 30 30 seconds if you don't have any existing injuries then you can go for 10
• 44:30 - 45:00 seconds MH and what you're going to find when you're doing these isometrics is your range of motion is actually going to improve much better than if we were to do a static stretch because if when we're doing a static stretch the muscle and the tendon aren't adapting in the same way as when we're doing an isometric hole and that's really important because my gym here the next gym over is the gymnastics gym here at UC Davis and I always remind people that if if passive flexibility was really important for decreasing tendon injury
• 45:00 - 45:30 then the women's gymnasts who have the most passive flexibility wouldn't be the NCAA sport with the highest rate of Achilles tendon rupture that's telling us something about that passive movement where we can do things and make us hyper flexible so injury related to flexibility is a U-shaped curve so our injuries are really high when we're very inflexible when we get into that sweet spot where we have good Mobility we can
• 45:30 - 46:00 do the full range of motion actually the injury rate is very low if we become hypermobile we actually have that injury rate go up as well and so that's really important because as you said jitsu martial arts you're doing a lot of things in a very long range emotion you have a lot of in some cases hypermobility and that puts those tendons and ligaments at a little bit more of a likelihood to get injured let me shift to just the timing question and the timing specifically makes me think back to Professor Hayashi and his his
• 46:00 - 46:30 poor little rabbits where he attached I guess I'm trying to recall this here but basically some type of metal filament or wire applied tension was this on the knee this was on the knee yep tell it to the tiia right and then lo and behold the adjacent natural tissue suddenly has all the indications of scarring and weakness and so on how soon after surgery and you can choose your surgery ACL take your pick dealer's choice would you start
• 46:30 - 47:00 loading the site of injury slrep so we do it the next day yeah we've had to have success in order for us to get there yeah because the first time we we did this with like a rugby player the the surgeon was like six weeks without loading and we were like let's load tomorrow and so we agreed that we would do it at like seven to nine days and that player got back fully a month fast than that surgeon had ever seen a player get back from that injury and so that surgeon is now much
• 47:00 - 47:30 more willing to do it at two days after injury because of that if you look at General populations Michael care who I think is the world's best sports medicine doctor for muscular skeletal injuries how do you spell that last name it's KJ a r he's in Copenhagen so he's he's Stanish sorry didn't realize that was going to be that hard sheer it's sheer but he allows the those of us who are are language deficient to call him care got it but he did a beautiful study
• 47:30 - 48:00 with one of his trainees Monica and what she did is she took a bunch of his patients that had injuries and she either had them load two days after injury or nine days after injury and then she followed them for when they got back to Sport and what she found is the ones that they loaded at day two after the injury they got back 25% faster than the ones that they loaded at N9 days that's incredible that's typical so as you said before what is our standard of care our standard of care is rice okay and so I'm going to go a step
• 48:00 - 48:30 further if you go and use spray your ankle and you go to the doctor very good doctor very well-meaning they're going to give you a boot and what is a boot so I told you that a scar forms when we get stress shielding what a boot is it is a mechanical stress shielder what it's designed to do is to take the stress off the tissue you've injured if I've told you that the thing that's going to cause that tissue to get a scar is that you take off the tension what I've just done
• 48:30 - 49:00 is I've made the problem worse yeah I always tell people that the first recorded immobilizer for an ankle or a leg is from Egyptian hieroglyphs where they showed pictures 4,500 years ago if I took you and you said you had cancer you would not want to treatment that was developed 4,500 years ago you would hope that something new has been deved veled in the last 4500 years that
• 49:00 - 49:30 is where we are for our Orthopedic situations I understand that you cannot put full load on a surgical repair immediately but what you can do is you can take it out at the beginning of the day you can remove it from the boot and I can do some isometric loads with low jerk so I'm going to develop Force slowly I am going to make sure that there's zero pain and I am going to hold that and then I'm going to let that off slowly and I'm going to do that four times times 30 seconds now I've given load and then I can put it back into
• 49:30 - 50:00 that boot stress Shield it I'm going to take the boot off at night I'm going to do it again just doing that I'm getting those two loads in this case the Achilles tendon that we've ruptured now what I've done is I've accelerated my return to activity massive again the key is we're not trying to be I'm the strongest in the world we're trying to say I'm putting a little bit of load through that okay yeah that is the is that you don't get all caught up in the machismo of it and you just say I just
• 50:00 - 50:30 want to feel tension across the area what we say is if you can feel an ice pick that means there's a very specific spot that hurts stop if I feel like a warm burning area like I'm muscle soreness after exercising that's totally okay that kind of kind of soreness not Point specific pain that's okay what we're doing add the load slowly hold hold it take the load off slowly now what we can do is we can get those
• 50:30 - 51:00 individuals back much much much faster so just a question for a friend because a friend of mine literally just sent me photos of his Achilles tendon surgery he former super high Lev volleyball player has not played volleyball in a long time but is still very physically or I should say muscularly strong went back for an alumni volleyball game and you guessed it pow snap and into the o r that's very recent last few days what type of
• 51:00 - 51:30 isometric would you advise for that particular Achilles rehab this becomes one of the issues that we have and orthopedic surgeons they hate me okay and the reason they hate me is because the thing that they want to do is they want it to be really strong when you leave the operating room so what they do for that is they use all of these reinforced sutures that are going to stay in that tissue for a long
• 51:30 - 52:00 time okay so now I've got a really strong suture going through my my tendon so if you load that where do you think the load is going to go it's going to go to the sutures it's going to go through the sutures so what happens is we don't actually load the native tissue but the way that the surgeon does it is they don't do it so that you can't load the tissue at all because if they did that you'd never be able to bring your toe up never be able to bend your ankle so what they do is they have it so that the sutures will take all the load when you
• 52:00 - 52:30 start to bend the ankle or you start to what we call dorsiflex the ankle and the tendon becomes longer so what that means is we have to work in the shortened position so we have to be in the planter flexed or our toe is pointing away from us so what you do is you do that so he can take his boot off and this is again this is from the science I don't have the medical components I always work with medical professionals who do this who actually put the program in the Place yeah but what the people that I work with do is they say okay we're
• 52:30 - 53:00 going to have you go in a relaxed position you're going to take the boot off I'm going to just have you be there and now all I want you to do is against you can slide yourself against the wall so that where your relaxed position is you're just going to lightly put tension on that you're just going to apply a little tension on the bottom like the ball of the foot something on the toes to the ball of the foot yeah and so all I'm going to do is push against that little wall and all I'm going to do is make it so that I feel a little little bit of tension through the area not so that I feel it pulling not so that I
• 53:00 - 53:30 just want to feel tension and all I'm getting is I'm getting a stimulus to whatever little bits are around of the Native tissue have been brought together and what that's going to allow me to do is that's going to allow me to get that tissue to keep active because what can happen if you have these really reinforced sutures and you're loading in a kind of traditional loading program where you're doing kind of faster movements or doing maybe Ecentric or whatever it is but you're not getting
• 53:30 - 54:00 load through the native tissue is that the native tissue becomes smaller and smaller over time it's like Hayashi it did that's exactly what Hayashi did and so what ends up happening is the native tissue doesn't become strong and then eventually we're putting so much load through the suture that the suture will eventually wear and tear and will break down and when that happens if we're not ready for it we'll rerupture the tissue if there are which I'm sure there are some Curious open-minded orthopedic surgeons out there who are asking
• 54:00 - 54:30 themselves well Keith I'm open-minded what would you recommend we do instead of suturing the way that we've been taught to suture what would you say so you can do the same procedural suture so you can go up and through the muscle you can do all the reinforcement but all we do is we say use a resorbable suture you said reabsorbable is that right yeah it gets resorbed into the body resorbed it's the ones that you can see all of my scar those are the ones that I got that were inside the skin so that they didn't have
• 54:30 - 55:00 to open up the skin and go get them again they become lactate basically because a lot of times it's a poly lactate that they use to make them anyway so I have a PhD student the same one who's my rock climber who's worked with AAL we've got a paper that she that she's the first author on basically showing that the abrah hang's increased strength as much as Max HS in a population about 500 climbers but she's an incredible surgeon so what did is she went into rats and she did she cut the
• 55:00 - 55:30 Achilles T and re and sewed it back with either a resorbable or a non-resorbable suture and then she at four weeks she cut him out and just saw is there a difference in the strength and there wasn't any difference in the strength the surgeons are really worried about two things with an Achilles ton rupture one is that we're going to lengthen the Achilles tendon because it's not going to be strong enough to the suture if you used a resorbable suture it wouldn't hold on long enough for it to prevent the lengthening of the
• 55:30 - 56:00 Achilles and what she showed is that even though we let the The Rats start walking right away there was no difference in the length of the Achilles based on whether she used a resorbable or a non-resorbable we saw that the resorbable actually had better like collagen synthesis markers than the non-resorbable just kind of like what we would anticipate so you can do the same repair just understand that if you use a suture that's going to resorb that's
• 56:00 - 56:30 going to allow you to then get the native tissue back if you are working with a team who is really good at then providing the load so the best tendon insurgents in the world tend to be in Finland for some I don't know why but never what have guessed there's a history of studying tendon in Finland for some reason and so a lot of the finnished surgeons use resorbable sutures and they do early loading they do that because they know that what they're trying to do is all they're
• 56:30 - 57:00 trying to do is attach the two ends so that the native tissue can can become functional so that's really what we would tell your friend is start in two positions you have to do it in two positions now because remember the Solus and the gastro both come into the Achilles the Solus muscle we use when we Bend our knee and we push down with our toe like a seated calfas something like that like a seated calf raise is for the Solus a straight leg calf raise is for the
• 57:00 - 57:30 gastro we need both of those for properly loading the Achilles ton so what you would do is you take off the boot or if you were worried about it you could do it in the boot and just push down on your the ball of your foot in the boot and you should feel tension across the back of the leg and that should be enough to give you a stimulus hold it for 30 seconds develop the tension over 3 to 5 Seconds hold it for 30 seconds let it off 3 to 5 Seconds MH so again you can begin to do it even in
• 57:30 - 58:00 the boot you can do it with a straight leg in the boot as well and then you're not doing anything that your doctor didn't tell you to do you're still keeping it immobilized if you want but we're actually loading that tendon so quick question on the tennis elbow because you mentioned the Solus and the gastr and I was watching a video actually surprise surprise if you look for One tennis elbow video on YouTube You're Going to get 7 million of them served to you but I did watch one from
• 58:00 - 58:30 Venus Williams and she mentioned something that I had been playing around with intuitively when I was doing some of these exercises which was let's just say with the external rotation like the tennis racket I've been doing yielding and not overcoming but I'll I'll switch that I'd been experimenting with having my elbow bent at 90° doing it with my arm completely straight doing it somewhere in the middle is that advisable inad advisable absolutely yeah so one of the things some of the baseball teams that we work
• 58:30 - 59:00 with they're like oh yeah we were doing some stuff for the rotator cuff using your isometrics and we were loading the rotator cuff and everybody's vul collateral ligament was feeling better when you're loading one thing you're going to get one response when you're isolating that muscle and that tendon that muscle tendon unit when I change which joints I'm moving now I'm getting a slightly different combination of muscles and tendons and both both of them are probably contributing to the pain that you're feeling so if you're
• 59:00 - 59:30 going to use that position so yeah a lot of people do the bent arm because that's what we're doing when we're doing a backhand but you also have to think that if I do that with a straight arm it's also going to have different contributions of the upper arm musculature which then feed in and load the tendon differently and in my case it's arm extended typically for the rock climbing hopefully my legs and pivoting more than pulling but eventually it's
• 59:30 - 60:00 this and that's where I start to feel it really get grumpy just to get really in the weeds here for a second so would you do one position per workout or let's just say it's four sets of 30 seconds would you do a different position for each of those sets what would you advise I would rotate through so I would do a 30 seconds on the external rotation when my my elbow is bent at 90° one when it's straight and then I could come back I could do one with my arm up over my head
• 60:00 - 60:30 it sounds like you've got a lot of a lot of tricep involvement so what I would do is actually do something where I'm extending the tricep so have a belt that goes down to the floor and I'm trying to push up like do a like do almost like a head Crusher but now it's over my head as an isometric yeah so I'm going to do it from here and I'm going to push it up so it's on like a door knob behind me i' put my belt around the door knob and now I'm going to push up on that so what I'm getting is I'm getting the forearms but
• 60:30 - 61:00 I'm also getting the tricep because that's also inserting on that joint yeah it sounds like for you you've got contributions on both sides it's a party so what we're going to do is I'm going to have maybe a a little 30 second rotation where each one goes 30 seconds by the time I get back now I'm ready to do the first one again because I've done the three other ones yeah and so that's perfect for the rotator cuff because I need to do elbow abducted internal rotation external rotation that's two and then I need to do elbow abducted
• 61:00 - 61:30 internal rotation external rotation that's another two so I can go through those 30 second isos and then rotate back through that and I get the whole system in 10 minutes yeah that's amazing let's talk about collagen synthesis because you had mentioned that I brought it up as well at least in one 2017 study athletes who took correct me if I'm getting this wrong roughly 15 grams of gelatin Plus somewhere around 200 to 250 milligrams of Vitamin C 1 hour before doing brief exercise we can talk about
• 61:30 - 62:00 what that brief exercise is but had double the markers of new collagen formation in their blood compared to control now I've heard you talk about elsewhere some of the nuances and complexities of these markers and how you might find that one goes up and one goes down from the intervention so how do you evaluate that but based on everything you have learned researched experimented with reviewed
• 62:00 - 62:30 what would your current recommendations be if any for collagen gelatin consumption and not all products are created equal there's a lot of garbage out there but what might the parameters or criteria be so the first thing is to address the last issue because what you're looking for in any collagen supplementation is that the source of the collagen is from a skin Source from pelts of the animal so fish skin B Vine
• 62:30 - 63:00 skin the reason that we say a skin Source because a lot of people use bone broth and bone broth is a great source of collagen the problem is that most mammals we store our heavy metals we sequester the heavy metals in our bones so when you do bone broth you're also getting some heavy metal so you just keep that as a background thing so that if you get it from the skin there's not going to be any of the heavy metal so that's the only thing that we would say about a collagen supplement okay you know I accidentally got the right thing
• 63:00 - 63:30 I was like I was looking at the back of this I'm not going to give them a free product placement because I don't actually know what the quality is here but this is a hydrolized grass-fed type 1 and three collagen peptide powder but on the back I was like Wow will it even indicate and it does say ingredient bovine HDE collagen peptide hydrolysate yeah if I'm saying that correctly you're saying it perfectly and so that's the only thing that we really are concerned with because you can say oh this is a type one type three doesn't really matter because we're not absorbing the
• 63:30 - 64:00 collagen as a whole molecule and just sticking it into our tendon we're breaking it down to its building blocks we're breaking it down to the amino acids and the thing about collagen is it has tons of glycine in it and lots of Proline and so when we take just milk protein like whey protein if we take that after a heavy lift our glycine levels actually dip in the period after after eating it and so that's work that Luke Van Lon has done where he shows that there's a drop in glycine probably
• 64:00 - 64:30 because we're synthesizing more connective tissue protein then we have glycine so all we're trying to do with the hydrolyzed collagen is we're trying to go in and we're trying to give building blocks so it doesn't matter if it started from type one type three you want it from the skin and that's going to be mostly type one and type three but that doesn't matter it doesn't matter if they've done a super High secret peptide isolation because the peptides don't seem to to play a big role because we've had some companies come to us and say oh well you're going
• 64:30 - 65:00 to have to use a lower dose of ours because we have the special peptide and it never works and we always go back to the other dose what dosing and timing do you recommend both for the collagen and for the vitamin C we recommend taking those things together just because the vitamin C is absolutely essential for your body's ability to synthesize collagen most of us have a perfectly normal level of vitamin C we're not going to get scurvy we're not
• 65:00 - 65:30 going to get any of these things but what we want to do is if we're going to increase collagen synthesis we want to also make sure that the co-actor for the enzyme that's going to allow us to make and Export that collagen is also present at a high enough amount so we take them together so we know for sure from studies that I was involved in when I was on sabatical with Luke vanloon in the Netherlands that if you give a blend of whey protein with 5 grams of hydroly collagen you're going to increase muscle
• 65:30 - 66:00 connective tissue protein synthesis and that's the first measure that's shown that oh connective tissue protein synthesis is sensitive to the diet when is that being consumed that one was consumed afterwards but that was because it was a study on muscle right the reason that the timing might matter is if I'm trying to Target it to a tendon the tendon doesn't have good blood supply if I'm trying to Target it to card or ligament it doesn't have good blood supply and the way that those tissues get their nutrients is by
• 66:00 - 66:30 getting either compressed or stretched and the The Matrix gets squeezed of the liquid and then as it relaxes it's going to bring liquid in from the environment if the environmental liquid has more of the amino acids and the vitamin C that we need to build more collagen having the collagen based before you do your exercise that's the ideal situation now it's not always possible it's still still okay to take it afterwards but if you're really trying to Target it to one
• 66:30 - 67:00 specific spot take it before about 30 minutes to an hour before and then those amino acids are going to Peak right when you're loading say your rotator cuff and now more of what you have eaten is going to be delivered to your rotator cuff I've heard you describe some of these injectable peptides bpc 157 I could I could name others as magic Elixir and I'd love for you just to describe briefly putting placebo effect aside I mean we could spend hours talking about
• 67:00 - 67:30 placebo effect but putting that aside why people might see benefits but not for the reasons they think they're seeing benefits yeah and then I'd love to ask you about some other orthobiologic stuff free of time for BP 156 we know that at least for the Tenon and ligament cells themselves it doesn't do anything and we know that because we've engineered our little engineered ligaments they're engineered human ligaments from human ACL cells we then have treated them with VPC 156 or 157
• 67:30 - 68:00 and basically there's no effect it doesn't change it doesn't improve doesn't doesn't impair so if somebody wants to spend their money on that I'd prefer that they just spend it send it to me I can send out a a little link to to the gift for my lab and you can send it to the lab and we'll do research with that money instead and that'll be much better for your tenants so the reason it might have a positive effect is one of the one of the treatments for tentis and tenin opathy has always been pithing okay pithing is
• 68:00 - 68:30 where you take something or debridment these are these really cool medical terms debridment means I take a scalpel and I go like this and I make little lines in your tendon I cut up your tendon and I make it weaker pithing means I stick your tendon with a needle a bunch of times all we're doing is remember we're getting a scar because of stress shielding if I start injecting a bunch of times into to the strong part of that tendon what I've done is put a whole bunch of holes in the strong part of the tendon now I can't stress Shield
• 68:30 - 69:00 the weak part and that's actually potentially beneficial it's actually the reason we think that there's any benefit at all to immobilization because if by immobilizing I have made whatever strong Parts weaker now when I start to load properly afterwards maybe it's going to be beneficial like we've done experiments in the in animals where we where we've got these 3D printed cast that we can stick onto a mouse and it just looks like the boot the doctor gives you 3
• 69:00 - 69:30 days later if we take out the tendon we've lost 15% of the collagen 15 to 20% of the collagen in that tendon it's mechanically about 30% weaker that's three days the muscle mass decrease is actually smaller than the decrease in collagen within the tendon what we're doing when we do some of these things like we're jabbing it with a needle or somebody's going to scrape you with a spoon and it's going to push there what we're trying to do is we're actually trying to they say they're
• 69:30 - 70:00 trying to break up Scar Tissue what we're actually doing is we're actually damaging the healthy tissue and the reason that that could potentially be beneficial is if I damag it just enough now I can't stress shield now maybe I'll get a little bit of load through the weaker part of the tissue now let me stand in for some folks who are super fans of BBC 157 okay just for a second if I go on let's just say Pub Med and do a little a little bit of a dig around there are a few studies now this is not
• 70:00 - 70:30 Ultra recent but 2014 this is molecules November 2014 pentadecapeptide bpc 157 enhances the growth hormone receptor expression and tendon fibr blasts now people might cite this or something like it but what you're saying is in practice you just have not seen it to make a difference that's a really fun paper because basically growth hormone doesn't have a direct effect on the tissue at all anyways growth hormone works on the tissue okay let's hear more about this
• 70:30 - 71:00 this is interesting it works on the tissue because what it does is it increases the local expression of igf-1 so whether your tendon cells have lots of receptors for growth hormone or not doesn't really help you what helps you with growth hormone is that either your liver is going to make igf-1 in response to it or the fat cells or other things that are in the joints are going to make igf-1 locally around that tended the igf-1 has a positive effect if we take our engineered ligaments and we add
• 71:00 - 71:30 growth hormone doesn't change their mechanics doesn't change their collagen content but if we had igf-1 we get this beautiful dose response and so yeah the paper says you get more growth hormone receptors okay ultimately who cares ultimately who cares basically in that situation what you're finding is if it's that specific what it means is they were looking really hard to find something and they found one thing that made sense with the story we try and do things that are the
• 71:30 - 72:00 things that that tissue does so instead of just adding something and saying oh look I see more of this I'm G to take it and I'm going to put it into a material testing system and I'm going to tear it to shreds and I'm G to say how much load did I have to put through it to tear it and if that changes now you've got me and now I'll go and I'll try and figure out exactly what is going on because that's something that's really working bpc 157 doesn't change anything at least in the in the isolated ligaments doesn't
• 72:00 - 72:30 mean it's not going to change maybe decreases inflammation or does something else I don't deny that but it doesn't work directly on the tendon are there any other interventions that you think I guess thinking has nothing to do with it just believe based on the data your experience that could have some efficacy in terms of helping with connective tissue injuries so I'll throw out a couple prol therapy PRP Shockwave therapy I'm sure we could add dozens
• 72:30 - 73:00 more to the list but does anything pop out as plausibly credible or compelling to you not especially might depend on the injury none in the lower body the reason that I say that is that the lower body I'll go in get my shot and then I'll walk out and I'll walk home as soon as I took those first three or four steps out of the doctor's office whatever I inject into my tendon I've just squeezed it out and it's going to go everywhere within my body it's not going to stay there the
• 73:00 - 73:30 reason that the upper body can work is I can immobilize it oh I'm not going to load my ulner collateral ligament or some of my you know other tendons in my upper body my my rotator cuff so I can hold that still and not put load through it it has a chance to sit there so what you'd have to do for orthobiologics to work in the lower body is you have to immobilize now I've got the complication of if I immobilize for 3 days I've lost it yeah right so that's where we get into the no part of it the best physical
• 73:30 - 74:00 therapist in the world is this guy Rob Whitley he's out at aspetar in Qatar and he's wonderful because he's an Australian who has just got he's been there long enough that people he gets to do whatever he wants to do it's kind of like the grumpy old man thing he'll tell you exactly what's going on he went to this super high-end conference with all these orthopedic surgeons he stood up in there goes none of the crap that these guys are telling you about works because they're all telling you to inject this inject that the only thing that works is
• 74:00 - 74:30 getting loaded through the tissue and he goes through the science of every single thing this is PRP this is stem cells this is proleter and he goes through and he just explains the data that when there's been a randomized controlled trial there's no benefit so patellar tentis there's been a there's been a randomized controlled trial where they don't know whether they're getting PRP or they're getting sailing there's no difference there's no worsening but there's also no improvement in your patellar tendon this was lower body yeah
• 74:30 - 75:00 lower body that was patellar tendon yeah so lower body the one place where they've seen it I think is in the rotator cuff where there's a small positive effect again we talk about collagen protein or whey protein whey protein will add about 5% maybe a little bit less than that to your strength gains or to your muscle mass gains collagen's probably about that 2 to 3% if I give you the best muscle building supplement in the world and you take it and you just sit on your butt all the time you are not going to get bigger muscles right 95 plus percent of why we
• 75:00 - 75:30 get bigger muscles stronger tendons all of these things is due to the Loading there's going to be maybe two maybe 5% that's going to be down to the collagen or to the Whey Protein but because it's a lot easier to eat something or drink something people are going to focus on that oh all I have to do is eat collagen I'm good you have to apply the stressor exactly you have to have the stimulus exactly but now I'll just push back a little bit I totally agree that if you're just rolling around on a bed of PRP injections and then chilling with
• 75:30 - 76:00 Netflix probably not going to solve all your problems but I mean there's certainly things that I would imagine and based on least my interactions with some pretty high level athletes I would think can accelerate certain adaptations right I mean if you put somebody on androne and a little bit of caml and human growth forone six days a week I would imagine that might accelerate certain adaptations I'm not recommending anybody do that but we were talking about I guess the orthobiologics like
• 76:00 - 76:30 the PRP and the Prolotherapy but in addition to let's just say the collagen plus vitamin C assuming that you're timing it correctly and applying a stimulus are there any other adjuncts or supplements doesn't need to be inestable or injectable that can accelerate the adaptations that we're hoping to provoke so we've we've got data on an FDA approved drug that improves tendon function so basically what we did is we
• 76:30 - 77:00 looked at the tendons of rats as they were develop between 7 days and 28 days and during that time their Achilles tend to get three times longer goes from 3 millimeters to 9 mm and their patella tendon gets twice as big so it grows in cross-sectional area by twice the amount and we did genetic analysis so we did transcriptomics so we looked at all of the rnas in those things and in the patellar Tenon that was getting twice as big the major signal was inhibition of a protein called Jack or Stat so the Jack
• 77:00 - 77:30 stat pathway is actually a growth hormone activated pathway but what we found is that when you inhibited it was associated with growth and so there's a series of drugs if you ever watch TV you see all of these drug commercials and if you look up at any of your drug commercials end any of the drugs end in nib aasa nib or baras nib or any of those types of nib drugs those are your jack stat inhibitors they're used for rheumatoid arthritis and they're used for Patric conditions skin problems yeah
• 77:30 - 78:00 psoriasis Etc psoriasis two collagen based syndromes so what we found is that when we used those drugs the tendons that we engineer got bigger and stronger which of those drugs did you select and why we selected three different ones that targeted different Jacks to see which of the Jacks were important so we did a jack one inhibitor Jack one two and a jack 3 inhibitor and all of them were beneficial so we don't know exactly which one it is yet and that's something we're working on we just finished a study just a quick study on development
• 78:00 - 78:30 so what would happen if we gave these drugs to a developing organism and we all know that part of the reason we grow is because we have colen that works at our growth plates and pushes our bones apart so that we get taller and one of the first things that we found is that the animals were 40% smaller so what that means is that they were getting bigger they were differentiating the T but they weren't able to push the growth plates apart because the collagen was
• 78:30 - 79:00 actually acting as if all right we're long enough now we have to get bigger and so what we think we're doing in that situation is we are we're adapting so that the tendon is getting a stimulus where it can grow bigger and stronger but in growing it bigger and stronger it prevents it from growing longer and so that's the first drug that we know of that's been identified that affects tenant property we have other things that we're working on where I can give you a hormone that your body produces and you will have a stiffer tendon what
• 79:00 - 79:30 hormone it's such a cliffhanger yeah it's a cliffhanger because it's not published yet so so I can't really give you that I got it I got it if you had only say a thousand listeners I would I would be okay stand by for round two folks exactly and there's also the opposite which is drugs that people already know about that cause an increase in tendon ruptures CYO yeah cypro but cypro is actually only half as bad as some of the other drugs that we found what are some of the other ones so
• 79:30 - 80:00 there's a study out of again Finland and the first author is NYY is the last name of the first author I can't remember the rest of it all I have to ever search on my computer is NY y because there's nothing else with those letters together except for a Finnish name but what they did is they looked in the Finish registry all the people who ruptured their Achilles Tenon what were the medicines they were on mhm so you find the fluoroquinolone antibiotics yeah they're there but they increased rupture
• 80:00 - 80:30 rate about 3 and A2 full I see of which cpro flaxin would be one exactly and then they found another class of drugs which are at-1 receptor drugs so Angiotensin receptor drug Inhibitors ah they're taken by over 15 million Americans every day and they increase the rate of tendon rupture 7.6 full wow what would be an example what are some of the names of such a drug those are the certain drugs mhm so if you're taking the certain drugs again you want to be careful with your physical activity and this is not something
• 80:30 - 81:00 that's really known I went and did a like a a work in progress seminar at our Orthopedics group and the chairman of the Orthopedics Department puts up his hand and goes this could explain why I've ruptured this and this and he goes through a list of like six tendons in his body that he's ruptured or ligaments it's like oh yeah that's probably possibility because a lot of people who are taking them that's that's one of the most common things but it's not really reported and so again that becomes a bit problematic because they are used by 15
• 81:00 - 81:30 million Americans wow yes we're decreasing your blood pressure but please don't exercise while you're doing it one of the things we're working on is trying to see is there a way that I can take what I need which is the decrease in blood pressure and can I figure out a way to do that without putting all of our tenons and ligaments at risk because as much as yes blood pressure is going to cause cardiovascular disease if you rupture your ACL you are 50% more likely to have a heart attack than somebody who didn't rupture your ACL wait what is
• 81:30 - 82:00 that because of the decrease in activity that is because of the decrease in activity yeah wow and so because of that habitual decrease in activity we are much more likely to have diabetes and heart disease and all of these other things if we're not exercising the number one cost to the US medical system is actually muscular skeletals brains strains and tears the back and the neck as well as the rest of the body it's more than diabetes and heart disease combined so wild but if you talk to oh
• 82:00 - 82:30 who's a serious scientist I'm not a serious scientist because I work on this stretchy material that is oh yeah you're old you have a bum knee that's just normal but if I worked on the heart now oh yeah super everything's about okay I understand that but at some point you have to realize that yes what your heart is doing in order for it to work optimally I have to get rhythmic contraction of my muscles to pump blood back to it so so it gets a stimulus so it can work properly if I don't do that because my tendons and ligaments don't
• 82:30 - 83:00 work your heart's not going to work very well either and so we need to get into a much better kind of understanding of the whole system instead of just saying well you're at 135 over 90 I better put you onto a drug that's not really going to be that much of a stress to the heart but it could end up rupturing your Achilles or rupturing your ACL we need to balance that much better and that's that's really what we're trying to do a lot of work on right now all right I want to be respectful of your time I
• 83:00 - 83:30 know you got some appointments coming up but before before we start to land the plane and we'll figure out how much time we have but wanted to give give something to the ladies specifically who are listening could you speak to injury risk maybe it's ACL specific and estrogen and maybe programming differences for men and women absolutely this is absolutely essential component of what we do so in our little engineered ligament so I had a student
• 83:30 - 84:00 come to me and she's she was an undergraduate student I think she was 19 at the time and she goes I'm really interested in what you do because I've ruptured three acl's and I'm like you don't have three legs oh yeah you've done the same one twice okay so she's wanting to know why she's rupturing her ACL and you go to literature and sure enough women are four to eight times more likely to rupture their ACL they're 80% less likely to have a muscle pull okay so what that is telling us is we pull our muscles we get muscle pulls
• 84:00 - 84:30 when our tendon is stiffer than the muscle is strong we get ACL or other ligament ruptures when there's too much laxity both of those two things could be explained if if the tenant or ligament was less stiff and so all she did and all I had her do is to take estrogen and add it every single day that we were making the ligaments at the low level that you would have normally around menstruation and early into the cycle and then as you get to when the ludal phase would be so that's when estrogen Rises right before the woman's going to
• 84:30 - 85:00 ovulate that goes up almost 100 fold the estrogen levels during those three three-ish days there so all I had to do is add 100 fold more estrogen the exact levels that you would see in the in a woman's body and what we found is that the stiffness of the ligament went down and then we looked at the collagen content the collagen content was exactly the same maybe a little bit higher what we fascinated by was this could explain like if you did this repeatedly and we did this we inhibited a specific enzyme
• 85:00 - 85:30 like like what the estrogen was doing and then we took that away and let them grow again what happened was the stiffness differentials was maintained as they got stiffer again after that period so what this kind of suggests is that girls until they get into puberty they're developing exactly the same as boys the stiffness of the connective tissue now as they get into puberty estrogen starts to Cy cycle what we discovered is the estrogen actually inhibits a protein within the within the tenor ligament and it's a really
• 85:30 - 86:00 important protein because what it does is it crosslinks the collagen and what that does is it makes it stiffer and so without changing the amount of collagen if I Crosslink it the tendon gets stiffer so when estrogen is present we decrease the activity of that tendon and what happens is it becomes stretchier and so now as that 12 to 13y old girl starts puberty she's already stronger than the boys when she starts puberty now she goes through these periods of intermittent decreases in stiffness and
• 86:00 - 86:30 now she can't transmit Force as well the stiffness of her tissues is going down so her power goes down relative to the boys who are continuing to increase and the result is a lot of the performance differences between men and women can be explained by the estrogen if we look at testosterone again you had mentioned earlier that some of you know all all you got to do is take nandrolone or all these no I didn't say all you have to do I just like people who put together these cocktails do some pretty
• 86:30 - 87:00 incredible things absolutely and so a lot of statisticians can go back to Major League Baseball and they can say that person was taking steroids that one and that one because what would happen is their performance would go up and then it would drop off a cliff because what testosterone does is the opposite it actually activates Lysol oxidase and it decreases collagen so what you get is you get a stiff tendon that has has less collagen and that's a brittle tendon so that's why all of these guys juicing on testosterone related products were
• 87:00 - 87:30 getting stronger bigger muscles but then what they were getting is they were getting brittle tendons so they would rupture a tendon because this big muscle is pulling out a weak tendon and so now we've got this differential also that effect on Lysol oxidase which is the cross- linking enzyme of estrogen and testosterone that's one of the reasons why men have higher blood pressure than women because in until women go through menopause the estrogen that circulates monthly is actually decreasing the stiffness of the connective tissue in
• 87:30 - 88:00 the aorta and allows it to stretch easier so you have lower blood pressure so there's all kinds of these things that are related to this connective tissue that we know about that is related to estrogen or testosterone levels is that fluctuation in connective tissue stiffness in women an evolutionary adaptation for birthing absolutely if you know that at some point that if you have periodic
• 88:00 - 88:30 inhibition of stiffness there's also other hormones that will be produced late in pregnancy that will decrease Tenon and ligament stiffness that's relaxing is one of them but if you start from a lower stiffness at the beginning now as you go to relax to allow birth to happen you don't have to relax from as high a level of stiffness and so the job of the relaxing becomes easier so that the individual can give birth much more comfortably and have less trauma associated with the birth and so yeah evolutionarily it makes sense but it's
• 88:30 - 89:00 also one of the reasons why we see a lot of the performance differences that we do between men and women because power is about how quickly we can transmit Force if I'm pulling on a stiffer tendon I can transmit the force faster if I'm pulling on a stretchy tendon it takes me longer to develop Force so that's directly power a lot of the differences that we see that we see between men and women's Athletics and injury rate are down to this connective tissue component where we have increased or decreased
• 89:00 - 89:30 stiffness Keith we've covered a lot of ground I expected we would and we haven't talked about a number of other things I'm going to make this one up to you do you want to talk about depending on which you think will be more interesting for folks and maybe L leave interesting mitochondrial biogenesis and mitochondria in general or we could talk about protein intake and what what amounts of protein you would suggest in what intervals people consume
• 89:30 - 90:00 for different purposes as far as kind of the protein intake I think most people have got that pretty well dialed in okay what was the other one that you were suggesting oh I was just very curious about pgc1 Alpha okay yeah and mitochondrial biogenesis but also things that have come since then I think that that's probably a good one because then we can get into the k enic diet component as well great let's do it but we can address this at the same time as talking about the protein component as
• 90:00 - 90:30 well love this idea because these two things are going to be related a little bit because what we talk about is we talk about the sciences and Stu Phillips has been talking about this for a number of years and now he's realizing that a lot of that was a bit of a problem with how we were measuring things so what he was talking about is this intermittent up and down of synthesis and degradation that happens in muscle that's corresponds to feeding that's really really effective when we're looking at supplements like whey protein supplementation it goes in goes
• 90:30 - 91:00 out we synthesize new protein and muscle and it goes away but as people started doing one meal a day and people started doing other things where they're consuming a huge amount of protein in a small setting the question became is that going to really show a big difference if we look at this over time a lot of stews and to his credit he says that no that was just an artifact when we look at it over more time it doesn't really matter if you're taking every four hours that high protein Luke vanloon just had a paper
• 91:00 - 91:30 while I was in his lab in mustri where basically what he was doing was he called it the barbecue study and it was feed people 100 grams of steak and then follow them for 12 hours to see whether they were still absorbing the amino acids and the proteins from that and all the way out as far as they were able to measure they were still absorbing the amino acids that were from that original steak the difference is one was a purified protein a hydrolysate or or easily digestible protein the other was
• 91:30 - 92:00 a large amount of protein that our body's going to take a much longer time digesting and absorb so the idea that we used to say every four hours you need to have 0.25 grams per kilogram body weight of protein and that's that's less the focus now it's more just saying look we want to get in about at least 1.2 grams per kilogram body weight of protein over the day over the day 1.6 over the day let's just do some math on this for a second because a lot of people listening
• 92:00 - 92:30 are going to be like kilo what so that's like saying the 20 grams of protein that's in a bar always says oh 20 grams of protein the reason for that is the 0.25 grams per kilogram body weight and the 75 kilograms of the average American weight multiply those together you get 20 and so what they were trying to do is get the minimal effective dose of protein into that one food so 75 kilg time 2.2 is 165 PBS that must be outside
• 92:30 - 93:00 of certain states in the United States but yeah 165 pounds and so how many of those 20 gram bars would you be consuming per day based on the recommendation if you were to do that as a young healthy person you'd be looking at say you know at least at least four maybe five of those got it okay and that's going to be anything that's 20 grand of protein a piece of meat the size of your fist is usually a good es now we've got this one meal a day people who are doing oh yeah
• 93:00 - 93:30 and then you're trying to say okay now I can play with these things and you were talking before about being with David satini and talking about mtor and rap ay use well one of the things that rapy does is it blocks mtor and that's the the core component of what it does but mtor is activated by two things it's either activated by growth factors or load those are the two things that can activate one part of it and it needs amino acids so the growth factor component is usually insulin
• 93:30 - 94:00 igf-1 the amino acids are from your protein that you're eating so now if I have the amino acids without the carbohydrates I don't get as much insulin and so I don't get as much mtor Activation so that's the Genesis of the ketogenic diet so the ketogenic diet yes it's been used for a lot of things for time but that's when we started looking at it because for long longevity a ketogenic diet is functionally doing what lowd do rapamycin does which is it's going to slow down mtor activity
• 94:00 - 94:30 that's going to decrease inflammation because we need mtor for our inflammatory cells so we did studies in mice where we fed them either a ketogenic diet and we did this by feeding them exact amounts one meal a day and so they were getting time-restricted feeding they were getting slight 10% fewer calories than they would need and they were getting either normal Chow a low carbohydrate Chow but still enough carbohydrate that they didn't go to ketogenic or a
• 94:30 - 95:00 ketogenic diet and what we found is that the ones on a ketogenic diet live 133% longer than the ones on the control diet are control animals lived longer than anybody else's control animals because my colleague John Ramsey is probably the best in the world at these longevity studies so they already living a long time the increase in lifespan corresponds really well to the rapy effects and then there's Longo down at USC sure and what does he say he says low protein diet the low protein diet is the other arm of that because if I need
• 95:00 - 95:30 both insulin and amino acids to activate mtor fully I can either take away the carbohydrate and get rid of the insulin or I can take away the protein and get rid of the amino acids and so both of the diets work to increase longevity one of them is going to be much harder on your on your muscle mass and it's going to be less applicable to humans and that's going to be the low protein diet but they're both trying to do the same thing at a molecular level all three of those things the low do Romy the
• 95:30 - 96:00 ketogenic diet and low protein diets they're all trying to decrease inor activity quick interjecting question we didn't have time to get into it maybe another time we'll get into it but we talked about the abrah hangs then we talked about Max hangs we didn't talk about ABR hangs plus Max hangs right which seem to have an additive effect would you expect that ketogenic diet plus rap ay would have an additive effect or are you already checking the box so there's a null effect basically
• 96:00 - 96:30 for one of them that's one of the things that we're studying right now to see whether that is going to have an additive effect and that both things together are better than one we know that for the abrah hangs they're doing two separate things the same way that mtor is activated by insulin and amino acids there our muscle strength is our brain's ability to turn on the muscle the size of the muscle as we talked about earlier but also the other component is the force transfer and so what we do with the ab hangs is we work
• 96:30 - 97:00 the force transfer what we do with the max hangs is we work our muscle mass and our brain's ability to turn on the muscle when we do them both together we get both of the stimuli together so that's when we have the biggest positive effect so the same thing could be true for the Romy together with a ketogenic diet but we don't have the data yet what we're saying is that one of the best things for muscle as far as the ketogenic diet goes is that one you have good amount of protein so you're maintaining protein you're maintaining the muscle mass the second really
• 97:00 - 97:30 important thing is because there's no carbohydrate you have to use mitochondria to produce all your energy so you produce better quality mitochondria and the other thing that happens as we decrease mtor activity is we activate a process called mitophagy mitophagy is when you break down mitochondria and usually the mitochondria you're breaking down are the ones that aren't working as well the old and the weak calling the herd exactly culling the herd now we're going to keep that herd stronger because we're culling the weak ones and we're allowing
• 97:30 - 98:00 that mitochondrial Mass to be maintained so what we found in the old animals that we had on a ketogenic diet is their strength was actually at the level of a young animal and their brain function as well just for people listening what are functions of mitochondria that people may not be aware of what do mitochondria do the mitochondria the most obvious thing is they PR produce most of the ATP for our body so most of the energy for our body and so that's where you you have to have
• 98:00 - 98:30 mitochondria to break down fat I don't need mitochondria if I just want to break down carbohydrate or I use the mitochondria slightly different so it's one of the reasons why people go through the keto flu component when you go onto a ketogenic diet for the first time because you're going onto a diet that has no carbohydrate if you've been using carbohydrate as your primary fuel source and you don't have lots of good quality mitochondria for a few days there you can't produce any energy and so you feel like you're dragging and you can't move
• 98:30 - 99:00 and you can't get out of bed because you're super tired like you have the flu that then turns around once you get enough mitochondria to start producing more energy to allow you to do your activities of daily living the important thing is and we wrote a paper on this is that if I'm an athlete ketogenic diet is not for me yeah because I can't go fast what I can't do on a ketogenic diet is I can't Sprint and it doesn't matter whether you are a marathoner or an Ultram marathoner at some point or maybe it does on an Ultram marathoner but even
• 99:00 - 99:30 a marathoner at some point you're going to have to Sprint to go at a high quality level and if anybody out there thinks they can run the four and a half minute mile per mile Pace to run a marathon to be competitive and you're not using sugar and you're going to use fat that's just not really possible you can't go that fast and Professor Ron man who's one of the original sport nutritionists he went through all the calcul for exactly how you're using carbohydrate to power that whole marathon and that's also why you need to take in
• 99:30 - 100:00 supplemental carbohydrate on your run because if you don't you don't have quite enough you've got enough to get to about 22 miles and what does everybody experience at 22 miles hit the wall they hit the wall so the reason that you can continue to the end is because you're taking in the carbohydrate along the way and your body can use that as a fuel so again we don't use a ketogenic diet if we want to go fast but if we're training for life we see that it increases longevity that the ketones themselves are really good for brain function the biggest downside to it is your bones so
• 100:00 - 100:30 if you have a history of osteoporosis Auto ketogenic diet bone mass actually becomes really a problem so the place that we see ketogenic diets in clinical settings is in kids with epilepsy epilepsy yeah the epilepsy you take and that's Lorenzo's Oil this great movie about all of that stuff you take the ketogenic diet because the the epilepsy and the brain function is deteriorating and when you get rid of the carbohydrate your brain uses the ketones you don't have that deterioration the reason that
• 100:30 - 101:00 kids have to go off the ketogenic diet and go back into an epileptic possibility is because their bone mass becomes so fragile that they're at much higher risk for if they were to have a seizure they would break multiple bones in the seizure so again there are always tradeoffs and it's always about what are the things that are most likely to take down and those are the things that I'm going to focus on you mentioned decreasing inflammation with the ketogenic diet a lot of people think
• 101:00 - 101:30 inflammation equals bad let me turn it off let me gobble ibuprofen or leave while I'm icing everything that hurts but I don't believe that is your particular recommendation for folks absolutely not when is it right to inhibit inflammation and when is it not inflammation is absolutely essential to adaptation there's a good study out of my former University University of Illinois Chicago where they actually knocked out the inflammatory cells and
• 101:30 - 102:00 they then gave a stimulus for muscle hypertrophy and the Animals couldn't hypertrophy their muscles nearly as well we know that if you take high levels of vitamin C and high levels of vitamin E you actually decrease aerobic adaptations because part of the stress is the reactive oxygen so we know that we know that if I take Ibuprofen and I'm young and I I've just done a heavy lift I can decrease increase some of the adaptations or if I sit in an ice bath I can decrease some of the muscle protein synthesis it's going to lead me to bigger stronger muscles what we have to
• 102:00 - 102:30 do is we have to find that balance between inflammation and anti-inflammatories again we're going to go full circle to the start of the podcast and say I am not going to use anti-inflammatories that are Pharmaceuticals or other things I am going to use load as an anti-inflammatory the reason that your muscle feels sore after you've done a heavy lift is because there's inflammation within the tendon the tendon has a little sensory organ called the Gog tendon organ what it does is it
• 102:30 - 103:00 senses tension on the tendon so if I put a whole bunch of water in there or fluid now there's more pressure and that's telling me that I've got more load on the muscle I don't have a pain sensor so I interpret that as pain so if I do an isometric contraction what I'm going to do is I'm going to squeeze all the water out of it and that's going to get rid of the inflammation so what I'm going to do is I'm going to do shorter duration isometric holds like even 5sec isometric holds are enough to squeeze the water
• 103:00 - 103:30 out and then I'm going to do that again go back five seconds so I can go right to left so I'm going to go five seconds on my right leg then I'm going to go over and I'm going to do a side lunge to the left and I'm going to do five seconds on the left what I'm trying to do there is I'm trying to use the loading and the muscle contraction to squeeze out the liquids from the connective tissues from the muscles so now now what I've done is instead of using something that's going to turn off everything I'm just adding a little bit of minor load that's not going to cause
• 103:30 - 104:00 my legs to get heavy or anything it's just going to squeeze out some of the inflammation and I start this the moment I twist my ankle I sit there and I'm doing alphabets so I'm going and doing capital letters where my toes are tracing the alphabet and all I'm trying to do is I'm trying to make sure that I'm using load through the tendons and the ligaments that have just been sprained by that pull when I've twisted my ankle and I can do that and I can twist my ankle really badly and I've done this where I've had a really bad
• 104:00 - 104:30 inversion spraying playing inner murals here with my lab at 55 that's not the best thing to do but you do that and then you're like oh crap I sprain my ankle but now at least I know I don't ice rest and do any of that stuff what I'm going to do is I'm going to do loads where I'm going to put load through those those ligaments I'm going to pull on them hold it release pull on them hold it release and that's going to pump all the liquid out the next day you wake up there's still bruising there but the ankle is the normal size and I can go out for my run what it tells us is it tells us that
• 104:30 - 105:00 we've gotten into a bit of a habit we're going to do pressure ice there's no harm in it so let's do it we're going to compress all of it is trying to do something that I can do if I just put load through that system so I don't use the anti-inflammatories I use load as an anti-inflammatory ice bath just as a fan of ice baths mostly for mood elevation kind of a Vincent Van go style when they used to prescribe cold bass for melancholy how much space would you
• 105:00 - 105:30 provide after a workout or training stimulus before doing something like an ice bath it's all about optimization so if you are training for life and you don't have to be the best you that you can be then what you want to do is you can say look do your ice bath in the morning lift in the afternoon that overnight you've got mtor activation all night long now you come out if you turn off mtor no big deal yep that's kind of what we're saying and then if I do that and I get out and I do a warmup and I go out and do my aerobic or my rhythmic exercise now I can actually go into that
• 105:30 - 106:00 with maybe feeling a little bit like the aches and pains are a little bit gone and now I can do that aerobic exercise in the morning and now I've got this split where I'm doing some of my strength when I'm my strongest in the afternoon and for your supplementation question right before my biggest protein meal of the day because I'm going to have most protein at dinner so now my strength is close to my dinner I'm going to then sleep and get all the recovery then I can get up and I can do my endurance in the morning and that's going to allow me to actually optimize those combination of strength and
• 106:00 - 106:30 endurance all right I think that's a beautiful place to wrap up Keith you do not disappoint you're a beast a gentleman and a scholar thank you for the time and for people who can't see the video you have all of the weight training equipment behind you which I know is your next step yep where can people learn more about you learn more about your work find you online where shall people people find you if they want to learn more I do things like LinkedIn and I do blue sky so on blue sky I'm muscle science so if you look
• 106:30 - 107:00 for muscle science all one word you'll find you'll find me there and you can keep an eye out for the company that we're developing is called sinuous sinuous s i n e w senu like your tendons ligaments and then us like us so I love it all right Keith thank you so much for the time absolutely I've taken a million notes I can't wait to go find a tennis racket or a pan or a golf club to do my overcoming isometrics and for everybody listening
• 107:00 - 107:30 we will link to all sorts of goodies everything we've mentioned including where you can find Keith in the show notes at t. Blog podcast just search keithb is there anything else Keith that you'd like to add before we wind up no so that's great because a lot of people don't understand necessarily the isometrics what they look like my medical school just came down and filmed a video of it and it's up online so I'll send you that for the show notes as well beautiful we'll put that in the show notes and everybody be safe out there
• 107:30 - 108:00 train smart perhaps incorporate some isometrics I don't know how you couldn't be tempted after this conversation and until next time be just a bit Kinder than is necessary to others also to yourself and thanks for tuning in