Dr. Gabrielle Lyon Show with Dr. Gerard D'Anzafo

welcome to the Dr Gabrielle lion show today I am honored to sit down with my friend and colleague Dr Gerard daao he was chief resident at Colombia and Cornell and did a fellowship in Spine and Sports at HSS which is the hospital for special surgery he is a physical medicine and rehab doctor and in this episode are you ready for it we talk about what you are missing if you only focus on muscle Health how tendons are the key to longevity and the role of hormones in tendon Health we talk about this and so much more as always I produce this content for free please take a moment to share it subscribe rate it like it you know the drill and if you are not part of our community head to my website Dr Gabriel lion.com and join us because remember we are Forever Strong together Dr Gerard denafo thank you so much for joining me I am very excited to have this conversation you and I have known each other for many years now you are extraordinary you are a physiatrist you&#39;re going to explain to The Listener what that is and I&#39;d love for you to talk about a little bit about what you&#39;re doing and how you got here fantastic so thanks for having me on so physiatrist is a specialist of physical medicine and rehabilitation so I did my residency in physical medicine and rehabilitation and you can think about that as a combination of a few Specialties so it&#39;s a bit of Neurology a bit of Orthopedics a bit of internal medicine we take care of patients along the entire spectrum of disability and ability so throughout the course of my medical training I&#39;ve taken care of patients with stroke hemiparesis and hemiplegia spinal cord injury patients worked a fair bit at the VA taking care of our veterans and then I&#39;ve also been on the sidelines of professional sports teams as a assistant team physician for the Nets organization and the Red Bulls organization so I&#39;ve seen human movement disability dysfunction pain these things and a physiatrist is a non-operative specialist specialist so we go through a variety of non-operative ways to help patients with their pain function Etc and basically improve quality of life uh it&#39;s amazing because it actually takes human movement into medicine yes why why why did you choose this specialty and by the way you know you&#39;re a very fit guy um but it&#39;s un it&#39;s an unusual specialty I would say yeah so I I started to learn about the specialty right as I was thinking about going to med school and I prior to medical school was a personal trainer and so what I used to do is uh during the Summers of college I studied up for my personal training certifications I used to be a personal trainer and I loved every second of it you get so much experience watching how people move and you get to see what it looks like when somebody has a dysfunctional movement pattern when they&#39;re being loaded correctly and you really see what happens when you load a system and that&#39;s what this all comes down to so we&#39;re loading somebody&#39;s biomechanics either those biomechanics are functional and they&#39;re going to improve they&#39;re going to put on muscle they&#39;re going to gain speed they&#39;re going to gain functionality or you&#39;re going to have dysfunction that leads to pain and disability whether it be something like back pain or tendinopathies which we&#39;ll speak more about but as a personal trainer I wanted to go into a field where exercise was a really important component so we pride ourselves as physiatrists as having very close relationships with physical therapists and writing detailed Physical Therapy prescriptions so we really are uncovering in the office what are the biomechanical determinants of pain so let&#39;s take for instance your shoulder hurts but your shoulder might be more the end product of dysfunctional movement at your shoulder blade so uncovering with a good physical exam and using things like x-rays MRIs CAT scans on the spot ultrasound and of course taking a very thorough history you could put together what is really the dysfunctional biomechanical diagnosis and then at the tissue level what&#39;s occurring so my residency training in Physical Medicine Rehabilitation preceded my sports medicine training and all of this has led to me having a great appreciation for the muscular skeletal system how it works and we were connected several years ago because I saw that you were talking a great deal about muscle Centric medicine and a lot of the endocrine determinance of muscle the importance of muscle as we age and looking at this holistic Ally if you were to think about how say a nefrologist goes into their training like Shane Urology they look at the macro structural approach they look at the micr functioning approach so like how does the organ actually look in the body what is it made of and then what does it do so I&#39;ve been you know viciously consuming your work and I&#39;ve read your book and I i&#39; I&#39;ve found great appreciation in it because it&#39;s looking at I&#39;m looking at the muscular skeletal function from Locomotion walking lifting things athletic Endeavors throwing kicking Etc but we&#39;re also I love that You&#39; brought to the table and to the scientific conversation what is the actual biochemical aspect of that now we&#39;re looking at the organ much more from the entire spectrum of what it is and quite frankly you and I have again been talking for years so it&#39;s really nice to be able to sit down have a conversation of course this is the beginning of you and I are working on um some projects behind the scenes you bring in a very important perspective it is wonderful to think about the health of SK Del to muscle from a metabolic standpoint from its impact on fasting insulin fasting glucose triglycerides and that&#39;s impact on say Dementia or cardiovascular disease the question becomes how do we get to these what I would consider inflection points inflection points of Aging or inflection points of disability I love how you said you look at individuals um and take care of them them through disability and ability yeah I really appreciate your perspective on skeletal muscle as its organ system which is exactly what physiatry does but I Al I also think that you have a very unique perspective that brings in um very closely the biome mechanical aspect that I don&#39;t think is actually super common in Physical Medicine and Rehab we talk about it as Physical Medicine and Rehab but your perspective is certainly becoming and you use this tagline in your Instagram antifragile yeah which there are a number of topics that I&#39;d love to discuss on this podcast um which included are not limited to the things that limit our ability to progress like tendon issues yes like back pain hip pain things that ultimately limit the quality of life for individuals and then other things Beyond like should we stretching but let&#39;s start with one of the things that I think that we both see in clinical practice are issues with tendons yeah and why are tendons important what are they how do we think about them in in a global sense sure so muscle is contractile tissue muscle is made of actin Mouse and filaments you have this incredible cross-linking phenomenon that&#39;s mediated by our energy molecule ATP and we contract muscle and ultimately to move bone but muscle doesn&#39;t attach directly to bone it attaches to Bone through tendons and collagen is our most abundant protein in the body and no surprise tendons that tendonous attachment from muscle to bone is predominantly made of collagen so tendons are by definition they are non-contractile tissue they&#39;re almost like if you think about a short bungee so they exist in a relaxed State called the crimp State and when you when the muscle contracts it pulls on that tendon takes the slack out and then it winds up attaching to the Bone to move the bone and attendons have this incredible quality called visco elasticity which is a cool word but everyone is going to be quizzed on this later there you go so viso elasticity it means that the the mechanic the mechanical behavior of that structure changes the degree of strain that you put on it so at low strain rates tendons dissipate energy at high strain rates they really put down the force and so you can think about as you&#39;re walking you might be putting a lot some tension through your Achilles tendon by definition um but you&#39;re not putting as much tension through it as you are when you&#39;re running and it&#39;s a really tight spring so the mechanical behavior of it does change the tendons are um an sort of an organizational level you know muscles have the contractile elements you have muscle facies um and facles for those who are listening are bundles of proteins so you have this structures you have a larger structure and then you also have in within that these composition of these micro structures of fases and fases are a fascinating thing because they are present in muscle tendon and nerve and the reason for that is because we don&#39;t F we&#39;re not uniplan or individuals we don&#39;t just function in one plane we function in forward and backwards left and right and also we rotate and so muscles and tendons as they&#39;re trying to move a bone they need to have specific elements stressed not the entire not the entire system stressed simultaneously but the fast schulls actually allow for tendons to be strained specifically so you could think about like a pitcher so a pitcher the job of a rotator cuff this is this is a cool point that I really like the job of a rotator cuff is actually to stabilize the ball on the socket we think about rotator cuff strengthening exercise you&#39;ll see a lot of people with bands and cables and strengthening up the rotator cuff and it does that it does rotate the arm hence its name but the shoulder is an inherently very mobile joint um it&#39;s comprised of four different joints actually it starts over here and at the stern cicular joint you have your AC joint and then you have your true glenor hemal joint and you have the the scapula shoulder blade that rests on the back at the rib cage so there&#39;s a lot of mobility in it which is why on average unless you&#39;re a rocket you can raise your arm higher in the air than you can your leg okay so similar ball and socket joint with the hip but more stability there job of the rotator cuff is to stabilize the the head of the the ball and socket joint it&#39;s almost like thinking about like a a golf ball on a te so as you raise your arm into a pitching motion all of your rotator cuff muscles are active but different fasal are actually more stressed during different phases of that so that&#39;s one of the fascinating elements of this it&#39;s a really cool mechanical adaptive thing that we&#39;ve evolved to have and we have it in all those mobile structures of the muscular Scuttle system we have it in muscle we have it in tendon we also have it in nerves to allow us to be more athletic and multipler motion so it&#39;s very it&#39;s very cool and and collagen itself is it most most of tendon dry weight is type one collagen and then you have lesser components of type 3 uh type 11 you have other types as well and when a tendon starts to become diseased or overloaded that can change it&#39;s actually part of the process of developing tendonopathy um let&#39;s talk about tendons would it be fair to say that you couldn&#39;t have a healthy muscle without having a healthy attendant or vice versa yes so it is fair to say and it&#39;s fair to say because we have general principles you know we use this word homeostasis to describe how everything is regulated healthy muscle to exhibit its mechanical effect of moving bone effectively needs a healthy tendon you can develop your muscle it&#39;s actually muscle will develop more quickly than tendon adaptation occurs muscle will develop more quickly than the tendon adaptation and is that why designing a really good training program is essential to avoid injury because essentially the people listening are thinking well why do we care about tendons yeah nothing will take you out of the game faster than a ACL tear than an Achilles r rupture tendonopathy which then becomes chronic um could you have a um I suppose a better question is which goes first yeah so this is a something known as the athletic accommodation timeline so when you start let&#39;s say you&#39;re not a runner or I I I could speak from a position of truth I&#39;m not a runner so I neither yeah yeah um so let&#39;s say I start running the first thing that occurs in the first six weeks is I learn how to run better and basically that&#39;s called neurokinetic response so starting all the way up in your brain at your motor cortex and going all the way through your nerves as they go through your spinal cord and go through your peripheral nerves and into the muscle you learn how to coordinate your motion you basically learn how to use your muscles for more efficient motion so if you were to test my ability to run in the first day it&#39;s not going to be as good I&#39;m going to be much more gassed I&#39;m going to go deep into those energy zones I&#39;m going to really kind of stress to do the activity but I get better at it with time then in muscle tissue during after the first couple weeks you start to get cyop plasmic hypertrophy so your your muscles start to bring in some products to help them function now the body perceives it seems putting down collagen putting down protein from one aspect we have a substrate driven issue which I think you&#39;ve elaborated on the importance of Lucine the importance of protein intake then the other aspect is you need a continuous stimulus to convince your body to say we need to put down some new framework here so then you start laying down some muscle by the time your tendons and ligaments start to adapt to the athletic Endeavor you engaging in you&#39;re almost looking at six to nine months and that is much more of a significant timeline than it would take for a muscle yeah to adapt and by the way tendon turnover is very slow it is so as opposed to muscles which have a very rich blood supply and a rich nerve Supply tendons do not have a rich blood supply they&#39;re relatively avascular compared to muscle so they&#39;re not going to turn over as fast about 90% of ATT tendon is more or less static and then you have maybe 5 to 10% that&#39;s the variable element that changes with time so this is the one of the important principles that I think gets missed we hear about this concept of progressive overload well you&#39;re not just Progressive overloading your muscle you&#39;re progressively overloading your tendons you&#39;re progressively overloading your joint capsules your ligaments Etc so this is when it my I sort of hearken back on my personal training principles I say well where is the periodization where are we dropping back where&#39;s the D loing where&#39;s are we working towards a goal in two to three months and then are we scaling back and maybe changing and kind of starting back from a point just ahead of where we started before you can&#39;t just progressively overload until you find yourself into injury and that&#39;s something I very commonly find one of your quotes I&#39;ll steal from you is um you can&#39;t change what you don&#39;t track and it&#39;s and it&#39;s too true and some people are very nuanced they know their bod really well they&#39;ve been training for 20 30 years they may not need to track as much but if you&#39;re a beginner or even an intermediate and you need to think about I want to train I I have a I have a long-term goal well your short-term goal should be proceed without pain without dysfunction and really just knock down the goals that are in front of me as opposed to train until I get an injury and change the training types for instance or give it up altoe right and that&#39;s so so important I see that in my office all the time I I ask what does your training program look like well I do you know they&#39;ll tell me a split I do back and buys on Mondays I Do shoulders and tries on Tuesdays I chest on Monday Universal chest day there you go I do uh yeah sorry yeah probably chest on Monday Matt Matt only does chest on Monday Matt Matt has a good chest so lots of push-ups lots of push-ups um and you&#39;ll tell me a training split per body part but what about the global period like what how are we actually looking at the overload of these tissues over 2 to 3 months and what is the expectation is the expectation that you&#39;re going to progressively overload until you&#39;re the world&#39;s strongest person or are you going to have to scale back this episode is brought to you by timeline nutrition uh mitop pure the product that I wish I had developed but didn&#39;t so I&#39;ve teamed up with timeline nutrition to bring you one of my ultimate favorite products and that&#39;s mitop pure mitop pure is a science-backed urethan a urethan a sounds like a species of something or other what it is it&#39;s a postbiotic and 30 to 40% of you humans cannot make it why is it important it&#39;s important because it&#39;s one of the first gut muscle access connection mitop pure helps the muscle and all mitochondria when you take it you can take it in pill form you can take it in um powder form I recommend trying the starter kit they have ginger and ber I put some in my yogurt it&#39;s amazing here&#39;s what it does for you it will improve your potentially your energy your strength your endurance again mitop pure helps with mitochondria hence the name mitop pure it helps with the Regeneration and cleaning out old mitochondria and if you remember anything about I don&#39;t know fifth grade science mitochondria they are the PowerHouse of the cell so you have to have good mitochondria to have good energy and one of the Hallmarks of Aging is a decline in this mitochondria so if it sounds like you need more energy more strength more endurance and something that tastes great mitop pure is a way to go go to timeline nutrition.com lion that&#39;s timelin nutrition.com lion and you&#39;ll get 10% off your first order I recommend either the starter pack or the pills try it I know that you&#39;re going to feel great back to the episode when you think about injury where do you see them and again you are a clinician you are seeing a lot of patients every day from a very early um early hour you know I&#39;ll call you in the morning we&#39;ll have some great idea and you&#39;ll already be there reading that&#39;s right very early what are some of the most common things that you see as it relates to tend tendon injury and I I really like how you discuss this Progressive overload is there something that we can do now that potentially can change the way that we move so that we don&#39;t have to deal with these injuries that um seem to really inhibit our capacity to live right like you said sometimes individuals will say well I used to do bench press but now I can&#39;t because I have I don&#39;t know tennis elbow sure sure and it&#39;s not the muscle that the problem it&#39;s the tenant it is that&#39;s right um You Will frequently you know and to some degree frequently depends on what you&#39;re seeing but you will see muscle strains um and muscle strains can be on a graded scale but the more frequent thing that I see in my practice is tendonopathy and the most common tendonopathy I see are rotator cuff tendonopathy specifically one muscle in the rotator cuff named the supinatus and the Latin terminology means that&#39;s above the spine of the scapula so it&#39;s one of the higher ones and then I&#39;ll see a lot of Achilles tendonopathy a good bit of patellar tendonopathy which is KNE right yes that&#39;s right so um and then Glu tendonopathy and that&#39;s one that really impacts um a lot of people over the age of 50 and is very much present when someone&#39;s walking so if you think about the importance of walking as it relates to not just calorie expenditure quality of life Locomotion um one of the most common things I see is something called greater trochanteric pain syndrome otherwise abbreviated as gtps um some people know it by a similar term which is btis okay so when when somebody has a btis and a lot of times you&#39;ll get the clinical diagnosis of btis you can get either a traumatic btis or an btis because you have an an adjacent tendon that has a low grade of inflammation more commonly I see the adjacent tendon that has a low grade of inflammation bersus sacs they exist in the body to allow tissues to glide on each other so we commonly see the greater choke andic Bersa which is in the in the sides of the hip that may be a little bit inflamed because the Glu tendons from the glutitis medius which is on the side of the hip and the glutitis Minimus will be inflamed because they&#39;re not connected to a rather they are connected to a muscle that&#39;s not doing its job and are there movements that we should all be able to do or is this um an impairment in our ability to be able to move appropriately yeah so some of it is the basic Sports Medicine principle of you have a loadbearing tissue you have exceeded the loadbearing capacity of that tissue and that tissue is now an a state of disrepair that is the Hallmark of tendonopathy so whereas tendon tear the collagen fibers actually separate tendonopathy is characterized by a state of chronic disrepair white blood cells are in the area you start to aggregate things like fat molecules you start to have the collagen type change a little bit and your body actually grows little nerve rootlets into the area to sense pain more readily oh that&#39;s not good that is not good and it&#39;s actually it&#39;s an interesting phenomenon because it is also preserved that the same thing just like fast schs or in other places the same thing occurs in intervertebral discs in the back you have a collagenous structure without a rich blood you know you have a nerve Supply at Baseline but the more frequently that you injure it it actually there&#39;s good scientific evidence to suggest that there&#39;s little nerve roots that will grow into the area and make you experience pain more readily basically telling you to stop it stop shut it down for a while so I think one of the things that you you don&#39;t ask me about what could all we all be doing take stock of what&#39;s bothering you listen to your body if you are you&#39;re training shoulders and you&#39;re doing a set of military presses but that night you notice that you&#39;re waking up and the side of your shoulder is hurting in the middle of the night that&#39;s a sign that one of your tendons is a little a little bit of pain and might have the beginnings of tendonopathy reexamine how you&#39;re doing a military press maybe sub that movement out for the time being don&#39;t ignore those things there are good pains and there are bad pains good muscle soreness I think anybody who trains you know it you feel good it&#39;s a you get the Endorphin release um you&#39;re for instance providing a stimulus to the tissue and it&#39;s and it&#39;s it&#39;s clearing that the byproducts have exercise over a couple days and you feel better bad soreness in a tendon you typically have you&#39;re either compressing the tendon too much during activity you feel like a snapping sensation when you&#39;re going through a military press um when you&#39;re walking you&#39;ll notice the sides your hips hurt a little bit more or you go for a run and you notice that your Achilles tenant actually feels painful to touch and is a little bit bigger listen to that decrease the training volume and then think about always pairing what you&#39;re doing in in your exertional work with what I call capacity work so it&#39;s a framework I always always bring to patience one thing you can learn from studying and working with professional athletes is that they take care of themselves very well in addition to having fantastic genetics and athletic ability you know they also take care of themselves in a way that we don&#39;t so we don&#39;t for instance spend a lot of time doing what I call restorative work boring exercises isometrics or really taking time and saying all right well I have to I&#39;m I&#39;m not going to train today because or I&#39;m going to train differently today because this structure is inflamed and it&#39;s a problem I&#39;m not just going to take a couple Advil and see if if I can train through it I&#39;m going to listen to my body and say it needs to heal I&#39;m not giving it adequate time and I&#39;m going to a portion a percentage of my time to that I like to use the 8020 principle with this so 80% of your time exertional work go for it you want to do your your cardiorespiratory work you want to do your strength training your power training whatever it might be some around somewhere around 20% you should think about the injuries you&#39;ve had in the past you should think about the stuff you&#39;re dealing with in the present and you should be building capacities in those tissues if you have to work with a physical therapist to learn how to do that appropriately that&#39;s fine but you also there&#39;s a lot of great content online about how to um how to restore normal mobility in joints how to strengthen up your tendons um so that&#39;s something I readily engage in and I encourage my patients to engaging it as well spend a a certain amount of your time increasing your capacity to then go exert yourself don&#39;t have the entirety of your program just be exerting yourself because the S the sum total of your human movement is not just the gym it&#39;s life right right you know so it&#39;s it&#39;s the degree to which you are sitting it&#39;s the physical and psychological stressors that you&#39;re putting on your body throughout the course of the day it&#39;s your ability to sleep well and repair well and get enough protein in and get adequate nutrient intake it&#39;s we we think about it in terms of the gym because for a lot of us the gym becomes our Sport and it becomes something that we really look forward to we kind of rise and fall and our in our performance within it and it can hurt a lot to think about well I can&#39;t engage in my workout the work my workout is my release I need my workout I need my workout as my foundation for my day but spend some time doing the hard stuff in the background and you&#39;ll be rewarded for it don&#39;t wait until you get a really bad injury until you learn how to to learn how to rehabilitate that and and then just it because I I think that as you age it becomes more challenging um to recover I was looking at some of their research on tendons and thinking about how can I relate this to something that I know about which is skeletal muscle sure that when you are very active and you are young you&#39;re improving these satellite cells you&#39;re able to Prime the body to be able to put on muscle later on in life the literature that I was reading about on tendons was that the activity in youth is really critical for the thickening and the ability for these tendons to form I don&#39;t want to say in a meaningful way but in a way that will withstand a lifetime of activity yeah which I want to ask you about what do we know about training up tendons in Youth and then is there a natural decline with skeletal muscle there is somewhat of a natural decline to skeletal muscle because of increasing anabolic resistance again there&#39;s some controversy in the space whether it&#39;s because of inactivity or a natural process of Aging but where if we were to think about a concept that we know a lot about which is skeletal muscle and maybe the listeners know more than I do about tendons which is why I wanted to have you on so that you can teach us all about tendons and injury and approaches to training but what is the progression from tendons from youth to aging yeah so in your teens and your 20s you build up the collagen content of your tendons you build up the area so we we talk about cross central area which is basically the thickness of the tendons and with time you do have a little bit of resistance to modifications in your tendons so we find that in the Aging athletes you have you tend to develop this low-grade tendonopathy or tendonopathy like features where you have your aggregating these other cell products like the the fat content or calcium content and it also tendons lose some of their stiffness with age and we want tendons to be stiff you do so tendons are supposed to be stiff by Design you want a good spring to be mechanically efficient you want a good spring to be mechanically efficient think about running bounding hopping Etc you want your muscle contraction to be highly efficient and go towards bone there&#39;s this really interesting principle called Young&#39;s modulus and Young&#39;s modulus is basically the a calculation based upon the stress strain curve of attendant so your Young&#39;s modulus should increase with training which basically is the efficiency of the tendon to do work and the the some resistance to injury every tendon in theory could be injured at its maximum just like a muscle could be you go try to pick up a car your bicep might tear no I could totally do it there you go there are some days I think I can do it too um but the tendon does appear to have a decrease in that Young&#39;s module it&#39;s a decrease in that ability to of its mechanical efficiency as we age you also will see some degree of decreased cross-sectional area of tendons and you&#39;ll also notice some decreased collagen content as we age but these are all modifiable but to the same extent as muscle less modifiable so building up good tendon tissue does not mean you want the largest tendon you want the mechanically most structured tendon and what this this is important to note larger doesn&#39;t always mean better because a tendonopathy actually are characterized by larger tendons they aggregate water they aggregate these things called proteoglycans so the tendon does get bigger we want the same way some Elite powerlifters aren&#39;t necessarily the most muscled individuals but they&#39;re some of the strongest individuals you have to think about well how are they the strongest individuals they&#39;re the strongest individuals because they&#39;re mechanically very efficient they know how to move neurok kinetically they know how to position their bodies they do have muscle strength but they don&#39;t necessarily have the largest muscles a bodybuilder will have larger muscles on average than a powerlifter in the case of tendons the collagen you know U we hear about DNA is a double helix and it&#39;s a very fascinating thing to learn about collagen is a triple helix so you actually have these cross linking of molecules in the collagen and that allows the collagen fibral within tendon to to link more effectively to move more effectively so a lot of times that we see whether with it&#39;s with weight training cardiorespiratory training like running um or even like a um a plyometric protocol you&#39;ll see that people get Young&#39;s modu is changed before they increase if ever cross-sectional area men have larger tendons than women on average but that doesn&#39;t necessarily mean that you that the tendon is always stronger just because it&#39;s larger larger a larger structure is only as good as the micro structure within it and the micro structure is more measured by Young&#39;s modulus so when we look at the studies that examine loading up the lower limb tendons the patellar tendon the Achilles tendon the glutes what we see is that that Young&#39;s modulus changes and that doesn&#39;t appear to change a little bit with ag so building that up while you&#39;re in the prime years is perhaps beneficial and then staying with it do we know the mechanism of action as why there is a decline I don&#39;t know U the body of literature when it comes to tendons and tendonopathy you know when I when I think about muscle we know that there is um motor de innervation there&#39;s a a decrease in the the quality of the satellite cell do we know why tendons decline so one thing is from a metabolic aspect They do change a little bit so they actually tendons are minimally aerobic tissues they don&#39;t really go through the they don&#39;t really use oxidative phosphorilation as a means by they&#39;re largely anerobic but they have some aerobic metabolism and it&#39;s actually hallmarked of the degree to which your tendon is conditioned that it can actually engage in aerobic respiration that&#39;s pretty fascinating isn&#39;t it it is it&#39;s um I think because it&#39;s such an onoff mechanism um meaning you&#39;re either engaging the tenant or you&#39;re not exactly you&#39;re either crimped or on tension you can kind of get away with an anerobic response is it um metabolically active tissue less active than muscle okay highly less active than muscle but the metabolism will change and your blood flow may change as you AG as well hypoxia or the absence of oxygen is considered to be a driving Factor behind tendon degeneration that&#39;s interesting because it&#39;s it&#39;s mostly avascular yes so it doesn&#39;t have a good blood supply to begin with yes so minor alterations as we age either to doe to the sedentary nature or just the fact that we&#39;re not moving well whatever else it is or just time um the other thing is we accumulate micro tears and a lot of micro Tears Don&#39;t heal uh is a a high rate of chronic tears and say like a rotator cuff or in other other areas of the body they may not heal and you may not need them to heal ultimately they may not progress to be a surgical issue but that will weaken the tendon when the nothing in the body is as strong as when you originally made it so if you have a collagenous structure It&#39;s relatively vascular you&#39;re going to try to put down a scar tissue within it it&#39;s almost never going to be as strong as when you first started it the other tendon fbls may take that load they may they may be able to do 99% of what they did before but it&#39;s tough to say that the magnitude effect of the tendon at its best will ever be the same so the metabolism changes and you also see cell inessence or some cells just dying off and that we see that in a lot of tissues so there&#39;s an element of tissue hypoxia there&#39;s a little bit of a change in tissue metabolism the collagen cross linking perhaps is not as efficient and so your Young&#39;s modulus goes down and then we also see that the some of these cells just die off with time and so it gets harder there&#39;s I think if you can maintain it it&#39;s very good you know it&#39;s it&#39;s tough because there&#39;s always the ab the um the abstract element of this we&#39;re examining literature that takes a point in time and and typically these studies are over months um it&#39;s tough to say what would happen if you informed a population of this when they were younger and they engaged in certain exercises could they in theory maintain a lot of this the same way that in theory we can maintain a lot of our muscle okay you got to listen to this and uh please don&#39;t turn off this ad because I got to tell you about Cozy Earth Resort towels how many showers do you think that I&#39;ve taken today uh like 27 that&#39;s how good these towels are I know I didn&#39;t really take 27 showers but I got the Cozy Earth Resort towels and I feel like I don&#39;t even have to go to the resort because these towels are so soft you know when you go to the and get these beach towels they&#39;re usually scratchy and they&#39;re big these are plush Resort SL beach towels and uh we are entering 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muscle fibers and so you need to be getting some degree of explosive work I think the biggest phase change that we see when when we look at a program for somebody and we try to see how they could be for instance we&#39;re seeing that they&#39;re overloading their Pell so the the the tendon that connects the kneecap to the shin bone and helps basically act as a mechanical lever for the quadriceps muscles maybe they&#39;re overloading the sagittal plane a little bit too much so explain to us what that is yes so sagittal is back and forth okay so a a squat is A sagittal plane movement to some degree a barbell squat you&#39;re doing some degree of frontal plane so that&#39;s left versus right stabilization and you&#39;re also not rotating with the bar in your back so that would be a classic sagittal plane movement the bench press is a satal plane movement okay okay but as we age it does appear that we just generally spend less time rotating and running and cutting and doing the things that we did as kids so when we try to go back to those activities that&#39;s when you&#39;ll hear about an acute til acute Achilles tendon rupture and some 30 to 50y old male who&#39;s doing a a backyard football game for the first time in a while so you&#39;ll hear about it and they&#39;ll pop their they&#39;ll pop their calf muscle and that&#39;s an Achilles tendon rupture so I like to look at globally in a program how much time are you spending in the three planes are you rotating are you rotating under load are you stabiliz a good example of a stabilization exercise in the frontal plane would be like a suitcase carry it&#39;s going to carry a kettle bell at my side I&#39;m going to go forwards and backwards and I&#39;m going to make sure that my body doesn&#39;t lean either way by engaging in sagittal and transverse movements you engage different muscles than you do with sagittal I&#39;m sorry transverse and frontal plane movements you engage different muscles than you do with sagittal plane movements a lot of the machines in the gym will keep you in the sagittal plane so and so this is something that I advise people to get off of machines get used to doing lunges get used to doing rotational work um and really challenge your body there&#39;s some degree of there&#39;s I think a very good scientific debate about what exercise is best for tendons I would love to know and I want to know if blood flow restriction has any influence on tendons yeah it&#39;s a good question um with regards to the types of exercise we look at predom dominantly the from the prevention aspect and from the treatment aspect from the prevention aspect there&#39;s nothing to say that we can justifiably tack down something to the wall and say you should only do isometrics or eccentrics or concentrics it&#39;s tough to say that it&#39;s there&#39;s a bit of conjecture in the literature about that but what&#39;s interesting is there was a very good study that looked at the rates of lower limb tendonopathy and soldiers in Israel and basically looked at a a prevention program and then used an ultrasound to take a look at the tendon health of the lower limb tendons and whether or not those tendons were aggregating those those products that are Hallmarks of tendonopathy and what they found was contrasting what you might think it was like an Achilles prevention program there were almost no calf phases in the protocol the entire protocol was hip and knee and it was all stabilization of the core rotational movement hip airplanes stuff like that so this is a another concept that I I very commonly bring up with patients which is smoke versus fire are your symptoms a representation of that tissue being at its it&#39;s overloaded but is the real problem a mechanical element that&#39;s missing from your program or missing from your life so in that particular study where they looked at prevention they did find that it was helpful when they underwent this prevention protocol which is largely comprised of hip stabilization exercises the entire kinetic chain is linked we cannot divorce one element from the other your body has to achieve most motion it has to get motion range of motion from some element okay so let&#39;s say you go bend down to go get something you&#39;re doing a squat there&#39;s so many moving Parts within that from your ankle to your knee to the intrinsic muscles of the foot and the bones in the foot to your hips to your low back interior thorax Etc so you&#39;re going to get Mobility from somewhere so is the answer to the question how can we actually prevent some of these things from happening it&#39;s can we identify your mechanical weak points ahead of time from a rehabilitative aspect we use isometrics commonly as the starting point in a tendonopathy rehab protocol so would you explain what what would be an example of an isometric yeah uh an isometric exercise is one where you&#39;re Contracting a muscle but you&#39;re not moving the limb so if I were to be rehabbing a biceps it would be just holding a dumbbell at my side right a concentric would be bringing the dumbbell up to my shoulder an Ecentric portion is when we&#39;re we&#39;re actively mitigating the lengthening of the muscle and those tend to be the hardest right so that&#39;s when we&#39;re lowering down a weight slowly so it was a scientist by the name of alfredson who came up with something called the alfredson protocol and since then we&#39;ve been really focusing on Ecentric as the sort of the go-to that&#39;s how we&#39;re trying to get by week six of a PT protocol for somebody&#39;s Achilles and and we&#39;ve broadly adopted that for other tendons as well and good comparative study came out a couple years ago that looked at heavy slow resistance training versus Ecentric training specifically and found that heavy slow resistance training was non inferior to Ecentric base training so basically the time under tension with deliberate motion meant to restore the capacity in the tendon is as beneficial as doing you know heel drops off of a a stair for for instance for Achilles tendonopathy for Blood Flow Restriction I can&#39;t say specifically um whether or not it&#39;s beneficial the thought of hyperemia so hyperemia is the process of getting more blood into a tissue and we do use therapeutic ultrasound to heat up tendons and we we use shock wave to heat up T to basically break up micro structures in a tendon to treat it when we put PRP we&#39;re putting blood products in an area right so the the thought of getting blood into this relatively a vascular structure is one that makes a lot of sense how effective is that which one in specifically um any any modality that utilizes um because the the structure is a largely avascular structure so now you&#39;re introducing something that potentially it&#39;s not exposed to routinely or with the amount of whatever you&#39;re going to use yeah PRP or however you&#39;re going to use any of these modalities how effective in treating a tendonopathy is it and and tendonopathy would be something that would cause pain over time and limit the capacity you know from a very practical aspect the reason we are really focused on tendonopathy is because those seem to injure before a muscular injury happens that&#39;s right it&#39;s the common denominator that limits the quality of life I think it&#39;s a li huge limiting factor in training programs and progression and I think it&#39;s one of the first things we see when somebody starts weight training and we start to see these things arise so we&#39;ll go through a couple treatments amazing all right so we have this relatively vascular structure it&#39;s in a state of disrepair let&#39;s think about what that means so the actual structural components are not as strong as they were and you can think about this like you have a house that is not perhaps built as well as it could be you have a leak whatever else it might be well first thing we&#39;re to do is we&#39;re going to bring in a GC and so that&#39;s your general contractor and like what&#39;s a GC oh yeah yeah so um we&#39;re gonna you have tenocytes so same thing in muscle you have your myocytes and you also have your osteocytes in bone you have these these cells that basically look at the tendon homeostasis and they help direct traffic and Os site is a standard it&#39;s called modified fiber blast cell so it helps to lay down collagen and also helps to direct traffic the ocytes will sense that something&#39;s wrong and they&#39;ll bring in other cellular products one of which is that you will start to grow little blood vessels in the area so part of tendonopathy is actually when we put uh color power doppler on ultrasound and we look at a tendon we&#39;ll see stuff light up that was previously that is a good Telltale one side versus the other do you have hyperemia in a tissue that&#39;s already a sign that things are going the wrong direction well now we say well now you&#39;ve aggregated this Scar Tissue you&#39;ve aggregated these other things that are there they&#39;re not that helpful well we might have to bring an excavator and the excavator is we have a couple different treatments for excavation one of our treatments is called pnt so percutaneous needle tenotomy which is when under an ultrasound will actually pass a needle through the tendon several times is that where dry needling came from it&#39;s it&#39;s very similar to dry or this came first and then dry needling was adopted yes so dry needling depending on your discipline dry needling is something that be performed by a physical therapist for myself I do these under ultrasound and visualize the portion of the tendon that&#39;s inop which I just want to highlight that that takes a ton of skill ultrasounds are not easy to use and um quite frankly I believe that that&#39;s how it should be done because then you actually can see where the injury is what tissue you&#39;re putting it in you&#39;re not doing it blinded you are being able to visualize it&#39;s it&#39;s it&#39;s important to visualize it&#39;s also going to tell you whether or not there&#39;s a tear there you don&#39;t want to needle a tear right so a tear is a different concept A Tear is a separation so we don&#39;t want an excavator in that area it&#39;s not helpful so the thought of passing a needle through tendon several times will actually help induce take this state of chronic disrepair and convert it to the acute inflammatory phase again and basically help to cycle out some of that stuff so that could be done through pnt it could also be done through something called a 10x procedure which helps to remove scar tissue remove calcium that&#39;s built up in tendons the Advent of PRP and why PRP is so interesting so PRP is a distillation of blood products so we spin down your peripheral blood it&#39;s still majority red blood cells but PRP means platelet rich plasma and there are two subtypes of platelet rich plasma the exact concentrations of which do differ in the literature based slightly depending on the study you&#39;re looking at so you have Lucy Rich so white blood cell rich platet platet rich plasma and Lucy poor PL rich plasma if I were treating a joint I would use Lucy poor I don&#39;t need white blood cells in a joint necessarily but when I&#39;m when I have this chronic state of disrepair I need a whole construction crew I need my white blood cells so I&#39;ll use Lucy Rich preparations and I typically will perform it with a tenotomy too to actually put some areas into the tendon where I can distribute that P now PRP has several growth factors um one of which is platelet derived growth factor and this helps to basically stimulate the tenocytes and another type of cell that resides in tendons called tsc&#39;s tendon stem progenitor cells so you do have a repository of stem cells within your tendons it&#39;s just a question of mobilizing them so conceptually we thought well PRP makes a lot of sense depending on the tendon and depending on the literature that you&#39;re examining it can be very effective on a hold I would say it&#39;s probably a 50-50 proposition depending on the chronicity of your tendon problem as well as whether or not you have a tear concominant and where that tear is not all tears are made equal the tendon itself right right so you have the the muscle coming towards the tendon you have a myot tendonous junction which basically looks like a finger where the tendon is interlocking with the muscle and some tears do occur there and those can be quite tough to treat but then you also have something called the enthesis which is where the tendon attaches to the Bone and so those are the most common ones we are treating now you can have a tear at any portion in that tendon so they all have different prognosis if you have a tendon on the bottom right by the bone that&#39;s a different prognosis than the one up by the top by the bursa so we try to extrapolate from the natural history of this what&#39;s the percentage chance it&#39;s going to heal where is it how big is it how impactful is it it to the amount of strength you can produce in the relevant muscle how impaired is it and then would we consider is this a large enough Terror that should go to surgery is this something that we should try PRP in um important for people to know if you do suffer a tendon tear there are different types in from a from a perspective of if we&#39;re just looking at a large tendon you can get what&#39;s called a full thickness tear which is when it&#39;s like as if somebody punched a hole in a paper goes straight through MH from top to bottom and you usually know when you do those yes uh that is I have had quite a few injuries and you know um when that happens it&#39;s not like ATT tendonopathy you don&#39;t necessarily you know might be a little irritation and then you go back to the thing and then you irritate a little bit more that&#39;s right but when you get a full thickness tear that is an acute injury that typically will take you to your knees or whatever yeah so the full thickness is the pothole and then there&#39;s something called so we say full thickness incomplete or full thickness complete incomplete would just be have a sheet of paper and I punch a punch a hole with a hole punch complete means I literally take a pair of scissors and I cut the paper in half if you have a complete tear now the tendon is no longer attached to the muscle that is a surgical problem okay that is not something that&#39;s likely to heal by itself that would be for example like a tricep tenant tear or a bicep rupture yeah so and depending on how important the bicep so for instance the bicep is interesting because the bicep is almost like a fifth rotator cuff muscle there are people walking around with bicep tend and tears without significant you know without significant symptoms but if you have a complete full thickness tear what will occur in time is because the muscle is not seeing any tension the body de prioritizes it and it will atrophy and if it atrophies to date I&#39;m not aware of any way to stop that or reverse it so those are the circumstances you know like I I brought up that example of the 30 to 50y old guy who pops his Achilles playing backyard football um because that&#39;s the most common age population to get acute Achilles tendon ruptures but if that occurs and that tendon is not reattached or it&#39;s not approximated you&#39;re put in a boot or something like that then foreseeably you&#39;ll atrophy your gastri and your Solus and that&#39;s going to be really tough functionally to to go through so essentially don&#39;t delay I think a lot of the patients um that I have and many people listening they don&#39;t want to stop their activity they&#39;ll injure themselves and they don&#39;t want to stop I don&#39;t want to get a bicep uh repair I I can still be just as strong but if you&#39;re going to do the intervention that requires surgery one should do it swiftly yeah you should be evaluated swiftly and and and you don&#39;t want to see on MRI or on ultrasound you don&#39;t want to see those atrophic changes occur that&#39;s a sign that your that muscle is not going to be as functional as it originally was and therefore your prognosis isn&#39;t as good I want to thank one of the sponsors of the show and that is mudwater did your mom ever tell you not to drink dirty water well she may have been wrong because mud water is amazing and actually it&#39;s not dirty water but it is brown and let me tell you about this it is chai tasting a little bit of caffeine has mushrooms in it it&#39;s what we would think of as a functional type of drink and I got to tell you it really helps me when I want a little bit of caffeine and not a lot of the Jitters this is amazing and what I do is I put a little bit of hydration pack so I use element hydration chocolate mix it a little together and well a lot together a froa together which by the way you can get your own frur they will send you one and $20 off when you order yours mud water has a little bit of chai cardamon might even have a little cacao type flavor which it does and if you are looking for what we would consider adult hot chocolate this is the way to go and it does a a lot of good for your body without a lot of the Jitters go to mudwater docomo Lion that&#39;s mudwater docomo lion for $20 off and a free frother why do you think that we see you know again you see patients often and it&#39;ll be daily um either a shoulder a knee or a hip do you believe that it&#39;s because of patterning why those the common injuries yeah um in the shoulder I think it&#39;s because we have mechanical compression underneath the bones of the shoulder and that&#39;s known as a symptom it&#39;s called subacromial impingement so basically you&#39;re moving your shoulder around and the tendon gets caught underneath a bone and that&#39;s you can sometimes hear a snapping sensation when you do something like a military press for patella it&#39;s because a lot of times patella tendonopathy is part of a greater clinical concept known as patelofemoral pain syndrome which by the way is most often associated with weakness of the Glu muscles so the knee is overloaded trying to do too much work and the glutes are not adequately um supporting the knee in the hip so the posterior train chain is actually affecting the anterior chain yes and posterior lateral specifically so Hallmark of patellar tendonopathy Patell femoral pain syndrome we we commonly will look at strengthening up the gluteus Medi on the side of the hip and then the the really the the whole goal there is can you get back to walking and running with stabilization at the hips so there&#39;s not so much pain at the knee once again smoke versus fire your knee hurts you do have ATT tendonopathy but mechanically speaking there&#39;s an insufficiency of some muscles that are higher up in the kinetic chain that&#39;s it it just seems really challenging as as we think about long-term projection of people&#39;s lives to figure out that you know I have a weak glute me and you have I don&#39;t know uh just pick a different muscle sure are there things that individuals should all be doing should we you know we wake up we brush our teeth we brush our hair should we be getting up and doing glute activation I don&#39;t know uh eyes T&#39;s and Y&#39;s for our shoulder are there things that that we could Embark upon now to very specifically prevent a mechanical injury from attendant that we don&#39;t even know that we have it&#39;s a great question um and to in trying to distill what makes a lot of sense I will give home exercise programs to patients almost to that exact effect they come in with a back injury but I say well now was an awful time good to start rehabilitating and prehab your hips so is prehab a real thing prehab is absolutely a real thing it&#39;s tough because prevention is difficult to study so it&#39;s more that&#39;s a really good point it&#39;s very very difficult to study so I&#39;m I&#39;m recommending this because conceptually it makes sense not because I have a study to point to that doing you know sideline hip abduction exercises helps Stave off the onset of something H so what I see for the shoulder a lot of times the the mechanical dysfunction is at the shoulder blade and how it&#39;s moving either it&#39;s elevating too much it&#39;s not appropriately what&#39;s called protracting um and a really good test to see how your shoulder blades working is to do a push-up with a plus so at the top of your push-up you push out the ground a little bit more if you&#39;re trying to achieve that motion by rounding your thoracic spine you can&#39;t appropriately actually work through the the back part of your rib cage and your shoulder blade get that work well so push-up with a plush that I like for the hips a single leg stance squat so would that be a pistol squat so actually I prefer this like skater skater variety so your your your ex Trail leg is behind you so I like to see single leg stability and single leg stability is a great determinant of how you are actually going to progress through your gate cycle so a lot of people this is a really good thing and I and I&#39;ll show off my PMR residency here so and is this standard so do all I do all Physical Medicine and Rehab Physicians need to learn biomechanics yeah it&#39;s a huge element of our training it is a part of your training and I&#39;ll tell you why because you unless you understand normal biomechanics through the gate cycle you can&#39;t rehabilitate somebody with a stroke once they&#39;re hemiparetic once they have a foot drop it&#39;s really tough so you have to know the normal mechanic mechanical determinants of gate to understand the dysfunctional elements of it so I like to see how you know with regards to the gate cycle 60% of your time is in stance phase 40% of your time is in swing phase there&#39;s a 20% portion that&#39;s called double support where both legs are simultaneously on the ground so your glute me is actually active to stabilize your pelvis so if you see somebody with a lot of hip movement while they&#39;re walking you don&#39;t want to have 100% stiffness but you want to have stability if you have a lot of hip movement when you&#39;re walking it&#39;s often times an indicator well it&#39;s not as not as stable as it could be there&#39;s not enough muscular tension to support the core the center of mass in the body is in the pelvis so my I always encourage young athletes I&#39;m like if you have to focus on a couple things it would be be very stable through your pelvis you can&#39;t shoot a cannon from a canoe okay so you need stability in the pelvis to put Force down through the legs all athletes regardless of what you&#39;re do are made in the legs so all athletes are made in the legs yes and I believe that very strongly great pitchers have of a of a good set of legs they know how to really drive off um even look at Mike Tyson right one of the greatest knockout artists that has ever existed in the heavyweight division he had monstrous legs right it it was a huge element why he was able to compete with people six inches taller than him so I I believe it&#39;s a St good stable core that can rotate underload good um strong glutes and knowing how to keep your spine stable is really important so good neutral spine throughout the range of motion and then when you&#39;re walking yeah you&#39;re you&#39;re going to be you do swing the thoracic spine in rotation a little bit while you&#39;re swinging your arms but you want your body to be stable you want your you want to be able to walk slow and you want to be able to Sprint fast and if you can do both of those you kind of check in with yourself if you can&#39;t walk slowly without feeling like you&#39;re off balance something&#39;s a little bit off do you think that everybody should continue to Sprint or never lose that ability I would love for everybody to Sprint um I think sprinting is fantastic it&#39;s also a great check-in to see where you&#39;re at um but if you are doing it you need to be very careful with load management because if you haven&#39;t done it in a while and you go back to it it could be a major risk factor for achillus tend and to be clear well actually I evoled my hamstring doing a long stride Sprint would you recommend you know people listening to this are thinking because we&#39;re going to cover zone two cardio and training uh because you and I really see eye to eye excuse me sure about how there&#39;s a lot of discussion about zone two and how that&#39;s going to be so effective Ive in cardiovascular health there&#39;s a lot of other ways to train um but this idea of picking up where you left off may not be the best thing so if you are at home listening to this moving fast is important because you lose speed and you lose power but perhaps not picking back up if you haven&#39;t sprinted or you haven&#39;t done a lot of these Motions like the guys that you&#39;re talking about between 30 and 50 jumping on the basketball court you probably have to build up to that is that fair to say it&#39;s absolutely fair to say can we talk a little bit about um well I mean let&#39;s tie up the rest of tendonopathy because I&#39;m curious about some risk factors which in my mind would include medication yeah common medications that may affect tendon Health yes the first one that comes to mind is floro quinolones so that&#39;s like cyof Lal floxic that&#39;s a whole class of medications those are antibiotics um fluoroquinolones are very strongly linked with tendon problems and tendon rupture um we believe that this impacts tendon metabolism and integrity to some degree so those are of concern you know there&#39;s some I think very good um discussion around statins and tendons specifically so whether or not they&#39;re beneficial so if you have somebody who has hyper cholesterol emia they can actually deposit what I&#39;m sure know you know this but xanthomas in their tendons so fatty deposits in the tendons so in that case a Statin might actually decrease the size of their tendon and improve the tendon Health but if they have if they had familial hypercholesterol in that&#39;s right but not if they just have high cholesterol it&#39;s tough to say okay it&#39;s tough to say because hypercholesteremia diabetes um gout these are in G SL hyperemia are all risk factors for tendonopathy and smoking so if you look at the metabolic syndrome Spectrum obesity is also a risk factor all of these things impair tissue healing anywhere in the body so in a in a structure that does not have a great blood supply that&#39;s constantly under load it&#39;s very much magnified um that&#39;s an interesting concept I I haven&#39;t quite thought about again because I&#39;m so fixated on muscle if someone is obese or struggling with any kind of metabolic dysfunction that would affect tendons yeah in general diabetes patients um will rehabilitate more slowly than non-diabetic patients and partly because tissue healing is slower so it&#39;s an excellent textbook that um I came across that actually looks at all the metabolic influences on tendonopathy and chapter by chapter goes through it and one of the aspects of it was just think about it like it&#39;s another structure in the body it heals more slowly yeah bone bone fractures heal more slowly microarchitecture and bonus more slow it&#39;s one of those things where it&#39;s reasonable to make a leap from one concept to another if tissue healing and tissue repair is is is not as quick as it could be or as um as comprehensive as it could be in one tissue there&#39;s no reason to suggest that it&#39;s going to be better than another so floro quinolones yes um can cause a risk of Tenon rupture yes which it&#39;s really important that Physicians educate their patients don&#39;t go sprinting don&#39;t go running when you&#39;re on these Statin St may have a positive effect depending on the person yes um anything else that is known to affect T corticosteroids so corticosteroids if you I had a great um a great attending while I was in residency he said if you if you just draw a a body diagram you can find a place that corticosteroids impact every part of it and it&#39;s the truth you can get hair loss they can get um you know your skin changes color and texture um and no surprise it does impair tissue healing now the question becomes a very good question because it is part of my practice to provide corticosteroids and also it&#39;s important to point out it&#39;s standard of care it is it is and so the question becomes why are we doing what we&#39;re doing and so in the circumstances of somebody has a tendonopathy and they&#39;re getting a corticosteroid injection that injection should be guided it should be into the adjacent Bersa you don&#39;t want to put cortico steroid into a tendon that&#39;s not going to help anybody but if you&#39;re putting in the adjacent Bersa there&#39;s theory that perhaps you&#39;re going to anesthetize and kind of decrease the pain signals coming from those little nerve inlets that have actually grown into the into the tendon themselves and if I get you some short-term pain relief for three months which is on average what we we councel people for corticosteroids if I get you some short-term pain relief and you could do the PT and your mechanics are improved are you in a better landing spot than if I didn&#39;t do it and that&#39;s a conversation I have with everybody around a corticosteroid now oral corticosteroids are prescribed for a variety of conditions rheumatologic conditions and we&#39;re talking about a prazone a metol dose pack that&#39;s exactly right um I even use them to some extent when um we&#39;re treating low back pain patients have a really bad low back pain bout um and they have a flare and we can&#39;t get them in for like an injection epidural um and we can&#39;t get them through PT because they&#39;re in such a bad spot we&#39;ll use a medal dose pack now Medrol itself is going to be absorbed by the body the body your body does not know exactly where to disperse this medication it&#39;s going to be absorbed it&#39;s going to impact hormone production it&#39;s going to suppress natural production of things like testosterone and sex hormones it&#39;s going to feed back on the pituitary and the hypothalamus and the whole chain and the adrenals but at the tendon level it can actually impact your ability to repair and so if you&#39;re if you&#39;re susceptible and you have a predating injury and you go through metal do pack and you go exert yourself there is a potential that you can injure yourself now once again risk benefit ratio in everything we do um I&#39;ve used this phrase with you once before and I&#39;ll use it again there is no free lunch in biology so it and it&#39;s too true it&#39;s too true so everything we do has side effects everything we do has a potential downside everything needs to be weighed for the person in front of you so in the risk benefit analysis that you&#39;re saying somebody has a tendonopathy it&#39;s been recalcitrant to PT you&#39;ve tried to do some stuff they have nighttime pain well now the nighttime pain is impacting the rest of their body because they can&#39;t sleep well is pain worse at night um depending on the tissue so let&#39;s say so if you have a shoulder uh btis as a consequence of ATT tendon problem in your shoulder nighttime pain is a Hallmark of it so and is it because cortisol is lower why is why is that happen mechanical compression so when you stop moving tissues that are relatively inflamed they will touch other structures around them and sensitize them and then specifically if you&#39;re like a stomach sleeper and you put your arm up to the side around your pillow you might feel like your your adultt wakes up really sore and that&#39;s because you&#39;re compressing a tendon tendons like load they don&#39;t like compression tendons like load they don&#39;t like compression that&#39;s right so same thing um we we&#39;re learning a lot of really good on liners over here really really great there&#39;s a um same thing somebody has a glal tendonopathy on the side of the hip lying on that side would be very painful at night time extended compression on a tissue that&#39;s irritated you&#39;re going to know about it um somebody has an Achilles tended problem Shoe Fits not correct or they they tried say they were in the first time in cleats for a while that they weren&#39;t in cleats before you might inflame that area um any other medications that can be harmful um there&#39;s perhaps more as well um these are the big ones those are the big ones I think more about the in some circumstances some of the hormone replacement that&#39;s helpful I was going to ask you I was going to ask you on the flip side of this are there potentially oral agents or injectable agents that could be beneficial for tendon Health broadly speaking from a nutrition aspect or like a neutraceutical aspect what we can take um hydrolized collagen has been proven to be a little bit helpful in studies um Lucine no surprise there has has been I&#39;m sure lucin&#39;s been on this podcast before no never heard of it yeah right so um Lucine is is actually a component of a prot glycan around tendons called decorin and it can help lubricate tendons it&#39;s also once again a concept that makes sense if it&#39;s good for muscle it&#39;s probably good for tendon so in these C good for muscle it&#39;s probably good for tendon I love this because we have really left tendon out of the conversation we&#39;re back we&#39;re back to your to your neck of the woods and muscle but the the interesting thing is we know that you need to some degree it&#39;s a substrate driven issue you do need adequate protein intake it is a collagenous structure whether you absolutely need collagen because your collagen is going to be broken down your stomach and brought back is I think a better question to ask so it has proven to be somewhat helpful omega-3 intake has been associated with decrease in tendinopathies and is that because of its impact you know I always think okay well what would the mechanism of action would that be an inflammatory perspective I think it&#39;s the low-grade anti-inflammatory U aspect of the resolving pathway yep so I think that that&#39;s it now um and for that reason it&#39;s important to point out a Hallmark of tendonopathy is Express of prostag gland and E2 and so for people who don&#39;t know E2 is something that is present in acute inflammatory processes it&#39;s why a lot of anti-inflammatory medications work so omegas act on the same aspect without a lot of the potential downsides so I will counsel patients to take omega3 supplementation DHA and EPA are superior so um I will counsel them to do that as well now with other aspects protein intake uh Lucin intake vitamin C is a co-factor in collagen synthesis so vitamin C makes a lot of sense vitamin and are there doses that we know of you know I&#39;d have to I&#39;d have to get back to you with exact dosing I just know that it&#39;s dietary intake of vitamin C is associated with improved tendon healing and have you heard of I don&#39;t know if you ever use these in in clinic but spms the specialized Pro resolven mediators Orly I&#39;ve not used them what is um yeah I I am not so sure on the data but um we&#39;ve used them uh some of my colleagues have used them a lot with operators okay but you and I will have to look at some of the the actual data but I I am curious yeah and vitamin D can be helpful as well so vitamin D has been proven to be helpful in tendinopathies as well can help decrease some of the pain vitamin D vitamin C and vitamin D deficient rats um have decreased Rotator cough healing after injury so it&#39;s interesting to think about Lucine Glycine and lysine are the amino acids that are most helpful um but having a good amino acid-rich diet with amino acid profile is probably best um from a hormonal aspect hormones are really interesting here because I think when we were speaking about this you had mentioned that you came when you were back in training you came across some patients and one of the first signs of some of their hypothyroidism was actually the acute development of tendinopathies which is fascinating yes um thyroid hormones basically T3 and T4 play a role of stopping apoptosis or program cell death in tendons in Tino sites so in your general contractors that are overseeing work on your tendon so if you have S insufficient thyroid hormone stim thyroid hormone circulating that&#39;s perhaps a major risk factor another thing that&#39;s a potential major risk factor is T4 actually mediates collagen metabolism so you need enough circulating um the sex hormones are awful interesting too so um estrogen is the in play of female sex hormones and so what these deeply collagenous structures like tendon and ligaments is the subject of Fascination for a whole body of literature so I don&#39;t want to do them Ma disservice by speaking about it very um quickly but there&#39;s been a good degree of insight into phases of the ovulatory cycle and risk of injury and in um in adolescent females who are are in the developing stage there and and engaging in sport that perhaps you could have a two to six times incre inre risk of ACL injury during specific phases and then we know in the postmenopausal population that tendinopathies tend to develop so the absence of estrogen appears to be a problem um same thing goes for testosterone now testosterone there&#39;s a clear um in that same post metapa pausal population the testosterone is going to decrease as well so testosterone appears to be beneficial for tendon where the where the conversation gets very interesting is are the testosterone analoges are the synthetic analoges detrimental and one that&#39;s a really good question so basically what he&#39;s saying is the use of certain anabolic steroids um going to injure tendons I think it&#39;s a really good question and the answer is they appear to be clearly due to the use of them the muscle the skeletal muscle is enormously sensitive to them but does it need to be testosterone specifically to help tendons and that&#39;s one of the great questions so let&#39;s say somebody starts on anabolic steroid regimen and they&#39;re drastically increasing their their muscle size well the athletic adaptation curve does not change you might not you might retain more muscle have less catabolic effect you might get more week-over-week training benefits but you still need time for the soft tissues to accommodate so it&#39;s one of those unfortunate things that plagues people is bicep tendon ruptures PEC tendon ruptures that&#39;s what we see a lot of time in the gym and so it&#39;s something important to think about does it need to testosterone specifically or is it or can it be something else the from the literature that I was reading it seems like it needs to be testosterone specifically so both estrogen and testosterone play some protective element and therefore another question is in individuals who are taking synthetics who are on robatas Inhibitors are they doing themselves some degree of a disservice are they are they throttling down estrogen so much so that it&#39;s not beneficial have you done your blood work uh if you haven&#39;t I have a solution for you and that is one of the sponsors of this the show inside tracker why is blood work so important well you know I use inside tracker my friends use inside tracker also my parents use inside tracker inside tracker makes getting blood work very easy and user friendly they have an amazing interface you can check it out on your phone you can check it out on the desktop which you know hopefully you&#39;re using a small one inside tracker allows you to look at really important biomarkers like hormones iron thyroid insulin the list goes on apob it never stops and by the way if you are a professional and you have clients inside tracker also has a pro platform amazing I really feel that inside tracker has revolutionized Healthcare and listen blood work can be expensive but it doesn&#39;t have to be inside tracker is offering my listeners 10% off 10% off anything on the store in the store anything uh as it relates to subscriptions 10% off go to inside track .c like insid tracking your body use the code Dr lion and do not wait if you are due for your blood work give this a shot it&#39;s extremely valuable back to the show you bring up a really good point and what he&#39;s talking about is um medications Aroma Inhibitors that would decrease estrad or overall estrogens and we know that estrogen is important for both men and women yes I can say clinically I um I like to see my men you know it&#39;s interesting for women there&#39;s a lot of EB and flow obviously we don&#39;t want their estrogen suppressed but for men I am happy with an estrogen level between 30 and 50 um individuals you will see sometimes are on something like Arimidex and they will suppress their estrogen and they&#39;ll feel terrible yeah they&#39;ll feel terrible perhaps they&#39;ll get injured you know in menopause I&#39;ve seen um somebody of literature talking about frozen shoulder yes and I&#39;m curious as to why frozen shoulder and menopause wouldn&#39;t that be whether it&#39;s shoulder whether it&#39;s a knee patella tendon issue or hip why why shoulder yeah it&#39;s adhesive capsulitis there are rare clinical accounts of it occurring in other joints but that&#39;s the clinical term for Frozen shoulders adhesive capsulitis which appears to be an acute thickening and contracture of the joint capsule so when we think about a joint you have two bones articulating with cartilage and so you have a cartilage interface that allows that you have typically have a pressurized area of joint fluid that joint fluid periodically gets turned over by the body and you have a capsule which is made of collagen and basically envelopes the entire joint to provide stability this is what um when you if you ever like carved a turkey and you take out the hip and you hear the suction break yeah you&#39;re breaking the suction seal that&#39;s within the joint so inhes of capsulitis is sort of most most common in women between the ages of 40 and 40 and 60 it can incur men as well um and it is the Hallmark is this very rapid onset of decreased range of motion of the shoulder to the point where some individuals can&#39;t raise their arm above their head without necessarily A predating injury some predating injuries can predispose you to it so let&#39;s say you have an acute R rotator cuff Terror you stop moving your shoulder altogether just to protect yourself and you&#39;re not going under undergoing the rehabilitative process perhaps that could actually predispose you to getting your shoulder Frozen it&#39;s also interesting because frozen shoulder is one of the few times in medicine that we can say corticosteroids are meaningfully disease modifying so we use corticosteroids in Sports and Spine practices for pain relief that&#39;s the main purpose their pain relief but in the process of frozen shoulder depending on which article you reference I like to look at the there was one article that described it in a way that I think is very easy understand freezing Frozen and thawing okay so makes a lot of sense if you catch it in the freezing phase and you give it a corticosteroid injection in the joint it actually decreases the duration of symptoms frozen shoulder untreated can lead to potentially years of symptoms in the shoulder so the question is is there is the absence of estrogen and the increasing rise of the um the precursors LH and FSH that are present in the in the state of menopause are these things predisposing to that because we also see it in premenopausal women as well so it&#39;s tough to tell but we know some risk factors for frozen shoulder one of them is obesity one of them is diabetes um and then the other one is perhaps a lot of these perimenopausal females you&#39;re seeing so tough condition to treat but yeah and these are all really important conversations because if we just focus on muscle and we miss tendons than when people get injured you know I I hate to say it it&#39;s not an if but it is a when at some point if you are pushing yourself or sedentary and then getting back into blend you&#39;re going to get hurt yeah and I would also say arguably it&#39;s not always the muscle it&#39;s probably the tendon firste yeah then it is and and and you know it&#39;s interesting too tendons degenerate at a speed that&#39;s quite rapid so if you stop using it it is a so I was thinking when I when I learned about this if it&#39;s very slow on right so it&#39;s 6 to n months for accommodation in tendon for the on phase but it can be a relatively fast off so depending on the degree of immobilization post injury is a potential that your tending could be the weakest element coming back so injuries will find their weakest element your bar biomechanics whatever it is you&#39;re going to find the weakest element in the chain that&#39;s how a lot of times we diagnose pediatric injuries with tendon so in Pediatrics the bone is weaker than the tendon the bone is weaker than the tend and in the majority of circumstances so you&#39;ll see this interesting um this interesting convergence of Pediatrics and geriatrics where because bones are weak relatively weak relative to tendons and muscles in both segments of that population so if you have say an osteoporotic person and they go and they trip and they catch themselves and they evulse their their hamstring right off of their isot tuberosity on the bottom of their pelvis it happens I know I did it but not for that reason yeah sorry so terrible um tough to treat now same thing goes for when you have kids um we will find bone fragments you know things called something called ATT traction apophysitis which is like your oods you see somebody&#39;s knee who has a little bit of a lump on it basically the tendon was pulling on the bone the extensor mechanism of the knee was overloaded and because the tendon was stronger than bone it convinced the bone to do what it wanted which was pulled the bone more towards it now we&#39;ll see that to some some extent in the population in between so if you have say you have a longstanding achilles problem but it&#39;s Achilles tendonopathy or you just overload your Achilles you will see the actual attachment point the bone changes form it&#39;s as if the tendon is pulling the bone up and actually because bone is constantly remod interesting yeah so x-rays despite the fact that tendon is a soft tissue problem so you wouldn&#39;t see a tendon on x-ray you would not see the discreet yeah you&#39;re not going to evaluate it to the same extent so as The Listener is thinking well how do I know if I have a tendon opathy the should I go get an x-ray you would not go get an x-ray I would get an x-ray only to look at the other elements of it but MRI and ultrasound are superior for tendon Imaging so um MRI has a very good degree of resolution and a very high degree of penetrance so the benefit of MRI is we can see to the level of the bone and Beyond ultrasound will stop at the bone so high very high resolution in some instances higher than MRI and so I will find commonly on someone&#39;s in a shoulder I&#39;ll find little in what are called interstitial tears in the middle of the tendon that were not visualized on the MRI because the MRI takes certain cuts the other benefit of ultrasound is dynamic so I can actually put the Probe on somebody have them move their shoulder around and if I&#39;m going to make the clinical diagnosis of you have shoulder impingment I can prove it and I can see is this something where you&#39;re acutely catching your shoulder under a structure that&#39;s going to help me formulate a therapeutic exercise routine for this person on the topic of you know not if it&#39;s when it&#39;s it&#39;s a it&#39;s a tough pill to swallow know and I hate to say it it&#39;s and I hate to say it as well because I do believe I&#39;m one of those people was like in the ideal circumstance could we avoid it yes if you didn&#39;t do anything you absolutely could avoid um but you&#39;re but in that case you&#39;re going to be on a freight train towards a bad state of health so uh you have to make a trade-off at some point now with restoration of normal mechanics and loading and periodically deloading I think we can do a lot for injury prevention and we know what normal mechanics are despite the fact that everyone has different arm lengths and different leg lengths We There are standards of mechanics there is if you look at like an Orthopedics textbook and know look at joint ranges of motion it&#39;ll look at specifically what&#39;s a norm like and these are all these are all Gan distributions bell curves so you&#39;re going to wind up with here you go you have majority of people should have 180 degrees of shoulder flection they should have 90 Dees of shoulder EXT rot external rotation when the arm is abducted you can find these things now if you restore a range of motion a very important principle in muscular skeletal health is mobility and stability okay when I evaluate somebody I&#39;m looking at them on a 2 by two table are you weak are you strong and we&#39;re talking about a specific element of their mechanics not generalized for example um raise your arm up up yeah right is this strong can you push it against exactly and what I what I like to look at is um say I&#39;m examining somebody&#39;s hip and I&#39;m going to isolate one of their Glu muscles with a specific range are you weak in that muscle so I like to look at weak versus strong and Mobile versus stiff weak versus strong Mobile versus stiff yeah so to give you an in for for instance of who kind of fits in each category so for our elderly patients who have unfortunately accommodated a lot of a lot of time and where they are most often stiff and weak so joint ranges emotion decrease with time you get calcification of soft tissues your joint capsules harden a little bit you stop moving them as much so it&#39;s natural to see a normal decreased range of motion as we age so now if you pair that with inactivity if you pair that with somebody who&#39;s uh not engaging in a lot of resistance training it&#39;ll be paired with weakness so stiff and weak because you you hear a lot about that people are very hypermobile yes um and it&#39;s interesting to hear but as they age that they would stiffen yeah just about everybody stiffens to some degree as you age and just about everybody&#39;s more mobile when they&#39;re younger now there&#39;s obviously variations within that depending on what modifiable behaviors you engage in now let&#39;s take for instance the hypermobile patients so hypermobility does come it&#39;s doesn&#39;t it&#39;s not always a dedicated eers Dan Los diagnosis we have something called the biteen score you should mention ERS downlo um because there I do have a few patients with it people are very curious about that just as we&#39;re talking about Mobility because there&#39;s probably a spectrum of it that&#39;s much more common than individuals recognize and it could predispose people to injury and other things so there is a a good evidence-based score it&#39;s called the Bon score that can actually be um that can be performed in the office to test for hypermobility and what we look at is can you bend down to the floor touch your palms on the floor can you bend your pinky back then greater than 90 degrees everyone&#39;s going to be trying it yeah go ahead Mia yeah so there&#39;s other tests within it but there is a spectrum of hypermobility and it&#39;s likely due to genetic determinance of col and um so when we think about is not treatable correct to the degree yeah so it can be treatable with modifiable with exercises and I&#39;ll explain that in a moment but you know these are things these are relative not absolutes so your mobile and weak patients are most commonly hypermobile the mobile and weak yeah so on the 2 by two stiff and weak is elderly you&#39;re mobile and weak or hypermobile now stiff and strong or stiffer and strong is like an offensive lineman if you examine an offensive lineman&#39;s hips they&#39;re not going to rotate a whole bunch but they&#39;re as strong as heck and they can put the power down so that&#39;s stiff and strong stiff and strong is not a bad place to be um then you&#39;re mobile and strong those are your Michael Jordans those are the people and strong that&#39;s that&#39;s the that&#39;s the gril so if you can for every bit of Mobility that you gain you have to be stable so range of motion if I just stretch myself into a range of motion but I don&#39;t know how to act ly activate muscles to protect my body in that range of motion it&#39;s just range of motion for range of motion&#39;s sake not all Mobility is uniformly beneficial in my opinion I believe that if you&#39;re going to have Mobility you need to have accompanying stability and if you&#39;re a more mobile person you have a larger responsibility to be stable through a larger range of motion now what are the determinants of Mobility is a really complicat a topic but you have your bony determinants so not everyone&#39;s hips are shaped the same not everyone&#39;s shoulders are shaped the same and those are your more mobile joints then you have your soft tissue determinant things like collagen play much more of a role there so whether you&#39;re hypermobile in a joint capsule women are more Mobile in their joint capsules than men women have more um type three collagen in their tendons than men so that&#39;s going to influence I didn&#39;t I didn&#39;t know that yeah just broadly speaking okay broadly speaking um so these are these are these are some determinants that are um going to predict some of the soft tissue extensibility and then the mo the mobility aspect and and really how stable you are a huge element of that is that that same neurokinetic element we spoke about before and the athletic accommodation timeline so if you can be stable and you know what muscle to contract in what position Mobility is fine but I for instance I would prefer for a lot of patients to be in a narrower range of motion but much more stable through it than as opposed to having just a very large range of motion if you think about the ranges of motion that we need to accomplish your day-to-day life you need to be able to do a good hip hinge you need to be able to do a good squat you need to be able to rotate um and you need to make sure that you&#39;re you&#39;re you&#39;re producing enough body tension that&#39;s centralized in your core to mitigate injury in those circumstances you don&#39;t have to be an elite um contortionist to to achieve everyday life and that&#39;s why the the concept of stretching is a very interesting conversation to have what we&#39;re achieving with stretching is a very interesting conversation to have should we do it this is going to bring me to the yes or no section oh dear okay so you&#39;re not going to like this because you&#39;re very academic but I&#39;m going you can only answer yes or no okay Pilates yes steroid injections yes zone two sure we&#39;ve never had a guest answer sure ever I think it&#39;s beneficial I think the question the question is the dose the type but see this is very difficult for people always this is why G this is why I&#39;m not on the hill okay if if I wanted to if I wanted yes or NOS i&#39; be a politician Fair yoga um whoa I love this section of the podcast yeah is that a yes or no I&#39;m not I&#39;m not no and I&#39;m not yes I&#39;m I&#39;m I&#39;m gonna bow out of that one I&#39;m GNA use my fifth amendment on that one this then leads me to stretching um stretching can be beneficial okay so it&#39;s not uniformally beneficial the question is what you&#39;re to achieve with it let&#39;s talk about protein specifically first forms Natural Way protein Formula 1 people ask me all the time what kind of protein powder I use what kind of protein powder I recommend Formula 1 makes many different kinds of protein powders different flavors a natural one you pick it it mixes amazing it makes it extremely easy to get your protein in and really they&#39;re it&#39;s a whey protein isolate so you&#39;re getting the majority of your calories from protein in the shake tastes great super easy to travel with great breakfast dinner maybe even lunch whatever you need it&#39;s got you covered and it has all the amino acids necessary will help improve body composition muscle mass all the things that protein does and by the way when do you need protein well you need it every day and that&#39;s why I love first forms protein powder their Formula 1 go to First form.com lion that&#39;s first form.com Lion now then let&#39;s talk about so that we do a so Matt loves having the yes or no because it obviously no answer is typically yes or no yeah but stretching tell us about should we be stretching before activity should we be stretching after um because I ran out of the gym yesterday because my sister said we trained with um Carlos mat he&#39;s my coach and my sister said you know we are done working out we should stretch I&#39;m like for what what are we stretching why are we doing this and then I said I&#39;m going to talk to Dr Gerard because I think you&#39;re wrong we probably don&#39;t need to stretch after we work out okay and now I&#39;m about to be schooled oh well let&#39;s let&#39;s see so there is this is one of those topics that I I have some relevance in but I I I don&#39;t feel 100% an expert level with um I have a lot more to learn on it but I&#39;m GNA I&#39;m going to give it a shot for you so stretching preactivity decreased neuromuscular firing decreased stability not beneficial for power athletes and can we Define power athletes so uh pitcher pitcher um shot putter um Elite powerlifter um you could even throw fighters in there that&#39;s a powerful sport so you&#39;re producing power is force over time so you&#39;re going to produce force over a very short period of time so static stretching probably not beneficial for anything or just we&#39;re talking about power pre pre uh pre-exercise for power generation now stretching there are different categories there static stretching so I&#39;m going to hold a pose for a while typically 20 seconds or more and hopes to elongate the tissue now you&#39;re not just stretching the the tendons you&#39;re not just stretching the muscles you&#39;re also providing neural feedback that can actually turn off some sensors that help to protect you under load are these the goldi spind viribus yeah so GOI see if I remembered anything hey so so GOI is interesting um you know the the other as apparate are also interesting but the the static stretching component perhaps has some benefit post exercise with relation to tendon Health specifically and it may actually help just elongate the tendon and actually if you&#39;re holding a pose maybe like a with an isometric or let&#39;s say you&#39;re going to do a heel drop and just hold it there that could have some benefit now for power or for for Recovery recovery for Recovery yeah now I I&#39;m I say a lot of I&#39;m gonna heavily wait the May here okay because I think it may help but I&#39;m also going to tell you from a personal aspect I don&#39;t do it so I think it&#39;s important you know that I don&#39;t neither does my husband there I&#39;ve never seen that guy stretch ever he&#39;s a smart man so so um now if you&#39;re going to if you&#39;re going to stretch with a hope to teach your muscles how to engage at a larger range of motion than you do PNF so proprioceptive neuromuscular facilitation and the answer for that is PNF PNF proprioception neuromuscular facilitation okay so PNF is a process by which okay so I&#39;m going to um I&#39;m going to stretch say my hamstring and somebody&#39;s going to push against my leg and I&#39;m going to actually try to control ract my hamstring at a larger length than than I did pre-stretch and then I&#39;m going to stretch from there and so there&#39;s typically these onoff Cycles like a 10-second isometric at a one length 10-second stretch at another and you can do that now and the benefit of that is the benefit of that is you are you&#39;re teaching somewhat that the muscle can relax at a larger length Okay so whether pre pre-exercise or post exercise I&#39;m not clear on and this seems to work with um a lot of people do do it with pain is that so is PNF used for mitigation of pain a muscle or yeah it&#39;s used it&#39;s used in rehab so it&#39;s it&#39;s it&#39;s used by physical therapists and atc&#39;s and other people who um who will rehabilitate patients so it&#39;s definitely part of it when I design uh Physical Therapy protocols for patients I I like eccentrics for lengthening so once again Ecentric your your muscle is Contracting periodically or mitigating that um the the elongation process I think that could be very beneficial the stretching component is interesting because once again we&#39;re not just stretching the muscle we&#39;re not just stretching the tendon we are also gliding the fascial layers so here&#39;s another love that you brought this up so here&#39;s here&#39;s fascia another that&#39;s a would you consider that an organ system uh it&#39;s interesting it&#39;s it&#39;s part of the muscular skeletal system but it&#39;s so richly inovated and so large it could be its own category what what is fascia fascia is interconnected connective tissue that can run the entire length of the body incredible here&#39;s why we don&#39;t get taught about fascia as much as we could we should be a lot of it is almost as if we during the process of medical school when we dissect k um dissect kabers it&#39;s gross it&#39;s necessary and it&#39;s absolutely disgusting it&#39;s it&#39;s also um important it&#39;s important and thank you to everybody who donates there who donates their body abely incredible that people are willing to do that when we dissect a aers most fascia dries out so much so that it aderes to adjacent structures and becomes incapable of dissecting it off of now I&#39;ve spoken to some scientists in Italy about this specifically you did you were just hey I wasn&#39;t in Italy it just happen you were just thinking I spoke to I spoke to somebody um basically because ultrasound is one of the main ways to evaluate fascia in the living specimen so there is specific cavic preservation techniques for preserving fascia but one of the reasons we don&#39;t crit really understand it or appreciate it to the level that we do is we just don&#39;t see enough of it so fascia can adapt fascia is if not the most richly innervated structure in the body one of the most richly inated structure in the body that means the most nerves does it have pain so does it feel you feel pain people feel mile fascial pain I believe it is a con it&#39;s part of the diagnostic spectrum of pain so you can have a muscle that hurts you can have a tendon that hurts you can have a joint that hurts you can have a ligament that hurts um in fact also can hurt in my op you feel it if someone were to say would that have anything to do with um fibromyalgia or it&#39;s interesting yeah so the the the concept around fibro is um I think it&#39;s part of it the the fascia is part of the issue um but we also see my fascial pain in people who don&#39;t have fibro you know and so we see M fascial pain and overuse syndromes a very common mile fascial pain that perhaps some people will experience is if if they have a pretty large asymmetry in their head hips how their hips move and function they feel a lot of mof fascial pain in like the top of their glute low back area now it&#39;s tough to discern and I it&#39;s been my job doing this every day Discerning what the main pain generator is and then describing how we can appropriately rehabilitate it and and treat that pain now fascia specifically do adapt to exercise and one of the best books I&#39;ve read about this by a guy by the name Bill paresi so um and he the forward was written by Stu McGill so talks about fascial adaptation to training and that basically this fascia system that extends in some circumstances the length of the body connects your glute on one side to your lat on the other is a lot of the reason that we don&#39;t move like rigid robots so allows us to move much more coherently now the question be in this circumstance is how much of a role is that in in pain how much of how much can we do about it now we know that it adapts some circumstances because there are some athletes that when you take them and train them a certain way they get athletically worse at what they&#39;re doing now there&#39;s changes at the neurokinetic level there there&#39;s changes at the muscle level there presumably there are some changes at the fasal level as well one of the accounts that bill talks about in his book is about um an elite quarterback who was training like an offensive lineman so basically they were putting the quarterback through the lifting protocols on offensive lineman and the quarterback all the numbers around throwing got worse spiral got worse velocity got worse worse arms started to hurt so maybe everybody needs to train towards towards a specific goal because on some level or another your entire body is adapting to that stressor so the you always have to keep that in mind of when you&#39;re training an athlete they can&#39;t all be treated the same not any exercise is uniformly the perfect one for everybody um for their specific needs you have to you have to do an individual needs assessment for that patient so FAS is very interesting um we do visualize it on and specifically where fascia are where the small nerves like say for instance the nerves that talk to the the muscles of the back fascia are the fascial layers are where they travel so the thought is behind my fascial pain is could you have these layers that are not appropriately gliding on each other and patients who have chronic pain there&#39;s some evidence that suggest that they don&#39;t Glide that well rounding this back up to the initial question around stretching um stretching also Glides fascia and so does that have its own therapeutic benefit could that actually be helping produce these proteoglycans these lubricant that are present in the body the same way that they&#39;re in tendons so is is it a lubrication problem and can we facilitate that with stretching so then there&#39;s also the question of Mile fascial release and what we do for individual people my I&#39;m less concerned about the modality we use to get people Mobility so much as I am more concerned with us restoring stability through that Mobility really well said I&#39;m learning just so much can we talk a little bit about training yes I&#39;ve learned quite a bit and you really have helped me reframe in fact we&#39;re working on a second I&#39;m I&#39;m working on a second book proposal and I&#39;m hoping you will be so gracious as to um impart some of your wisdom in in part of that process and I&#39;ve learned a lot about think thinking about how we train the current Paradigm the current narrative is all about zone two M it is um that zone two is where we need to focus and then we have other groups that we talk about resistance training do it three to four days a week There&#39;s and understandably so there is only so many ways that we can make Global recommendations yes that being said I would love your take about um you and I have spoken about minimal amount of movements exercise kettle bells more effective ways to utilize our body I&#39;m just gonna leave that for you to take it wherever that you&#39;d like to sure so the concept of Zone 2 is an interesting one I think that a lot of the excitement around it is that it&#39;s helping to promote mitochondrial function and that mitochondrial function appears to be absolutely essential as we age and can we improve mitochondrial function to decrease things like insulin resistance improve metabolic Health improve our athletic performance and the concept there it&#39;s interesting to see how depending on what you look at these different terms that describe similar phenomena so submax V2 training Zone 2 moderate intensity continuous training I did a presentation a while back um specifically as it regarded patients who were recently diagnosed with cancer undergoing cancer treatment or finished cancer treatment and what exercise recommendations we could make for them because their V2 Max and Muscle Max muscle mass help predict how they do and we know that quality of life mortality morb morbidity the more fit you are from a cardiorespiratory and muscular aspect the better you will do with treatments so how can we help people and so the question was in the presentation should we be engaging in high inter intensity interval training um or moderate intensity continuous training and the answer is of course both can be helpful per uni time high-intensity training might be more beneficial to your V2 Max upwards but what are we really thinking about with V2 Max one is if we&#39;re going to test V2 Max in somebody they should be familiar with the movement of which we are testing them it&#39;s not fair to say somebody has a suboptimal V2 Max but it&#39;s their first time doing a certain athletic activity they&#39;re never going to be you&#39;re going to be gassed if if I even if even if I&#39;m I&#39;m a marathon runner if you throw me into a boxing earring I&#39;m going to be Gass in two rounds because now you might be amazing but a normal person yeah but um the truth is as I would be guessed and the it&#39;s because I&#39;m not familiar with the movements is the way that I should be so it&#39;s important that&#39;s important caveat don&#39;t get down in yourself if your V2 Max is not where you think it should be because you did some modified Bruce protocol in a gym it might not be where it should be because you don&#39;t have a familiarity with the movement if you&#39;re on a bike there are so many determinants of how your performance on a bike absolutely your positioning your familiarity with it what muscles you&#39;re activating your shoe angle with with with with the actual pedal um and I&#39;m out of my league there I know that that&#39;s that the very very surface layer of it so we&#39;re looking at substrate utilization fats versus carbohydrates versus creatine phosphate and we&#39;re looking at what can be done um to maximize fat oxidation so this concept around Zone 2 as I understand it is fat Max like we&#39;re trying to maximally use fat for fuel while we exercise to teach our mitochondria to metabolize fat more readily to decrease insulin resistance that&#39;s what makes sense to me at least now uh with high-intensity interval training there&#39;s no I think the downside of zone two is time I think that&#39;s it I think you have two children and a beautiful wife and a full practice yes and time is tough so I I don&#39;t engage in a ton of Zone to myself if I had more time in the week perhaps I would but then high intensity high-intensity interval training appears to be as beneficial for v2 Max as as the zone 2 but you&#39;re training it two different ways from high intensity interval trading you&#39;re like raising the ceiling of your house higher right you&#39;re just you&#39;re getting better at pushing it higher but the V the the zone two training appears to be that like you&#39;re solidifying the foundation you&#39;re getting better in the lower levels that predict success at the higher levels so we might be describing it this way but athletes have intuitively known this for decades when they run they&#39;re not gassing themselves every workout they leave a little bit on the table and the body goes through a period of compensation to basically mount response to that stressor and then when they do peak one or two times a year they&#39;re in really good shape so same principle applies to weight training so are should we or could we be going to neuromuscular failure if our goal is muscle hypertrophy should we be focusing on just muscle hypertrophy and specific muscle segments or generalize strength and instability I think these are good questions but the um I find the way I trade with kettle bells um is I want to be number one thing for me is don&#39;t lose stability in all three planes of motion sagittal transverse and frontal like we spoke about before when you work a kettle bell um most of the time it&#39;s in one hand and that by Nature destabilizes you and you&#39;re not going to get destabilization if you&#39;re working only with barbells so if you&#39;re you&#39;re not going to get destabilization working with bar balls only you know as it relates right as it relates to the frontal and the transverse plane so you&#39;ll be stable as all heck in the sagittal plane if you work with the barbell I was the sagittal plane hero I went to the gym and I did well done bench lats I did squats I did deadlifts and I became very proficient in those areas but then I would go play golf and like things would hurt and i&#39; be like well well that&#39;s interesting you know I&#39;m not the world&#39;s best scaler but it shouldn&#39;t hurt as much as it did and I thought it was basically because I wasn&#39;t as proficient in translating force in rotation so I like to use a kettle bell I think you can get a lot out of it I think the the work from the strong first organization and um and Dan John on online and his own uh Endeavors have done a great job elucidating the cardiorespiratory benefits of kettle bells that you can get strength and conditioning um and so I try to follow that I I also do something and we spoke about this this term exercise snacks which I don&#39;t particularly love but I don&#39;t either I I but I can&#39;t think of we&#39;ll we&#39;ll find a way to Rebrand it but um definitely yeah um I call call it farm hand strength so like if you&#39;re working on an outdoor let&#39;s say you&#39;re not a farm hand let&#39;s say you&#39;re just somebody mulching your yard you&#39;re not going to um basically go to the point where you&#39;re falling down every single time you&#39;re going to leave a little bit on the table you&#39;re going to come back to it you&#39;re going to go do a different activity for a short period of time and you&#39;re going to come back to it and so what I do what I&#39;ll do is I&#39;ll intermix like some sets of kettle bell swings throughout the day I might do a set at 9:00 a.m. and do a set at you know 10:30 I&#39;m not looking to build a sweat I&#39;m just looking to get better at at the movement so I&#39;m really stressing that neurokinetic element am I getting more am I getting better at the movement am I doing a little bit of stimulation of muscle but by no means am I getting a you know a skin ripping pump out of it but potentially you could build a workout like that yeah there&#39;s the a com there are you know when we look at some of the really good uh people who are training um and what they do and a lot of Rehabilitation from injury sometimes it&#39;s three five 10 minute rests you know and so question become I think in there is do you want to be really do you want to be super proficient with a movement or do you want to get as much training in in a short period of time as possible so there&#39;s different strategies there but we move throughout the course of the day it&#39;s not like we only move for 30 minutes and then we&#39;re immobilized for 23 and a half hours so the concept of going to the gym I think is something that needs some work where we we we think about going to the gym we dedicate time but should we be interspersing movement throughout the day I think some people fortunately in their jobs can do that and some people unfortunately can&#39;t do that um but I like like you I saw you both do a set of push-ups before as its own little stimulant prior to the podcast our that&#39;s our um pregame push-up there you go we we do a a podcast ritual now is is that not helpful because you only did one set of course it&#39;s helpful you didn&#39;t know that we&#39;re doing some after this well I&#39;m happy to do it um but you did you did one set in isolation and you benefited from not overloading your tissues you benefited from a short-term increase in your heart rate you learned how to become a better push uper and that has something to do with it too so I think the coming back to the concept around zone two it&#39;s if you were to train I think the the probably what makes sense for a metabolic corollary with weight training is like if you&#39;re going to neuromuscular Fair your muscles are on fire you&#39;re not in zone two right I think we can comfortably say that right yes so your probably in zone five or four or five so you&#39;re you&#39;re really getting there now if you train and you say you do 10 repetitions of something explosively and then you wait a couple minutes and do it again could you still be in zone two and that&#39;s the this concept that has come up called anti-g glycolitic training which is um a way to build endurance and strength um which has been subject to my own personal Fascination I&#39;m not in a position where I could speak from an educated perspective on it a lot of the literature behind it is in Russian so so I can&#39;t read get learning but I&#39;ve read pavo&#39;s work and pav does a great job with that um and I&#39;ve I&#39;ve recently read a couple of his books and I think it&#39;s something I&#39;ve experimented with the same way that we might all experiment with Zone 2 or a hit training or powerlifting or whatever it might be I a lot I think one of the benefits to my patients is that I I&#39;ve gone through the process of experimenting a lot with this played baseball and football I was a personal trainer um I did a good bit of just you know casual powerlifting I tried to be you know a a crappy bodybuilder for a period of time and I wasn&#39;t great at it but uh and then on top of that you know I might not have I might might not be running a marathon like Shane in a couple weeks but I did run a half and you learn so much going through those through those individual experiences so I try to maintain a radical open-mindedness about what could be helpful and and try it myself when if I can and that&#39;s really valuable a physician that sees patients and also walks the walk and experiences it and I I do think that you bring a very unique perspective um in your practice how do you incorporate some of these things so you practice in um where are you in practice right now I&#39;m in Floren Park New Jersey I work for Summit Health okay and people could make an appointment with you if they would like to I so let me just tell you guys something every guest is incredibly vetted before they come on the podcast I have so much respect for Dr Gerard I send patients to him if you are in the area if you are not he is definitely worth the trip I would love to hear a little bit about what makes your practice different unique we&#39;ve heard a lot about your philosophy and how you think about things from both a biomechanical aspect I know where you sit from a nutritional aspect but also um you&#39;re Fellowship trained yes I I&#39;d love for you to expand upon your training and just your individual practice so my my practice is a Sports and Spine practice I did a Sports and Spine fellowship at the hospital for special surgery which by the way is one of the best in the country if not one of the best places in the world yeah it&#39;s a great place to train a great place to be I&#39;m I have been I think the very important take-home for anybody who&#39;s listening outside of me kind of speaking about myself for a moment is if you can find mentors that are really good for you really pursue their mentorship yes um that&#39;s how that&#39;s how you and I have developed this relationship I have um a mentor almost at every different phase of the career so I kind of have mentors that are closer to me in age I have mid-career people I have later stage career people and I also have mentors who are non-clinical or not even doctors you know who who are out people in different fields getting their perspective has been so important and anything that I do is is the great Fortune of having a great family and a great upbringing and great wife and kids at home and parents and brother and friends so I I&#39;m fortunate that that every day I go to work I feel like I bring the best version of myself because I have a great backing amazing now from my perspect for my practice my practice focuses heavily on the biomechanical determinance of pain and when we patient comes in let&#39;s say I see a back pain patient it&#39;s less difficult to make the diagnosis of a pinch nerve in the back from a herniated disc and more difficult to discern why that disc herniated and to unravel in a relatively short time frame what determinance in that person&#39;s life or in their training predispose them to that injury and how are those things going to be encumbrances to them getting better in the future so that takes some refining and I&#39;ve gotten better at it with time but uh every day we try to build a little bit and I try to find what is motivating this person what are your goals and I ask every patient what are your goals for this visit some people just want Clarity of diagnosis well the first thing we need to do beyond anything else is Clarity of diagnosis from a biomechanical element and from a tissue layer element do you have a herniated disc yes why repetitive flexion movements without appropriate lumbar stabilization insufficient HP mobility and then they didn&#39;t have the appropriate brace from the obliques that&#39;s a good starting point now let&#39;s use this inflection point of injury and let&#39;s build you back to a point of antifragility so the concept of antifragility is one that I borrowed from Nasim talib&#39;s book uh which is one one of four books in the inero which are very difficult and fun to read um I love I very thick book yes very thick there are books about everything if you ask me what they&#39;re about they&#39;re about everything but this concept of anti fragility is actually a concept that is exhibited in muscle and tendon and Bone which is you provide a stressor to a structure it doesn&#39;t break but in time if the stretcher is adequate stresser is adequate the Str the structure can actually get stronger so I branded myself antifragile MD because I love that concept I love that&#39;s the essence of my practice can we use stressors rather than hurting you and disabling you to make you stronger yes sir so well said and I know that&#39;s you too I know that&#39;s you too so um I look at is can we get people from a point of injury to back to a state of athleticism and what are the goals do you want to be on the the ground plane with your grandkids are you somebody who&#39;s going to run a marathon in a couple weeks and we kind of look at all these things in the variety of treatments that I can offer and when there is an Evidence Bas to draw from we will draw from that evidence base if there&#39;s no evidence based to draw from an area we&#39;ll extrapolate based upon the knowledge of my bi biological foundations so but I I my practice is is a Sports and Spine practice so I see a lot of hip pain back pain um shoulder pain neck pain to a li Li extent elbow and then of course um knee and some ankle ankle foot as well and the two main three or four main conditions I treat are back specifically low back pain tendinopathies around the body and then a lot of neck pain and you&#39;ll find that patients who have low back pain have tendinopathic problems as well and you&#39;ll find in the in shoulder it&#39;s it&#39;s a whole sling so the whole whole sling can have problems but I I think it&#39;s you&#39;ll find specifically that there there are insufficiencies in the in the pelvis and the peripelvic muscles like the glutes and so it&#39;s not uncommon to find a tendon problem there so I like to uncover what the root cause is and that&#39;s really what gets me out of bed every morning is root cause diagnosis and then if your diagnosis is accurate and you can correlate it with the diagnostic testing we have x-rays M ultrasounds Etc and it matches up with a good physical exam well now we have CL CL ity of diagnosis then the treatment everything we provide from a treatment aspect there out is much more beneficial and what I love about what you&#39;re saying is it&#39;s not about the end pain or the end symptom it&#39;s a root cause approach which traditionally medicine is not about a root cause approach and that&#39;s what I think what makes you and your practice so exceptional is that what is at the foundation so that you can get people better where do you see the field going so I think that there&#39;s uh a good interest around regenerative medicine and there are a variety of regenerative therapies that we have now PRP um you know we spoke about the athletic accommodation curve there&#39;s also the you know the Innovation curve of companies and products and I&#39;m instead of like being on the absolute first phase of stuff I&#39;m probably one phase delayed I I feel the same way we have to make sure that things are safe effective while for patients to spend their money yes agreed um and first rule of medicine is Do no harm that&#39;s right so Do no harm anything we do we want to understand what we&#39;re doing we want to put it in the right place um so I think there&#39;s some very interesting work that&#39;s going on from a stem cell aspect um fat concentrate procedures further subcategorization of PRP when to use it when not to use it and I think the field will continue to develop that I think as we evolve um as a field going forward we&#39;ll begin to understand a little bit more about things like fascia we&#39;ll begin to understand a little bit more about mechanics other than just isolated joint range of motion and whole body movement um I think that the it takes a lot of interest in that and study to do it but I think we&#39;re getting there and I think the the Last Frontier is in in a lot of ways the first most important which is prevention ounce of prevention is worth a pound of cure and how can we prevent these injuries or you know you see this word circulate on like bulletproofing like we going to bulletproof your shoulders bulletproof your knees um and so that&#39;s where a lot of my own self- experimentation comes in and trying to learn that as well as watch people do it and experiment with that but as a field um I hope we I hope we study more of that and then of course predictive U Predictive Analytics around who who is going to wear a joint in a specific pattern based upon their bony development we have some evidence to understand that now particularly in the hips but in the we&#39;re starting I think to in a greater degree to look at that in the shoulders and surgeons specifically are doing a great job of looking at that and then from a tendon aspect you know like we said are there exercises we can engage in I&#39;m certainly going to do my best to find out and I think and to and to figure out what is the most effective ones I think the the question becomes minimally effective dose of everything yes training medication yes how much is too much and are we overtraining tissues and that&#39;s why we&#39;re seeing so many muscles skeletal problems or are we just inefficiently training and is it because we just don&#39;t know how to do it if you can restore you know quote unquote normal mechanics it varies from person to person but if you can restore normal mechanics a lot of things get better and I think what we&#39;re seeing now is people like yourself are doing a great job of highlighting well we need power we need muscle mass we need cardiorespiratory potential um what movements can get all of those in a in a minimal dose of time because we&#39;re all busy and then what nutrition can Empower those goals and what sleep you know determinants can help us so I love how holistically you look at everything because you can&#39;t look at one thing in isolation the body is not isolation everything works everything works together and it&#39;s funny we we have this concept of organ systems and things like this and it&#39;s uh when you look at the the muscular skeletal system it&#39;s like well B cells are present in chronic tendonopathy does that mean it&#39;s now part of the immune system you know it&#39;s they all work together they&#39;re all constantly connected and and communicating with one another to generate our homostasis so hopefully we understand more about the aging process what we can do in the prime years to to to arm ourselves to that and then what activities we can really get back people back to as they Age and and age gracefully Dr Gerard denafo thank you so much for spending time with us you are a wealth of knowledge I&#39;ve just been very impressed with you over the years and you continue to impress me thanks for having me on where can people find you so I&#39;m on uh Instagram as antifragile MD and then my um my website is with my employer Summit health so if you search my name Gerard denafo you&#39;ll find that I have a web page there and you can book appointments from that point and over time I think um I&#39;m also on YouTube at antifragile MD and uh we&#39;ll be publishing more content in the coming months and years yes sir thank you again thank you

welcome to the Dr Gabrielle lion show today I am honored to sit down with my friend and colleague Dr Gerard daao he was chief resident at Colombia and Cornell and did a fellowship in Spine and Sports at HSS which is the hospital for special surgery he is a physical medicine and rehab doctor and in this episode are you ready for it we talk about what you are missing if you only focus on muscle Health how tendons are the key to longevity and the role of hormones in tendon Health we talk about this and so much more as always I produce this content for free please take a moment to share it subscribe rate it like it you know the drill and if you are not part of our community head to my website Dr Gabriel lion.com and join us because remember we are Forever Strong together Dr Gerard denafo thank you so much for joining me I am very excited to have this conversation you and I have known each other for many years now you are extraordinary you are a physiatrist you&amp;#39;re going to explain to The Listener what that is and I&amp;#39;d love for you to talk about a little bit about what you&amp;#39;re doing and how you got here fantastic so thanks for having me on so physiatrist is a specialist of physical medicine and rehabilitation so I did my residency in physical medicine and rehabilitation and you can think about that as a combination of a few Specialties so it&amp;#39;s a bit of Neurology a bit of Orthopedics a bit of internal medicine we take care of patients along the entire spectrum of disability and ability so throughout the course of my medical training I&amp;#39;ve taken care of patients with stroke hemiparesis and hemiplegia spinal cord injury patients worked a fair bit at the VA taking care of our veterans and then I&amp;#39;ve also been on the sidelines of professional sports teams as a assistant team physician for the Nets organization and the Red Bulls organization so I&amp;#39;ve seen human movement disability dysfunction pain these things and a physiatrist is a non-operative specialist specialist so we go through a variety of non-operative ways to help patients with their pain function Etc and basically improve quality of life uh it&amp;#39;s amazing because it actually takes human movement into medicine yes why why why did you choose this specialty and by the way you know you&amp;#39;re a very fit guy um but it&amp;#39;s un it&amp;#39;s an unusual specialty I would say yeah so I I started to learn about the specialty right as I was thinking about going to med school and I prior to medical school was a personal trainer and so what I used to do is uh during the Summers of college I studied up for my personal training certifications I used to be a personal trainer and I loved every second of it you get so much experience watching how people move and you get to see what it looks like when somebody has a dysfunctional movement pattern when they&amp;#39;re being loaded correctly and you really see what happens when you load a system and that&amp;#39;s what this all comes down to so we&amp;#39;re loading somebody&amp;#39;s biomechanics either those biomechanics are functional and they&amp;#39;re going to improve they&amp;#39;re going to put on muscle they&amp;#39;re going to gain speed they&amp;#39;re going to gain functionality or you&amp;#39;re going to have dysfunction that leads to pain and disability whether it be something like back pain or tendinopathies which we&amp;#39;ll speak more about but as a personal trainer I wanted to go into a field where exercise was a really important component so we pride ourselves as physiatrists as having very close relationships with physical therapists and writing detailed Physical Therapy prescriptions so we really are uncovering in the office what are the biomechanical determinants of pain so let&amp;#39;s take for instance your shoulder hurts but your shoulder might be more the end product of dysfunctional movement at your shoulder blade so uncovering with a good physical exam and using things like x-rays MRIs CAT scans on the spot ultrasound and of course taking a very thorough history you could put together what is really the dysfunctional biomechanical diagnosis and then at the tissue level what&amp;#39;s occurring so my residency training in Physical Medicine Rehabilitation preceded my sports medicine training and all of this has led to me having a great appreciation for the muscular skeletal system how it works and we were connected several years ago because I saw that you were talking a great deal about muscle Centric medicine and a lot of the endocrine determinance of muscle the importance of muscle as we age and looking at this holistic Ally if you were to think about how say a nefrologist goes into their training like Shane Urology they look at the macro structural approach they look at the micr functioning approach so like how does the organ actually look in the body what is it made of and then what does it do so I&amp;#39;ve been you know viciously consuming your work and I&amp;#39;ve read your book and I i&amp;#39; I&amp;#39;ve found great appreciation in it because it&amp;#39;s looking at I&amp;#39;m looking at the muscular skeletal function from Locomotion walking lifting things athletic Endeavors throwing kicking Etc but we&amp;#39;re also I love that You&amp;#39; brought to the table and to the scientific conversation what is the actual biochemical aspect of that now we&amp;#39;re looking at the organ much more from the entire spectrum of what it is and quite frankly you and I have again been talking for years so it&amp;#39;s really nice to be able to sit down have a conversation of course this is the beginning of you and I are working on um some projects behind the scenes you bring in a very important perspective it is wonderful to think about the health of SK Del to muscle from a metabolic standpoint from its impact on fasting insulin fasting glucose triglycerides and that&amp;#39;s impact on say Dementia or cardiovascular disease the question becomes how do we get to these what I would consider inflection points inflection points of Aging or inflection points of disability I love how you said you look at individuals um and take care of them them through disability and ability yeah I really appreciate your perspective on skeletal muscle as its organ system which is exactly what physiatry does but I Al I also think that you have a very unique perspective that brings in um very closely the biome mechanical aspect that I don&amp;#39;t think is actually super common in Physical Medicine and Rehab we talk about it as Physical Medicine and Rehab but your perspective is certainly becoming and you use this tagline in your Instagram antifragile yeah which there are a number of topics that I&amp;#39;d love to discuss on this podcast um which included are not limited to the things that limit our ability to progress like tendon issues yes like back pain hip pain things that ultimately limit the quality of life for individuals and then other things Beyond like should we stretching but let&amp;#39;s start with one of the things that I think that we both see in clinical practice are issues with tendons yeah and why are tendons important what are they how do we think about them in in a global sense sure so muscle is contractile tissue muscle is made of actin Mouse and filaments you have this incredible cross-linking phenomenon that&amp;#39;s mediated by our energy molecule ATP and we contract muscle and ultimately to move bone but muscle doesn&amp;#39;t attach directly to bone it attaches to Bone through tendons and collagen is our most abundant protein in the body and no surprise tendons that tendonous attachment from muscle to bone is predominantly made of collagen so tendons are by definition they are non-contractile tissue they&amp;#39;re almost like if you think about a short bungee so they exist in a relaxed State called the crimp State and when you when the muscle contracts it pulls on that tendon takes the slack out and then it winds up attaching to the Bone to move the bone and attendons have this incredible quality called visco elasticity which is a cool word but everyone is going to be quizzed on this later there you go so viso elasticity it means that the the mechanic the mechanical behavior of that structure changes the degree of strain that you put on it so at low strain rates tendons dissipate energy at high strain rates they really put down the force and so you can think about as you&amp;#39;re walking you might be putting a lot some tension through your Achilles tendon by definition um but you&amp;#39;re not putting as much tension through it as you are when you&amp;#39;re running and it&amp;#39;s a really tight spring so the mechanical behavior of it does change the tendons are um an sort of an organizational level you know muscles have the contractile elements you have muscle facies um and facles for those who are listening are bundles of proteins so you have this structures you have a larger structure and then you also have in within that these composition of these micro structures of fases and fases are a fascinating thing because they are present in muscle tendon and nerve and the reason for that is because we don&amp;#39;t F we&amp;#39;re not uniplan or individuals we don&amp;#39;t just function in one plane we function in forward and backwards left and right and also we rotate and so muscles and tendons as they&amp;#39;re trying to move a bone they need to have specific elements stressed not the entire not the entire system stressed simultaneously but the fast schulls actually allow for tendons to be strained specifically so you could think about like a pitcher so a pitcher the job of a rotator cuff this is this is a cool point that I really like the job of a rotator cuff is actually to stabilize the ball on the socket we think about rotator cuff strengthening exercise you&amp;#39;ll see a lot of people with bands and cables and strengthening up the rotator cuff and it does that it does rotate the arm hence its name but the shoulder is an inherently very mobile joint um it&amp;#39;s comprised of four different joints actually it starts over here and at the stern cicular joint you have your AC joint and then you have your true glenor hemal joint and you have the the scapula shoulder blade that rests on the back at the rib cage so there&amp;#39;s a lot of mobility in it which is why on average unless you&amp;#39;re a rocket you can raise your arm higher in the air than you can your leg okay so similar ball and socket joint with the hip but more stability there job of the rotator cuff is to stabilize the the head of the the ball and socket joint it&amp;#39;s almost like thinking about like a a golf ball on a te so as you raise your arm into a pitching motion all of your rotator cuff muscles are active but different fasal are actually more stressed during different phases of that so that&amp;#39;s one of the fascinating elements of this it&amp;#39;s a really cool mechanical adaptive thing that we&amp;#39;ve evolved to have and we have it in all those mobile structures of the muscular Scuttle system we have it in muscle we have it in tendon we also have it in nerves to allow us to be more athletic and multipler motion so it&amp;#39;s very it&amp;#39;s very cool and and collagen itself is it most most of tendon dry weight is type one collagen and then you have lesser components of type 3 uh type 11 you have other types as well and when a tendon starts to become diseased or overloaded that can change it&amp;#39;s actually part of the process of developing tendonopathy um let&amp;#39;s talk about tendons would it be fair to say that you couldn&amp;#39;t have a healthy muscle without having a healthy attendant or vice versa yes so it is fair to say and it&amp;#39;s fair to say because we have general principles you know we use this word homeostasis to describe how everything is regulated healthy muscle to exhibit its mechanical effect of moving bone effectively needs a healthy tendon you can develop your muscle it&amp;#39;s actually muscle will develop more quickly than tendon adaptation occurs muscle will develop more quickly than the tendon adaptation and is that why designing a really good training program is essential to avoid injury because essentially the people listening are thinking well why do we care about tendons yeah nothing will take you out of the game faster than a ACL tear than an Achilles r rupture tendonopathy which then becomes chronic um could you have a um I suppose a better question is which goes first yeah so this is a something known as the athletic accommodation timeline so when you start let&amp;#39;s say you&amp;#39;re not a runner or I I I could speak from a position of truth I&amp;#39;m not a runner so I neither yeah yeah um so let&amp;#39;s say I start running the first thing that occurs in the first six weeks is I learn how to run better and basically that&amp;#39;s called neurokinetic response so starting all the way up in your brain at your motor cortex and going all the way through your nerves as they go through your spinal cord and go through your peripheral nerves and into the muscle you learn how to coordinate your motion you basically learn how to use your muscles for more efficient motion so if you were to test my ability to run in the first day it&amp;#39;s not going to be as good I&amp;#39;m going to be much more gassed I&amp;#39;m going to go deep into those energy zones I&amp;#39;m going to really kind of stress to do the activity but I get better at it with time then in muscle tissue during after the first couple weeks you start to get cyop plasmic hypertrophy so your your muscles start to bring in some products to help them function now the body perceives it seems putting down collagen putting down protein from one aspect we have a substrate driven issue which I think you&amp;#39;ve elaborated on the importance of Lucine the importance of protein intake then the other aspect is you need a continuous stimulus to convince your body to say we need to put down some new framework here so then you start laying down some muscle by the time your tendons and ligaments start to adapt to the athletic Endeavor you engaging in you&amp;#39;re almost looking at six to nine months and that is much more of a significant timeline than it would take for a muscle yeah to adapt and by the way tendon turnover is very slow it is so as opposed to muscles which have a very rich blood supply and a rich nerve Supply tendons do not have a rich blood supply they&amp;#39;re relatively avascular compared to muscle so they&amp;#39;re not going to turn over as fast about 90% of ATT tendon is more or less static and then you have maybe 5 to 10% that&amp;#39;s the variable element that changes with time so this is the one of the important principles that I think gets missed we hear about this concept of progressive overload well you&amp;#39;re not just Progressive overloading your muscle you&amp;#39;re progressively overloading your tendons you&amp;#39;re progressively overloading your joint capsules your ligaments Etc so this is when it my I sort of hearken back on my personal training principles I say well where is the periodization where are we dropping back where&amp;#39;s the D loing where&amp;#39;s are we working towards a goal in two to three months and then are we scaling back and maybe changing and kind of starting back from a point just ahead of where we started before you can&amp;#39;t just progressively overload until you find yourself into injury and that&amp;#39;s something I very commonly find one of your quotes I&amp;#39;ll steal from you is um you can&amp;#39;t change what you don&amp;#39;t track and it&amp;#39;s and it&amp;#39;s too true and some people are very nuanced they know their bod really well they&amp;#39;ve been training for 20 30 years they may not need to track as much but if you&amp;#39;re a beginner or even an intermediate and you need to think about I want to train I I have a I have a long-term goal well your short-term goal should be proceed without pain without dysfunction and really just knock down the goals that are in front of me as opposed to train until I get an injury and change the training types for instance or give it up altoe right and that&amp;#39;s so so important I see that in my office all the time I I ask what does your training program look like well I do you know they&amp;#39;ll tell me a split I do back and buys on Mondays I Do shoulders and tries on Tuesdays I chest on Monday Universal chest day there you go I do uh yeah sorry yeah probably chest on Monday Matt Matt only does chest on Monday Matt Matt has a good chest so lots of push-ups lots of push-ups um and you&amp;#39;ll tell me a training split per body part but what about the global period like what how are we actually looking at the overload of these tissues over 2 to 3 months and what is the expectation is the expectation that you&amp;#39;re going to progressively overload until you&amp;#39;re the world&amp;#39;s strongest person or are you going to have to scale back this episode is brought to you by timeline nutrition uh mitop pure the product that I wish I had developed but didn&amp;#39;t so I&amp;#39;ve teamed up with timeline nutrition to bring you one of my ultimate favorite products and that&amp;#39;s mitop pure mitop pure is a science-backed urethan a urethan a sounds like a species of something or other what it is it&amp;#39;s a postbiotic and 30 to 40% of you humans cannot make it why is it important it&amp;#39;s important because it&amp;#39;s one of the first gut muscle access connection mitop pure helps the muscle and all mitochondria when you take it you can take it in pill form you can take it in um powder form I recommend trying the starter kit they have ginger and ber I put some in my yogurt it&amp;#39;s amazing here&amp;#39;s what it does for you it will improve your potentially your energy your strength your endurance again mitop pure helps with mitochondria hence the name mitop pure it helps with the Regeneration and cleaning out old mitochondria and if you remember anything about I don&amp;#39;t know fifth grade science mitochondria they are the PowerHouse of the cell so you have to have good mitochondria to have good energy and one of the Hallmarks of Aging is a decline in this mitochondria so if it sounds like you need more energy more strength more endurance and something that tastes great mitop pure is a way to go go to timeline nutrition.com lion that&amp;#39;s timelin nutrition.com lion and you&amp;#39;ll get 10% off your first order I recommend either the starter pack or the pills try it I know that you&amp;#39;re going to feel great back to the episode when you think about injury where do you see them and again you are a clinician you are seeing a lot of patients every day from a very early um early hour you know I&amp;#39;ll call you in the morning we&amp;#39;ll have some great idea and you&amp;#39;ll already be there reading that&amp;#39;s right very early what are some of the most common things that you see as it relates to tend tendon injury and I I really like how you discuss this Progressive overload is there something that we can do now that potentially can change the way that we move so that we don&amp;#39;t have to deal with these injuries that um seem to really inhibit our capacity to live right like you said sometimes individuals will say well I used to do bench press but now I can&amp;#39;t because I have I don&amp;#39;t know tennis elbow sure sure and it&amp;#39;s not the muscle that the problem it&amp;#39;s the tenant it is that&amp;#39;s right um You Will frequently you know and to some degree frequently depends on what you&amp;#39;re seeing but you will see muscle strains um and muscle strains can be on a graded scale but the more frequent thing that I see in my practice is tendonopathy and the most common tendonopathy I see are rotator cuff tendonopathy specifically one muscle in the rotator cuff named the supinatus and the Latin terminology means that&amp;#39;s above the spine of the scapula so it&amp;#39;s one of the higher ones and then I&amp;#39;ll see a lot of Achilles tendonopathy a good bit of patellar tendonopathy which is KNE right yes that&amp;#39;s right so um and then Glu tendonopathy and that&amp;#39;s one that really impacts um a lot of people over the age of 50 and is very much present when someone&amp;#39;s walking so if you think about the importance of walking as it relates to not just calorie expenditure quality of life Locomotion um one of the most common things I see is something called greater trochanteric pain syndrome otherwise abbreviated as gtps um some people know it by a similar term which is btis okay so when when somebody has a btis and a lot of times you&amp;#39;ll get the clinical diagnosis of btis you can get either a traumatic btis or an btis because you have an an adjacent tendon that has a low grade of inflammation more commonly I see the adjacent tendon that has a low grade of inflammation bersus sacs they exist in the body to allow tissues to glide on each other so we commonly see the greater choke andic Bersa which is in the in the sides of the hip that may be a little bit inflamed because the Glu tendons from the glutitis medius which is on the side of the hip and the glutitis Minimus will be inflamed because they&amp;#39;re not connected to a rather they are connected to a muscle that&amp;#39;s not doing its job and are there movements that we should all be able to do or is this um an impairment in our ability to be able to move appropriately yeah so some of it is the basic Sports Medicine principle of you have a loadbearing tissue you have exceeded the loadbearing capacity of that tissue and that tissue is now an a state of disrepair that is the Hallmark of tendonopathy so whereas tendon tear the collagen fibers actually separate tendonopathy is characterized by a state of chronic disrepair white blood cells are in the area you start to aggregate things like fat molecules you start to have the collagen type change a little bit and your body actually grows little nerve rootlets into the area to sense pain more readily oh that&amp;#39;s not good that is not good and it&amp;#39;s actually it&amp;#39;s an interesting phenomenon because it is also preserved that the same thing just like fast schs or in other places the same thing occurs in intervertebral discs in the back you have a collagenous structure without a rich blood you know you have a nerve Supply at Baseline but the more frequently that you injure it it actually there&amp;#39;s good scientific evidence to suggest that there&amp;#39;s little nerve roots that will grow into the area and make you experience pain more readily basically telling you to stop it stop shut it down for a while so I think one of the things that you you don&amp;#39;t ask me about what could all we all be doing take stock of what&amp;#39;s bothering you listen to your body if you are you&amp;#39;re training shoulders and you&amp;#39;re doing a set of military presses but that night you notice that you&amp;#39;re waking up and the side of your shoulder is hurting in the middle of the night that&amp;#39;s a sign that one of your tendons is a little a little bit of pain and might have the beginnings of tendonopathy reexamine how you&amp;#39;re doing a military press maybe sub that movement out for the time being don&amp;#39;t ignore those things there are good pains and there are bad pains good muscle soreness I think anybody who trains you know it you feel good it&amp;#39;s a you get the Endorphin release um you&amp;#39;re for instance providing a stimulus to the tissue and it&amp;#39;s and it&amp;#39;s it&amp;#39;s clearing that the byproducts have exercise over a couple days and you feel better bad soreness in a tendon you typically have you&amp;#39;re either compressing the tendon too much during activity you feel like a snapping sensation when you&amp;#39;re going through a military press um when you&amp;#39;re walking you&amp;#39;ll notice the sides your hips hurt a little bit more or you go for a run and you notice that your Achilles tenant actually feels painful to touch and is a little bit bigger listen to that decrease the training volume and then think about always pairing what you&amp;#39;re doing in in your exertional work with what I call capacity work so it&amp;#39;s a framework I always always bring to patience one thing you can learn from studying and working with professional athletes is that they take care of themselves very well in addition to having fantastic genetics and athletic ability you know they also take care of themselves in a way that we don&amp;#39;t so we don&amp;#39;t for instance spend a lot of time doing what I call restorative work boring exercises isometrics or really taking time and saying all right well I have to I&amp;#39;m I&amp;#39;m not going to train today because or I&amp;#39;m going to train differently today because this structure is inflamed and it&amp;#39;s a problem I&amp;#39;m not just going to take a couple Advil and see if if I can train through it I&amp;#39;m going to listen to my body and say it needs to heal I&amp;#39;m not giving it adequate time and I&amp;#39;m going to a portion a percentage of my time to that I like to use the 8020 principle with this so 80% of your time exertional work go for it you want to do your your cardiorespiratory work you want to do your strength training your power training whatever it might be some around somewhere around 20% you should think about the injuries you&amp;#39;ve had in the past you should think about the stuff you&amp;#39;re dealing with in the present and you should be building capacities in those tissues if you have to work with a physical therapist to learn how to do that appropriately that&amp;#39;s fine but you also there&amp;#39;s a lot of great content online about how to um how to restore normal mobility in joints how to strengthen up your tendons um so that&amp;#39;s something I readily engage in and I encourage my patients to engaging it as well spend a a certain amount of your time increasing your capacity to then go exert yourself don&amp;#39;t have the entirety of your program just be exerting yourself because the S the sum total of your human movement is not just the gym it&amp;#39;s life right right you know so it&amp;#39;s it&amp;#39;s the degree to which you are sitting it&amp;#39;s the physical and psychological stressors that you&amp;#39;re putting on your body throughout the course of the day it&amp;#39;s your ability to sleep well and repair well and get enough protein in and get adequate nutrient intake it&amp;#39;s we we think about it in terms of the gym because for a lot of us the gym becomes our Sport and it becomes something that we really look forward to we kind of rise and fall and our in our performance within it and it can hurt a lot to think about well I can&amp;#39;t engage in my workout the work my workout is my release I need my workout I need my workout as my foundation for my day but spend some time doing the hard stuff in the background and you&amp;#39;ll be rewarded for it don&amp;#39;t wait until you get a really bad injury until you learn how to to learn how to rehabilitate that and and then just it because I I think that as you age it becomes more challenging um to recover I was looking at some of their research on tendons and thinking about how can I relate this to something that I know about which is skeletal muscle sure that when you are very active and you are young you&amp;#39;re improving these satellite cells you&amp;#39;re able to Prime the body to be able to put on muscle later on in life the literature that I was reading about on tendons was that the activity in youth is really critical for the thickening and the ability for these tendons to form I don&amp;#39;t want to say in a meaningful way but in a way that will withstand a lifetime of activity yeah which I want to ask you about what do we know about training up tendons in Youth and then is there a natural decline with skeletal muscle there is somewhat of a natural decline to skeletal muscle because of increasing anabolic resistance again there&amp;#39;s some controversy in the space whether it&amp;#39;s because of inactivity or a natural process of Aging but where if we were to think about a concept that we know a lot about which is skeletal muscle and maybe the listeners know more than I do about tendons which is why I wanted to have you on so that you can teach us all about tendons and injury and approaches to training but what is the progression from tendons from youth to aging yeah so in your teens and your 20s you build up the collagen content of your tendons you build up the area so we we talk about cross central area which is basically the thickness of the tendons and with time you do have a little bit of resistance to modifications in your tendons so we find that in the Aging athletes you have you tend to develop this low-grade tendonopathy or tendonopathy like features where you have your aggregating these other cell products like the the fat content or calcium content and it also tendons lose some of their stiffness with age and we want tendons to be stiff you do so tendons are supposed to be stiff by Design you want a good spring to be mechanically efficient you want a good spring to be mechanically efficient think about running bounding hopping Etc you want your muscle contraction to be highly efficient and go towards bone there&amp;#39;s this really interesting principle called Young&amp;#39;s modulus and Young&amp;#39;s modulus is basically the a calculation based upon the stress strain curve of attendant so your Young&amp;#39;s modulus should increase with training which basically is the efficiency of the tendon to do work and the the some resistance to injury every tendon in theory could be injured at its maximum just like a muscle could be you go try to pick up a car your bicep might tear no I could totally do it there you go there are some days I think I can do it too um but the tendon does appear to have a decrease in that Young&amp;#39;s module it&amp;#39;s a decrease in that ability to of its mechanical efficiency as we age you also will see some degree of decreased cross-sectional area of tendons and you&amp;#39;ll also notice some decreased collagen content as we age but these are all modifiable but to the same extent as muscle less modifiable so building up good tendon tissue does not mean you want the largest tendon you want the mechanically most structured tendon and what this this is important to note larger doesn&amp;#39;t always mean better because a tendonopathy actually are characterized by larger tendons they aggregate water they aggregate these things called proteoglycans so the tendon does get bigger we want the same way some Elite powerlifters aren&amp;#39;t necessarily the most muscled individuals but they&amp;#39;re some of the strongest individuals you have to think about well how are they the strongest individuals they&amp;#39;re the strongest individuals because they&amp;#39;re mechanically very efficient they know how to move neurok kinetically they know how to position their bodies they do have muscle strength but they don&amp;#39;t necessarily have the largest muscles a bodybuilder will have larger muscles on average than a powerlifter in the case of tendons the collagen you know U we hear about DNA is a double helix and it&amp;#39;s a very fascinating thing to learn about collagen is a triple helix so you actually have these cross linking of molecules in the collagen and that allows the collagen fibral within tendon to to link more effectively to move more effectively so a lot of times that we see whether with it&amp;#39;s with weight training cardiorespiratory training like running um or even like a um a plyometric protocol you&amp;#39;ll see that people get Young&amp;#39;s modu is changed before they increase if ever cross-sectional area men have larger tendons than women on average but that doesn&amp;#39;t necessarily mean that you that the tendon is always stronger just because it&amp;#39;s larger larger a larger structure is only as good as the micro structure within it and the micro structure is more measured by Young&amp;#39;s modulus so when we look at the studies that examine loading up the lower limb tendons the patellar tendon the Achilles tendon the glutes what we see is that that Young&amp;#39;s modulus changes and that doesn&amp;#39;t appear to change a little bit with ag so building that up while you&amp;#39;re in the prime years is perhaps beneficial and then staying with it do we know the mechanism of action as why there is a decline I don&amp;#39;t know U the body of literature when it comes to tendons and tendonopathy you know when I when I think about muscle we know that there is um motor de innervation there&amp;#39;s a a decrease in the the quality of the satellite cell do we know why tendons decline so one thing is from a metabolic aspect They do change a little bit so they actually tendons are minimally aerobic tissues they don&amp;#39;t really go through the they don&amp;#39;t really use oxidative phosphorilation as a means by they&amp;#39;re largely anerobic but they have some aerobic metabolism and it&amp;#39;s actually hallmarked of the degree to which your tendon is conditioned that it can actually engage in aerobic respiration that&amp;#39;s pretty fascinating isn&amp;#39;t it it is it&amp;#39;s um I think because it&amp;#39;s such an onoff mechanism um meaning you&amp;#39;re either engaging the tenant or you&amp;#39;re not exactly you&amp;#39;re either crimped or on tension you can kind of get away with an anerobic response is it um metabolically active tissue less active than muscle okay highly less active than muscle but the metabolism will change and your blood flow may change as you AG as well hypoxia or the absence of oxygen is considered to be a driving Factor behind tendon degeneration that&amp;#39;s interesting because it&amp;#39;s it&amp;#39;s mostly avascular yes so it doesn&amp;#39;t have a good blood supply to begin with yes so minor alterations as we age either to doe to the sedentary nature or just the fact that we&amp;#39;re not moving well whatever else it is or just time um the other thing is we accumulate micro tears and a lot of micro Tears Don&amp;#39;t heal uh is a a high rate of chronic tears and say like a rotator cuff or in other other areas of the body they may not heal and you may not need them to heal ultimately they may not progress to be a surgical issue but that will weaken the tendon when the nothing in the body is as strong as when you originally made it so if you have a collagenous structure It&amp;#39;s relatively vascular you&amp;#39;re going to try to put down a scar tissue within it it&amp;#39;s almost never going to be as strong as when you first started it the other tendon fbls may take that load they may they may be able to do 99% of what they did before but it&amp;#39;s tough to say that the magnitude effect of the tendon at its best will ever be the same so the metabolism changes and you also see cell inessence or some cells just dying off and that we see that in a lot of tissues so there&amp;#39;s an element of tissue hypoxia there&amp;#39;s a little bit of a change in tissue metabolism the collagen cross linking perhaps is not as efficient and so your Young&amp;#39;s modulus goes down and then we also see that the some of these cells just die off with time and so it gets harder there&amp;#39;s I think if you can maintain it it&amp;#39;s very good you know it&amp;#39;s it&amp;#39;s tough because there&amp;#39;s always the ab the um the abstract element of this we&amp;#39;re examining literature that takes a point in time and and typically these studies are over months um it&amp;#39;s tough to say what would happen if you informed a population of this when they were younger and they engaged in certain exercises could they in theory maintain a lot of this the same way that in theory we can maintain a lot of our muscle okay you got to listen to this and uh please don&amp;#39;t turn off this ad because I got to tell you about Cozy Earth Resort towels how many showers do you think that I&amp;#39;ve taken today uh like 27 that&amp;#39;s how good these towels are I know I didn&amp;#39;t really take 27 showers but I got the Cozy Earth Resort towels and I feel like I don&amp;#39;t even have to go to the resort because these towels are so soft you know when you go to the and get these beach towels they&amp;#39;re usually scratchy and they&amp;#39;re big these are plush Resort SL beach 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program yeah um I think everybody should be training type two muscle fibers and so you need to be getting some degree of explosive work I think the biggest phase change that we see when when we look at a program for somebody and we try to see how they could be for instance we&amp;#39;re seeing that they&amp;#39;re overloading their Pell so the the the tendon that connects the kneecap to the shin bone and helps basically act as a mechanical lever for the quadriceps muscles maybe they&amp;#39;re overloading the sagittal plane a little bit too much so explain to us what that is yes so sagittal is back and forth okay so a a squat is A sagittal plane movement to some degree a barbell squat you&amp;#39;re doing some degree of frontal plane so that&amp;#39;s left versus right stabilization and you&amp;#39;re also not rotating with the bar in your back so that would be a classic sagittal plane movement the bench press is a satal plane movement okay okay but as we age it does appear that we just generally spend less time rotating and running and cutting and doing the things that we did as kids so when we try to go back to those activities that&amp;#39;s when you&amp;#39;ll hear about an acute til acute Achilles tendon rupture and some 30 to 50y old male who&amp;#39;s doing a a backyard football game for the first time in a while so you&amp;#39;ll hear about it and they&amp;#39;ll pop their they&amp;#39;ll pop their calf muscle and that&amp;#39;s an Achilles tendon rupture so I like to look at globally in a program how much time are you spending in the three planes are you rotating are you rotating under load are you stabiliz a good example of a stabilization exercise in the frontal plane would be like a suitcase carry it&amp;#39;s going to carry a kettle bell at my side I&amp;#39;m going to go forwards and backwards and I&amp;#39;m going to make sure that my body doesn&amp;#39;t lean either way by engaging in sagittal and transverse movements you engage different muscles than you do with sagittal I&amp;#39;m sorry transverse and frontal plane movements you engage different muscles than you do with sagittal plane movements a lot of the machines in the gym will keep you in the sagittal plane so and so this is something that I advise people to get off of machines get used to doing lunges get used to doing rotational work um and really challenge your body there&amp;#39;s some degree of there&amp;#39;s I think a very good scientific debate about what exercise is best for tendons I would love to know and I want to know if blood flow restriction has any influence on tendons yeah it&amp;#39;s a good question um with regards to the types of exercise we look at predom dominantly the from the prevention aspect and from the treatment aspect from the prevention aspect there&amp;#39;s nothing to say that we can justifiably tack down something to the wall and say you should only do isometrics or eccentrics or concentrics it&amp;#39;s tough to say that it&amp;#39;s there&amp;#39;s a bit of conjecture in the literature about that but what&amp;#39;s interesting is there was a very good study that looked at the rates of lower limb tendonopathy and soldiers in Israel and basically looked at a a prevention program and then used an ultrasound to take a look at the tendon health of the lower limb tendons and whether or not those tendons were aggregating those those products that are Hallmarks of tendonopathy and what they found was contrasting what you might think it was like an Achilles prevention program there were almost no calf phases in the protocol the entire protocol was hip and knee and it was all stabilization of the core rotational movement hip airplanes stuff like that so this is a another concept that I I very commonly bring up with patients which is smoke versus fire are your symptoms a representation of that tissue being at its it&amp;#39;s overloaded but is the real problem a mechanical element that&amp;#39;s missing from your program or missing from your life so in that particular study where they looked at prevention they did find that it was helpful when they underwent this prevention protocol which is largely comprised of hip stabilization exercises the entire kinetic chain is linked we cannot divorce one element from the other your body has to achieve most motion it has to get motion range of motion from some element okay so let&amp;#39;s say you go bend down to go get something you&amp;#39;re doing a squat there&amp;#39;s so many moving Parts within that from your ankle to your knee to the intrinsic muscles of the foot and the bones in the foot to your hips to your low back interior thorax Etc so you&amp;#39;re going to get Mobility from somewhere so is the answer to the question how can we actually prevent some of these things from happening it&amp;#39;s can we identify your mechanical weak points ahead of time from a rehabilitative aspect we use isometrics commonly as the starting point in a tendonopathy rehab protocol so would you explain what what would be an example of an isometric yeah uh an isometric exercise is one where you&amp;#39;re Contracting a muscle but you&amp;#39;re not moving the limb so if I were to be rehabbing a biceps it would be just holding a dumbbell at my side right a concentric would be bringing the dumbbell up to my shoulder an Ecentric portion is when we&amp;#39;re we&amp;#39;re actively mitigating the lengthening of the muscle and those tend to be the hardest right so that&amp;#39;s when we&amp;#39;re lowering down a weight slowly so it was a scientist by the name of alfredson who came up with something called the alfredson protocol and since then we&amp;#39;ve been really focusing on Ecentric as the sort of the go-to that&amp;#39;s how we&amp;#39;re trying to get by week six of a PT protocol for somebody&amp;#39;s Achilles and and we&amp;#39;ve broadly adopted that for other tendons as well and good comparative study came out a couple years ago that looked at heavy slow resistance training versus Ecentric training specifically and found that heavy slow resistance training was non inferior to Ecentric base training so basically the time under tension with deliberate motion meant to restore the capacity in the tendon is as beneficial as doing you know heel drops off of a a stair for for instance for Achilles tendonopathy for Blood Flow Restriction I can&amp;#39;t say specifically um whether or not it&amp;#39;s beneficial the thought of hyperemia so hyperemia is the process of getting more blood into a tissue and we do use therapeutic ultrasound to heat up tendons and we we use shock wave to heat up T to basically break up micro structures in a tendon to treat it when we put PRP we&amp;#39;re putting blood products in an area right so the the thought of getting blood into this relatively a vascular structure is one that makes a lot of sense how effective is that which one in specifically um any any modality that utilizes um because the the structure is a largely avascular structure so now you&amp;#39;re introducing something that potentially it&amp;#39;s not exposed to routinely or with the amount of whatever you&amp;#39;re going to use yeah PRP or however you&amp;#39;re going to use any of these modalities how effective in treating a tendonopathy is it and and tendonopathy would be something that would cause pain over time and limit the capacity you know from a very practical aspect the reason we are really focused on tendonopathy is because those seem to injure before a muscular injury happens that&amp;#39;s right it&amp;#39;s the common denominator that limits the quality of life I think it&amp;#39;s a li huge limiting factor in training programs and progression and I think it&amp;#39;s one of the first things we see when somebody starts weight training and we start to see these things arise so we&amp;#39;ll go through a couple treatments amazing all right so we have this relatively vascular structure it&amp;#39;s in a state of disrepair let&amp;#39;s think about what that means so the actual structural components are not as strong as they were and you can think about this like you have a house that is not perhaps built as well as it could be you have a leak whatever else it might be well first thing we&amp;#39;re to do is we&amp;#39;re going to bring in a GC and so that&amp;#39;s your general contractor and like what&amp;#39;s a GC oh yeah yeah so um we&amp;#39;re gonna you have tenocytes so same thing in muscle you have your myocytes and you also have your osteocytes in bone you have these these cells that basically look at the tendon homeostasis and they help direct traffic and Os site is a standard it&amp;#39;s called modified fiber blast cell so it helps to lay down collagen and also helps to direct traffic the ocytes will sense that something&amp;#39;s wrong and they&amp;#39;ll bring in other cellular products one of which is that you will start to grow little blood vessels in the area so part of tendonopathy is actually when we put uh color power doppler on ultrasound and we look at a tendon we&amp;#39;ll see stuff light up that was previously that is a good Telltale one side versus the other do you have hyperemia in a tissue that&amp;#39;s already a sign that things are going the wrong direction well now we say well now you&amp;#39;ve aggregated this Scar Tissue you&amp;#39;ve aggregated these other things that are there they&amp;#39;re not that helpful well we might have to bring an excavator and the excavator is we have a couple different treatments for excavation one of our treatments is called pnt so percutaneous needle tenotomy which is when under an ultrasound will actually pass a needle through the tendon several times is that where dry needling came from it&amp;#39;s it&amp;#39;s very similar to dry or this came first and then dry needling was adopted yes so dry needling depending on your discipline dry needling is something that be performed by a physical therapist for myself I do these under ultrasound and visualize the portion of the tendon that&amp;#39;s inop which I just want to highlight that that takes a ton of skill ultrasounds are not easy to use and um quite frankly I believe that that&amp;#39;s how it should be done because then you actually can see where the injury is what tissue you&amp;#39;re putting it in you&amp;#39;re not doing it blinded you are being able to visualize it&amp;#39;s it&amp;#39;s it&amp;#39;s important to visualize it&amp;#39;s also going to tell you whether or not there&amp;#39;s a tear there you don&amp;#39;t want to needle a tear right so a tear is a different concept A Tear is a separation so we don&amp;#39;t want an excavator in that area it&amp;#39;s not helpful so the thought of passing a needle through tendon several times will actually help induce take this state of chronic disrepair and convert it to the acute inflammatory phase again and basically help to cycle out some of that stuff so that could be done through pnt it could also be done through something called a 10x procedure which helps to remove scar tissue remove calcium that&amp;#39;s built up in tendons the Advent of PRP and why PRP is so interesting so PRP is a distillation of blood products so we spin down your peripheral blood it&amp;#39;s still majority red blood cells but PRP means platelet rich plasma and there are two subtypes of platelet rich plasma the exact concentrations of which do differ in the literature based slightly depending on the study you&amp;#39;re looking at so you have Lucy Rich so white blood cell rich platet platet rich plasma and Lucy poor PL rich plasma if I were treating a joint I would use Lucy poor I don&amp;#39;t need white blood cells in a joint necessarily but when I&amp;#39;m when I have this chronic state of disrepair I need a whole construction crew I need my white blood cells so I&amp;#39;ll use Lucy Rich preparations and I typically will perform it with a tenotomy too to actually put some areas into the tendon where I can distribute that P now PRP has several growth factors um one of which is platelet derived growth factor and this helps to basically stimulate the tenocytes and another type of cell that resides in tendons called tsc&amp;#39;s tendon stem progenitor cells so you do have a repository of stem cells within your tendons it&amp;#39;s just a question of mobilizing them so conceptually we thought well PRP makes a lot of sense depending on the tendon and depending on the literature that you&amp;#39;re examining it can be very effective on a hold I would say it&amp;#39;s probably a 50-50 proposition depending on the chronicity of your tendon problem as well as whether or not you have a tear concominant and where that tear is not all tears are made equal the tendon itself right right so you have the the muscle coming towards the tendon you have a myot tendonous junction which basically looks like a finger where the tendon is interlocking with the muscle and some tears do occur there and those can be quite tough to treat but then you also have something called the enthesis which is where the tendon attaches to the Bone and so those are the most common ones we are treating now you can have a tear at any portion in that tendon so they all have different prognosis if you have a tendon on the bottom right by the bone that&amp;#39;s a different prognosis than the one up by the top by the bursa so we try to extrapolate from the natural history of this what&amp;#39;s the percentage chance it&amp;#39;s going to heal where is it how big is it how impactful is it it to the amount of strength you can produce in the relevant muscle how impaired is it and then would we consider is this a large enough Terror that should go to surgery is this something that we should try PRP in um important for people to know if you do suffer a tendon tear there are different types in from a from a perspective of if we&amp;#39;re just looking at a large tendon you can get what&amp;#39;s called a full thickness tear which is when it&amp;#39;s like as if somebody punched a hole in a paper goes straight through MH from top to bottom and you usually know when you do those yes uh that is I have had quite a few injuries and you know um when that happens it&amp;#39;s not like ATT tendonopathy you don&amp;#39;t necessarily you know might be a little irritation and then you go back to the thing and then you irritate a little bit more that&amp;#39;s right but when you get a full thickness tear that is an acute injury that typically will take you to your knees or whatever yeah so the full thickness is the pothole and then there&amp;#39;s something called so we say full thickness incomplete or full thickness complete incomplete would just be have a sheet of paper and I punch a punch a hole with a hole punch complete means I literally take a pair of scissors and I cut the paper in half if you have a complete tear now the tendon is no longer attached to the muscle that is a surgical problem okay that is not something that&amp;#39;s likely to heal by itself that would be for example like a tricep tenant tear or a bicep rupture yeah so and depending on how important the bicep so for instance the bicep is interesting because the bicep is almost like a fifth rotator cuff muscle there are people walking around with bicep tend and tears without significant you know without significant symptoms but if you have a complete full thickness tear what will occur in time is because the muscle is not seeing any tension the body de prioritizes it and it will atrophy and if it atrophies to date I&amp;#39;m not aware of any way to stop that or reverse it so those are the circumstances you know like I I brought up that example of the 30 to 50y old guy who pops his Achilles playing backyard football um because that&amp;#39;s the most common age population to get acute Achilles tendon ruptures but if that occurs and that tendon is not reattached or it&amp;#39;s not approximated you&amp;#39;re put in a boot or something like that then foreseeably you&amp;#39;ll atrophy your gastri and your Solus and that&amp;#39;s going to be really tough functionally to to go through so essentially don&amp;#39;t delay I think a lot of the patients um that I have and many people listening they don&amp;#39;t want to stop their activity they&amp;#39;ll injure themselves and they don&amp;#39;t want to stop I don&amp;#39;t want to get a bicep uh repair I I can still be just as strong but if you&amp;#39;re going to do the intervention that requires surgery one should do it swiftly yeah you should be evaluated swiftly and and and you don&amp;#39;t want to see on MRI or on ultrasound you don&amp;#39;t want to see those atrophic changes occur that&amp;#39;s a sign that your that muscle is not going to be as functional as it originally was and therefore your prognosis isn&amp;#39;t as good I want to thank one of the sponsors of the show and that is 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docomo Lion that&amp;#39;s mudwater docomo lion for $20 off and a free frother why do you think that we see you know again you see patients often and it&amp;#39;ll be daily um either a shoulder a knee or a hip do you believe that it&amp;#39;s because of patterning why those the common injuries yeah um in the shoulder I think it&amp;#39;s because we have mechanical compression underneath the bones of the shoulder and that&amp;#39;s known as a symptom it&amp;#39;s called subacromial impingement so basically you&amp;#39;re moving your shoulder around and the tendon gets caught underneath a bone and that&amp;#39;s you can sometimes hear a snapping sensation when you do something like a military press for patella it&amp;#39;s because a lot of times patella tendonopathy is part of a greater clinical concept known as patelofemoral pain syndrome which by the way is most often associated with weakness of the Glu muscles so the knee is overloaded trying to do too much work and the glutes are not adequately um supporting the knee in the hip so the posterior train chain is actually affecting the anterior chain yes and posterior lateral specifically so Hallmark of patellar tendonopathy Patell femoral pain syndrome we we commonly will look at strengthening up the gluteus Medi on the side of the hip and then the the really the the whole goal there is can you get back to walking and running with stabilization at the hips so there&amp;#39;s not so much pain at the knee once again smoke versus fire your knee hurts you do have ATT tendonopathy but mechanically speaking there&amp;#39;s an insufficiency of some muscles that are higher up in the kinetic chain that&amp;#39;s it it just seems really challenging as as we think about long-term projection of people&amp;#39;s lives to figure out that you know I have a weak glute me and you have I don&amp;#39;t know uh just pick a different muscle sure are there things that individuals should all be doing should we you know we wake up we brush our teeth we brush our hair should we be getting up and doing glute activation I don&amp;#39;t know uh eyes T&amp;#39;s and Y&amp;#39;s for our shoulder are there things that that we could Embark upon now to very specifically prevent a mechanical injury from attendant that we don&amp;#39;t even know that we have it&amp;#39;s a great question um and to in trying to distill what makes a lot of sense I will give home exercise programs to patients almost to that exact effect they come in with a back injury but I say well now was an awful time good to start rehabilitating and prehab your hips so is prehab a real thing prehab is absolutely a real thing it&amp;#39;s tough because prevention is difficult to study so it&amp;#39;s more that&amp;#39;s a really good point it&amp;#39;s very very difficult to study so I&amp;#39;m I&amp;#39;m recommending this because conceptually it makes sense not because I have a study to point to that doing you know sideline hip abduction exercises helps Stave off the onset of something H so what I see for the shoulder a lot of times the the mechanical dysfunction is at the shoulder blade and how it&amp;#39;s moving either it&amp;#39;s elevating too much it&amp;#39;s not appropriately what&amp;#39;s called protracting um and a really good test to see how your shoulder blades working is to do a push-up with a plus so at the top of your push-up you push out the ground a little bit more if you&amp;#39;re trying to achieve that motion by rounding your thoracic spine you can&amp;#39;t appropriately actually work through the the back part of your rib cage and your shoulder blade get that work well so push-up with a plush that I like for the hips a single leg stance squat so would that be a pistol squat so actually I prefer this like skater skater variety so your your your ex Trail leg is behind you so I like to see single leg stability and single leg stability is a great determinant of how you are actually going to progress through your gate cycle so a lot of people this is a really good thing and I and I&amp;#39;ll show off my PMR residency here so and is this standard so do all I do all Physical Medicine and Rehab Physicians need to learn biomechanics yeah it&amp;#39;s a huge element of our training it is a part of your training and I&amp;#39;ll tell you why because you unless you understand normal biomechanics through the gate cycle you can&amp;#39;t rehabilitate somebody with a stroke once they&amp;#39;re hemiparetic once they have a foot drop it&amp;#39;s really tough so you have to know the normal mechanic mechanical determinants of gate to understand the dysfunctional elements of it so I like to see how you know with regards to the gate cycle 60% of your time is in stance phase 40% of your time is in swing phase there&amp;#39;s a 20% portion that&amp;#39;s called double support where both legs are simultaneously on the ground so your glute me is actually active to stabilize your pelvis so if you see somebody with a lot of hip movement while they&amp;#39;re walking you don&amp;#39;t want to have 100% stiffness but you want to have stability if you have a lot of hip movement when you&amp;#39;re walking it&amp;#39;s often times an indicator well it&amp;#39;s not as not as stable as it could be there&amp;#39;s not enough muscular tension to support the core the center of mass in the body is in the pelvis so my I always encourage young athletes I&amp;#39;m like if you have to focus on a couple things it would be be very stable through your pelvis you can&amp;#39;t shoot a cannon from a canoe okay so you need stability in the pelvis to put Force down through the legs all athletes regardless of what you&amp;#39;re do are made in the legs so all athletes are made in the legs yes and I believe that very strongly great pitchers have of a of a good set of legs they know how to really drive off um even look at Mike Tyson right one of the greatest knockout artists that has ever existed in the heavyweight division he had monstrous legs right it it was a huge element why he was able to compete with people six inches taller than him so I I believe it&amp;#39;s a St good stable core that can rotate underload good um strong glutes and knowing how to keep your spine stable is really important so good neutral spine throughout the range of motion and then when you&amp;#39;re walking yeah you&amp;#39;re you&amp;#39;re going to be you do swing the thoracic spine in rotation a little bit while you&amp;#39;re swinging your arms but you want your body to be stable you want your you want to be able to walk slow and you want to be able to Sprint fast and if you can do both of those you kind of check in with yourself if you can&amp;#39;t walk slowly without feeling like you&amp;#39;re off balance something&amp;#39;s a little bit off do you think that everybody should continue to Sprint or never lose that ability I would love for everybody to Sprint um I think sprinting is fantastic it&amp;#39;s also a great check-in to see where you&amp;#39;re at um but if you are doing it you need to be very careful with load management because if you haven&amp;#39;t done it in a while and you go back to it it could be a major risk factor for achillus tend and to be clear well actually I evoled my hamstring doing a long stride Sprint would you recommend you know people listening to this are thinking because we&amp;#39;re going to cover zone two cardio and training uh because you and I really see eye to eye excuse me sure about how there&amp;#39;s a lot of discussion about zone two and how that&amp;#39;s going to be so effective Ive in cardiovascular health there&amp;#39;s a lot of other ways to train um but this idea of picking up where you left off may not be the best thing so if you are at home listening to this moving fast is important because you lose speed and you lose power but perhaps not picking back up if you haven&amp;#39;t sprinted or you haven&amp;#39;t done a lot of these Motions like the guys that you&amp;#39;re talking about between 30 and 50 jumping on the basketball court you probably have to build up to that is that fair to say it&amp;#39;s absolutely fair to say can we talk a little bit about um well I mean let&amp;#39;s tie up the rest of tendonopathy because I&amp;#39;m curious about some risk factors which in my mind would include medication yeah common medications that may affect tendon Health yes the first one that comes to mind is floro quinolones so that&amp;#39;s like cyof Lal floxic that&amp;#39;s a whole class of medications those are antibiotics um fluoroquinolones are very strongly linked with tendon problems and tendon rupture um we believe that this impacts tendon metabolism and integrity to some degree so those are of concern you know there&amp;#39;s some I think very good um discussion around statins and tendons specifically so whether or not they&amp;#39;re beneficial so if you have somebody who has hyper cholesterol emia they can actually deposit what I&amp;#39;m sure know you know this but xanthomas in their tendons so fatty deposits in the tendons so in that case a Statin might actually decrease the size of their tendon and improve the tendon Health but if they have if they had familial hypercholesterol in that&amp;#39;s right but not if they just have high cholesterol it&amp;#39;s tough to say okay it&amp;#39;s tough to say because hypercholesteremia diabetes um gout these are in G SL hyperemia are all risk factors for tendonopathy and smoking so if you look at the metabolic syndrome Spectrum obesity is also a risk factor all of these things impair tissue healing anywhere in the body so in a in a structure that does not have a great blood supply that&amp;#39;s constantly under load it&amp;#39;s very much magnified um that&amp;#39;s an interesting concept I I haven&amp;#39;t quite thought about again because I&amp;#39;m so fixated on muscle if someone is obese or struggling with any kind of metabolic dysfunction that would affect tendons yeah in general diabetes patients um will rehabilitate more slowly than non-diabetic patients and partly because tissue healing is slower so it&amp;#39;s an excellent textbook that um I came across that actually looks at all the metabolic influences on tendonopathy and chapter by chapter goes through it and one of the aspects of it was just think about it like it&amp;#39;s another structure in the body it heals more slowly yeah bone bone fractures heal more slowly microarchitecture and bonus more slow it&amp;#39;s one of those things where it&amp;#39;s reasonable to make a leap from one concept to another if tissue healing and tissue repair is is is not as quick as it could be or as um as comprehensive as it could be in one tissue there&amp;#39;s no reason to suggest that it&amp;#39;s going to be better than another so floro quinolones yes um can cause a risk of Tenon rupture yes which it&amp;#39;s really important that Physicians educate their patients don&amp;#39;t go sprinting don&amp;#39;t go running when you&amp;#39;re on these Statin St may have a positive effect depending on the person yes um anything else that is known to affect T corticosteroids so corticosteroids if you I had a great um a great attending while I was in residency he said if you if you just draw a a body diagram you can find a place that corticosteroids impact every part of it and it&amp;#39;s the truth you can get hair loss they can get um you know your skin changes color and texture um and no surprise it does impair tissue healing now the question becomes a very good question because it is part of my practice to provide corticosteroids and also it&amp;#39;s important to point out it&amp;#39;s standard of care it is it is and so the question becomes why are we doing what we&amp;#39;re doing and so in the circumstances of somebody has a tendonopathy and they&amp;#39;re getting a corticosteroid injection that injection should be guided it should be into the adjacent Bersa you don&amp;#39;t want to put cortico steroid into a tendon that&amp;#39;s not going to help anybody but if you&amp;#39;re putting in the adjacent Bersa there&amp;#39;s theory that perhaps you&amp;#39;re going to anesthetize and kind of decrease the pain signals coming from those little nerve inlets that have actually grown into the into the tendon themselves and if I get you some short-term pain relief for three months which is on average what we we councel people for corticosteroids if I get you some short-term pain relief and you could do the PT and your mechanics are improved are you in a better landing spot than if I didn&amp;#39;t do it and that&amp;#39;s a conversation I have with everybody around a corticosteroid now oral corticosteroids are prescribed for a variety of conditions rheumatologic conditions and we&amp;#39;re talking about a prazone a metol dose pack that&amp;#39;s exactly right um I even use them to some extent when um we&amp;#39;re treating low back pain patients have a really bad low back pain bout um and they have a flare and we can&amp;#39;t get them in for like an injection epidural um and we can&amp;#39;t get them through PT because they&amp;#39;re in such a bad spot we&amp;#39;ll use a medal dose pack now Medrol itself is going to be absorbed by the body the body your body does not know exactly where to disperse this medication it&amp;#39;s going to be absorbed it&amp;#39;s going to impact hormone production it&amp;#39;s going to suppress natural production of things like testosterone and sex hormones it&amp;#39;s going to feed back on the pituitary and the hypothalamus and the whole chain and the adrenals but at the tendon level it can actually impact your ability to repair and so if you&amp;#39;re if you&amp;#39;re susceptible and you have a predating injury and you go through metal do pack and you go exert yourself there is a potential that you can injure yourself now once again risk benefit ratio in everything we do um I&amp;#39;ve used this phrase with you once before and I&amp;#39;ll use it again there is no free lunch in biology so it and it&amp;#39;s too true it&amp;#39;s too true so everything we do has side effects everything we do has a potential downside everything needs to be weighed for the person in front of you so in the risk benefit analysis that you&amp;#39;re saying somebody has a tendonopathy it&amp;#39;s been recalcitrant to PT you&amp;#39;ve tried to do some stuff they have nighttime pain well now the nighttime pain is impacting the rest of their body because they can&amp;#39;t sleep well is pain worse at night um depending on the tissue so let&amp;#39;s say so if you have a shoulder uh btis as a consequence of ATT tendon problem in your shoulder nighttime pain is a Hallmark of it so and is it because cortisol is lower why is why is that happen mechanical compression so when you stop moving tissues that are relatively inflamed they will touch other structures around them and sensitize them and then specifically if you&amp;#39;re like a stomach sleeper and you put your arm up to the side around your pillow you might feel like your your adultt wakes up really sore and that&amp;#39;s because you&amp;#39;re compressing a tendon tendons like load they don&amp;#39;t like compression tendons like load they don&amp;#39;t like compression that&amp;#39;s right so same thing um we we&amp;#39;re learning a lot of really good on liners over here really really great there&amp;#39;s a um same thing somebody has a glal tendonopathy on the side of the hip lying on that side would be very painful at night time extended compression on a tissue that&amp;#39;s irritated you&amp;#39;re going to know about it um somebody has an Achilles tended problem Shoe Fits not correct or they they tried say they were in the first time in cleats for a while that they weren&amp;#39;t in cleats before you might inflame that area um any other medications that can be harmful um there&amp;#39;s perhaps more as well um these are the big ones those are the big ones I think more about the in some circumstances some of the hormone replacement that&amp;#39;s helpful I was going to ask you I was going to ask you on the flip side of this are there potentially oral agents or injectable agents that could be beneficial for tendon Health broadly speaking from a nutrition aspect or like a neutraceutical aspect what we can take um hydrolized collagen has been proven to be a little bit helpful in studies um Lucine no surprise there has has been I&amp;#39;m sure lucin&amp;#39;s been on this podcast before no never heard of it yeah right so um Lucine is is actually a component of a prot glycan around tendons called decorin and it can help lubricate tendons it&amp;#39;s also once again a concept that makes sense if it&amp;#39;s good for muscle it&amp;#39;s probably good for tendon so in these C good for muscle it&amp;#39;s probably good for tendon I love this because we have really left tendon out of the conversation we&amp;#39;re back we&amp;#39;re back to your to your neck of the woods and muscle but the the interesting thing is we know that you need to some degree it&amp;#39;s a substrate driven issue you do need adequate protein intake it is a collagenous structure whether you absolutely need collagen because your collagen is going to be broken down your stomach and brought back is I think a better question to ask so it has proven to be somewhat helpful omega-3 intake has been associated with decrease in tendinopathies and is that because of its impact you know I always think okay well what would the mechanism of action would that be an inflammatory perspective I think it&amp;#39;s the low-grade anti-inflammatory U aspect of the resolving pathway yep so I think that that&amp;#39;s it now um and for that reason it&amp;#39;s important to point out a Hallmark of tendonopathy is Express of prostag gland and E2 and so for people who don&amp;#39;t know E2 is something that is present in acute inflammatory processes it&amp;#39;s why a lot of anti-inflammatory medications work so omegas act on the same aspect without a lot of the potential downsides so I will counsel patients to take omega3 supplementation DHA and EPA are superior so um I will counsel them to do that as well now with other aspects protein intake uh Lucin intake vitamin C is a co-factor in collagen synthesis so vitamin C makes a lot of sense vitamin and are there doses that we know of you know I&amp;#39;d have to I&amp;#39;d have to get back to you with exact dosing I just know that it&amp;#39;s dietary intake of vitamin C is associated with improved tendon healing and have you heard of I don&amp;#39;t know if you ever use these in in clinic but spms the specialized Pro resolven mediators Orly I&amp;#39;ve not used them what is um yeah I I am not so sure on the data but um we&amp;#39;ve used them uh some of my colleagues have used them a lot with operators okay but you and I will have to look at some of the the actual data but I I am curious yeah and vitamin D can be helpful as well so vitamin D has been proven to be helpful in tendinopathies as well can help decrease some of the pain vitamin D vitamin C and vitamin D deficient rats um have decreased Rotator cough healing after injury so it&amp;#39;s interesting to think about Lucine Glycine and lysine are the amino acids that are most helpful um but having a good amino acid-rich diet with amino acid profile is probably best um from a hormonal aspect hormones are really interesting here because I think when we were speaking about this you had mentioned that you came when you were back in training you came across some patients and one of the first signs of some of their hypothyroidism was actually the acute development of tendinopathies which is fascinating yes um thyroid hormones basically T3 and T4 play a role of stopping apoptosis or program cell death in tendons in Tino sites so in your general contractors that are overseeing work on your tendon so if you have S insufficient thyroid hormone stim thyroid hormone circulating that&amp;#39;s perhaps a major risk factor another thing that&amp;#39;s a potential major risk factor is T4 actually mediates collagen metabolism so you need enough circulating um the sex hormones are awful interesting too so um estrogen is the in play of female sex hormones and so what these deeply collagenous structures like tendon and ligaments is the subject of Fascination for a whole body of literature so I don&amp;#39;t want to do them Ma disservice by speaking about it very um quickly but there&amp;#39;s been a good degree of insight into phases of the ovulatory cycle and risk of injury and in um in adolescent females who are are in the developing stage there and and engaging in sport that perhaps you could have a two to six times incre inre risk of ACL injury during specific phases and then we know in the postmenopausal population that tendinopathies tend to develop so the absence of estrogen appears to be a problem um same thing goes for testosterone now testosterone there&amp;#39;s a clear um in that same post metapa pausal population the testosterone is going to decrease as well so testosterone appears to be beneficial for tendon where the where the conversation gets very interesting is are the testosterone analoges are the synthetic analoges detrimental and one that&amp;#39;s a really good question so basically what he&amp;#39;s saying is the use of certain anabolic steroids um going to injure tendons I think it&amp;#39;s a really good question and the answer is they appear to be clearly due to the use of them the muscle the skeletal muscle is enormously sensitive to them but does it need to be testosterone specifically to help tendons and that&amp;#39;s one of the great questions so let&amp;#39;s say somebody starts on anabolic steroid regimen and they&amp;#39;re drastically increasing their their muscle size well the athletic adaptation curve does not change you might not you might retain more muscle have less catabolic effect you might get more week-over-week training benefits but you still need time for the soft tissues to accommodate so it&amp;#39;s one of those unfortunate things that plagues people is bicep tendon ruptures PEC tendon ruptures that&amp;#39;s what we see a lot of time in the gym and so it&amp;#39;s something important to think about does it need to testosterone specifically or is it or can it be something else the from the literature that I was reading it seems like it needs to be testosterone specifically so both estrogen and testosterone play some protective element and therefore another question is in individuals who are taking synthetics who are on robatas Inhibitors are they doing themselves some degree of a disservice are they are they throttling down estrogen so much so that it&amp;#39;s not beneficial have you done your blood work uh if you haven&amp;#39;t I have a solution for you and that is one of the 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and do not wait if you are due for your blood work give this a shot it&amp;#39;s extremely valuable back to the show you bring up a really good point and what he&amp;#39;s talking about is um medications Aroma Inhibitors that would decrease estrad or overall estrogens and we know that estrogen is important for both men and women yes I can say clinically I um I like to see my men you know it&amp;#39;s interesting for women there&amp;#39;s a lot of EB and flow obviously we don&amp;#39;t want their estrogen suppressed but for men I am happy with an estrogen level between 30 and 50 um individuals you will see sometimes are on something like Arimidex and they will suppress their estrogen and they&amp;#39;ll feel terrible yeah they&amp;#39;ll feel terrible perhaps they&amp;#39;ll get injured you know in menopause I&amp;#39;ve seen um somebody of literature talking about frozen shoulder yes and I&amp;#39;m curious as to why frozen shoulder and menopause wouldn&amp;#39;t that be whether it&amp;#39;s shoulder whether it&amp;#39;s a knee patella tendon issue or hip why why shoulder yeah it&amp;#39;s adhesive capsulitis there are rare clinical accounts of it occurring in other joints but that&amp;#39;s the clinical term for Frozen shoulders adhesive capsulitis which appears to be an acute thickening and contracture of the joint capsule so when we think about a joint you have two bones articulating with cartilage and so you have a cartilage interface that allows that you have typically have a pressurized area of joint fluid that joint fluid periodically gets turned over by the body and you have a capsule which is made of collagen and basically envelopes the entire joint to provide stability this is what um when you if you ever like carved a turkey and you take out the hip and you hear the suction break yeah you&amp;#39;re breaking the suction seal that&amp;#39;s within the joint so inhes of capsulitis is sort of most most common in women between the ages of 40 and 40 and 60 it can incur men as well um and it is the Hallmark is this very rapid onset of decreased range of motion of the shoulder to the point where some individuals can&amp;#39;t raise their arm above their head without necessarily A predating injury some predating injuries can predispose you to it so let&amp;#39;s say you have an acute R rotator cuff Terror you stop moving your shoulder altogether just to protect yourself and you&amp;#39;re not going under undergoing the rehabilitative process perhaps that could actually predispose you to getting your shoulder Frozen it&amp;#39;s also interesting because frozen shoulder is one of the few times in medicine that we can say corticosteroids are meaningfully disease modifying so we use corticosteroids in Sports and Spine practices for pain relief that&amp;#39;s the main purpose their pain relief but in the process of frozen shoulder depending on which article you reference I like to look at the there was one article that described it in a way that I think is very easy understand freezing Frozen and thawing okay so makes a lot of sense if you catch it in the freezing phase and you give it a corticosteroid injection in the joint it actually decreases the duration of symptoms frozen shoulder untreated can lead to potentially years of symptoms in the shoulder so the question is is there is the absence of estrogen and the increasing rise of the um the precursors LH and FSH that are present in the in the state of menopause are these things predisposing to that because we also see it in premenopausal women as well so it&amp;#39;s tough to tell but we know some risk factors for frozen shoulder one of them is obesity one of them is diabetes um and then the other one is perhaps a lot of these perimenopausal females you&amp;#39;re seeing so tough condition to treat but yeah and these are all really important conversations because if we just focus on muscle and we miss tendons than when people get injured you know I I hate to say it it&amp;#39;s not an if but it is a when at some point if you are pushing yourself or sedentary and then getting back into blend you&amp;#39;re going to get hurt yeah and I would also say arguably it&amp;#39;s not always the muscle it&amp;#39;s probably the tendon firste yeah then it is and and and you know it&amp;#39;s interesting too tendons degenerate at a speed that&amp;#39;s quite rapid so if you stop using it it is a so I was thinking when I when I learned about this if it&amp;#39;s very slow on right so it&amp;#39;s 6 to n months for accommodation in tendon for the on phase but it can be a relatively fast off so depending on the degree of immobilization post injury is a potential that your tending could be the weakest element coming back so injuries will find their weakest element your bar biomechanics whatever it is you&amp;#39;re going to find the weakest element in the chain that&amp;#39;s how a lot of times we diagnose pediatric injuries with tendon so in Pediatrics the bone is weaker than the tendon the bone is weaker than the tend and in the majority of circumstances so you&amp;#39;ll see this interesting um this interesting convergence of Pediatrics and geriatrics where because bones are weak relatively weak relative to tendons and muscles in both segments of that population so if you have say an osteoporotic person and they go and they trip and they catch themselves and they evulse their their hamstring right off of their isot tuberosity on the bottom of their pelvis it happens I know I did it but not for that reason yeah sorry so terrible um tough to treat now same thing goes for when you have kids um we will find bone fragments you know things called something called ATT traction apophysitis which is like your oods you see somebody&amp;#39;s knee who has a little bit of a lump on it basically the tendon was pulling on the bone the extensor mechanism of the knee was overloaded and because the tendon was stronger than bone it convinced the bone to do what it wanted which was pulled the bone more towards it now we&amp;#39;ll see that to some some extent in the population in between so if you have say you have a longstanding achilles problem but it&amp;#39;s Achilles tendonopathy or you just overload your Achilles you will see the actual attachment point the bone changes form it&amp;#39;s as if the tendon is pulling the bone up and actually because bone is constantly remod interesting yeah so x-rays despite the fact that tendon is a soft tissue problem so you wouldn&amp;#39;t see a tendon on x-ray you would not see the discreet yeah you&amp;#39;re not going to evaluate it to the same extent so as The Listener is thinking well how do I know if I have a tendon opathy the should I go get an x-ray you would not go get an x-ray I would get an x-ray only to look at the other elements of it but MRI and ultrasound are superior for tendon Imaging so um MRI has a very good degree of resolution and a very high degree of penetrance so the benefit of MRI is we can see to the level of the bone and Beyond ultrasound will stop at the bone so high very high resolution in some instances higher than MRI and so I will find commonly on someone&amp;#39;s in a shoulder I&amp;#39;ll find little in what are called interstitial tears in the middle of the tendon that were not visualized on the MRI because the MRI takes certain cuts the other benefit of ultrasound is dynamic so I can actually put the Probe on somebody have them move their shoulder around and if I&amp;#39;m going to make the clinical diagnosis of you have shoulder impingment I can prove it and I can see is this something where you&amp;#39;re acutely catching your shoulder under a structure that&amp;#39;s going to help me formulate a therapeutic exercise routine for this person on the topic of you know not if it&amp;#39;s when it&amp;#39;s it&amp;#39;s a it&amp;#39;s a tough pill to swallow know and I hate to say it it&amp;#39;s and I hate to say it as well because I do believe I&amp;#39;m one of those people was like in the ideal circumstance could we avoid it yes if you didn&amp;#39;t do anything you absolutely could avoid um but you&amp;#39;re but in that case you&amp;#39;re going to be on a freight train towards a bad state of health so uh you have to make a trade-off at some point now with restoration of normal mechanics and loading and periodically deloading I think we can do a lot for injury prevention and we know what normal mechanics are despite the fact that everyone has different arm lengths and different leg lengths We There are standards of mechanics there is if you look at like an Orthopedics textbook and know look at joint ranges of motion it&amp;#39;ll look at specifically what&amp;#39;s a norm like and these are all these are all Gan distributions bell curves so you&amp;#39;re going to wind up with here you go you have majority of people should have 180 degrees of shoulder flection they should have 90 Dees of shoulder EXT rot external rotation when the arm is abducted you can find these things now if you restore a range of motion a very important principle in muscular skeletal health is mobility and stability okay when I evaluate somebody I&amp;#39;m looking at them on a 2 by two table are you weak are you strong and we&amp;#39;re talking about a specific element of their mechanics not generalized for example um raise your arm up up yeah right is this strong can you push it against exactly and what I what I like to look at is um say I&amp;#39;m examining somebody&amp;#39;s hip and I&amp;#39;m going to isolate one of their Glu muscles with a specific range are you weak in that muscle so I like to look at weak versus strong and Mobile versus stiff weak versus strong Mobile versus stiff yeah so to give you an in for for instance of who kind of fits in each category so for our elderly patients who have unfortunately accommodated a lot of a lot of time and where they are most often stiff and weak so joint ranges emotion decrease with time you get calcification of soft tissues your joint capsules harden a little bit you stop moving them as much so it&amp;#39;s natural to see a normal decreased range of motion as we age so now if you pair that with inactivity if you pair that with somebody who&amp;#39;s uh not engaging in a lot of resistance training it&amp;#39;ll be paired with weakness so stiff and weak because you you hear a lot about that people are very hypermobile yes um and it&amp;#39;s interesting to hear but as they age that they would stiffen yeah just about everybody stiffens to some degree as you age and just about everybody&amp;#39;s more mobile when they&amp;#39;re younger now there&amp;#39;s obviously variations within that depending on what modifiable behaviors you engage in now let&amp;#39;s take for instance the hypermobile patients so hypermobility does come it&amp;#39;s doesn&amp;#39;t it&amp;#39;s not always a dedicated eers Dan Los diagnosis we have something called the biteen score you should mention ERS downlo um because there I do have a few patients with it people are very curious about that just as we&amp;#39;re talking about Mobility because there&amp;#39;s probably a spectrum of it that&amp;#39;s much more common than individuals recognize and it could predispose people to injury and other things so there is a a good evidence-based score it&amp;#39;s called the Bon score that can actually be um that can be performed in the office to test for hypermobility and what we look at is can you bend down to the floor touch your palms on the floor can you bend your pinky back then greater than 90 degrees everyone&amp;#39;s going to be trying it yeah go ahead Mia yeah so there&amp;#39;s other tests within it but there is a spectrum of hypermobility and it&amp;#39;s likely due to genetic determinance of col and um so when we think about is not treatable correct to the degree yeah so it can be treatable with modifiable with exercises and I&amp;#39;ll explain that in a moment but you know these are things these are relative not absolutes so your mobile and weak patients are most commonly hypermobile the mobile and weak yeah so on the 2 by two stiff and weak is elderly you&amp;#39;re mobile and weak or hypermobile now stiff and strong or stiffer and strong is like an offensive lineman if you examine an offensive lineman&amp;#39;s hips they&amp;#39;re not going to rotate a whole bunch but they&amp;#39;re as strong as heck and they can put the power down so that&amp;#39;s stiff and strong stiff and strong is not a bad place to be um then you&amp;#39;re mobile and strong those are your Michael Jordans those are the people and strong that&amp;#39;s that&amp;#39;s the that&amp;#39;s the gril so if you can for every bit of Mobility that you gain you have to be stable so range of motion if I just stretch myself into a range of motion but I don&amp;#39;t know how to act ly activate muscles to protect my body in that range of motion it&amp;#39;s just range of motion for range of motion&amp;#39;s sake not all Mobility is uniformly beneficial in my opinion I believe that if you&amp;#39;re going to have Mobility you need to have accompanying stability and if you&amp;#39;re a more mobile person you have a larger responsibility to be stable through a larger range of motion now what are the determinants of Mobility is a really complicat a topic but you have your bony determinants so not everyone&amp;#39;s hips are shaped the same not everyone&amp;#39;s shoulders are shaped the same and those are your more mobile joints then you have your soft tissue determinant things like collagen play much more of a role there so whether you&amp;#39;re hypermobile in a joint capsule women are more Mobile in their joint capsules than men women have more um type three collagen in their tendons than men so that&amp;#39;s going to influence I didn&amp;#39;t I didn&amp;#39;t know that yeah just broadly speaking okay broadly speaking um so these are these are these are some determinants that are um going to predict some of the soft tissue extensibility and then the mo the mobility aspect and and really how stable you are a huge element of that is that that same neurokinetic element we spoke about before and the athletic accommodation timeline so if you can be stable and you know what muscle to contract in what position Mobility is fine but I for instance I would prefer for a lot of patients to be in a narrower range of motion but much more stable through it than as opposed to having just a very large range of motion if you think about the ranges of motion that we need to accomplish your day-to-day life you need to be able to do a good hip hinge you need to be able to do a good squat you need to be able to rotate um and you need to make sure that you&amp;#39;re you&amp;#39;re you&amp;#39;re producing enough body tension that&amp;#39;s centralized in your core to mitigate injury in those circumstances you don&amp;#39;t have to be an elite um contortionist to to achieve everyday life and that&amp;#39;s why the the concept of stretching is a very interesting conversation to have what we&amp;#39;re achieving with stretching is a very interesting conversation to have should we do it this is going to bring me to the yes or no section oh dear okay so you&amp;#39;re not going to like this because you&amp;#39;re very academic but I&amp;#39;m going you can only answer yes or no okay Pilates yes steroid injections yes zone two sure we&amp;#39;ve never had a guest answer sure ever I think it&amp;#39;s beneficial I think the question the question is the dose the type but see this is very difficult for people always this is why G this is why I&amp;#39;m not on the hill okay if if I wanted to if I wanted yes or NOS i&amp;#39; be a politician Fair yoga um whoa I love this section of the podcast yeah is that a yes or no I&amp;#39;m not I&amp;#39;m not no and I&amp;#39;m not yes I&amp;#39;m I&amp;#39;m I&amp;#39;m gonna bow out of that one I&amp;#39;m GNA use my fifth amendment on that one this then leads me to stretching um stretching can be beneficial okay so it&amp;#39;s not uniformally beneficial the question is what you&amp;#39;re to achieve with it let&amp;#39;s talk about protein specifically first forms Natural Way protein Formula 1 people ask me all the time what kind of protein powder I use what kind of protein powder I recommend Formula 1 makes many different kinds of protein powders different flavors a natural one you pick it it mixes amazing it makes it extremely easy to get your protein in and really they&amp;#39;re it&amp;#39;s a whey protein isolate so you&amp;#39;re getting the majority of your calories from protein in the shake tastes great super easy to travel with great breakfast dinner maybe even lunch whatever you need it&amp;#39;s got you covered and it has all the amino acids necessary will help improve body composition muscle mass all the things that protein does and by the way when do you need protein well you need it every day and that&amp;#39;s why I love first forms protein powder their Formula 1 go to First form.com lion that&amp;#39;s first form.com Lion now then let&amp;#39;s talk about so that we do a so Matt loves having the yes or no because it obviously no answer is typically yes or no yeah but stretching tell us about should we be stretching before activity should we be stretching after um because I ran out of the gym yesterday because my sister said we trained with um Carlos mat he&amp;#39;s my coach and my sister said you know we are done working out we should stretch I&amp;#39;m like for what what are we stretching why are we doing this and then I said I&amp;#39;m going to talk to Dr Gerard because I think you&amp;#39;re wrong we probably don&amp;#39;t need to stretch after we work out okay and now I&amp;#39;m about to be schooled oh well let&amp;#39;s let&amp;#39;s see so there is this is one of those topics that I I have some relevance in but I I I don&amp;#39;t feel 100% an expert level with um I have a lot more to learn on it but I&amp;#39;m GNA I&amp;#39;m going to give it a shot for you so stretching preactivity decreased neuromuscular firing decreased stability not beneficial for power athletes and can we Define power athletes so uh pitcher pitcher um shot putter um Elite powerlifter um you could even throw fighters in there that&amp;#39;s a powerful sport so you&amp;#39;re producing power is force over time so you&amp;#39;re going to produce force over a very short period of time so static stretching probably not beneficial for anything or just we&amp;#39;re talking about power pre pre uh pre-exercise for power generation now stretching there are different categories there static stretching so I&amp;#39;m going to hold a pose for a while typically 20 seconds or more and hopes to elongate the tissue now you&amp;#39;re not just stretching the the tendons you&amp;#39;re not just stretching the muscles you&amp;#39;re also providing neural feedback that can actually turn off some sensors that help to protect you under load are these the goldi spind viribus yeah so GOI see if I remembered anything hey so so GOI is interesting um you know the the other as apparate are also interesting but the the static stretching component perhaps has some benefit post exercise with relation to tendon Health specifically and it may actually help just elongate the tendon and actually if you&amp;#39;re holding a pose maybe like a with an isometric or let&amp;#39;s say you&amp;#39;re going to do a heel drop and just hold it there that could have some benefit now for power or for for Recovery recovery for Recovery yeah now I I&amp;#39;m I say a lot of I&amp;#39;m gonna heavily wait the May here okay because I think it may help but I&amp;#39;m also going to tell you from a personal aspect I don&amp;#39;t do it so I think it&amp;#39;s important you know that I don&amp;#39;t neither does my husband there I&amp;#39;ve never seen that guy stretch ever he&amp;#39;s a smart man so so um now if you&amp;#39;re going to if you&amp;#39;re going to stretch with a hope to teach your muscles how to engage at a larger range of motion than you do PNF so proprioceptive neuromuscular facilitation and the answer for that is PNF PNF proprioception neuromuscular facilitation okay so PNF is a process by which okay so I&amp;#39;m going to um I&amp;#39;m going to stretch say my hamstring and somebody&amp;#39;s going to push against my leg and I&amp;#39;m going to actually try to control ract my hamstring at a larger length than than I did pre-stretch and then I&amp;#39;m going to stretch from there and so there&amp;#39;s typically these onoff Cycles like a 10-second isometric at a one length 10-second stretch at another and you can do that now and the benefit of that is the benefit of that is you are you&amp;#39;re teaching somewhat that the muscle can relax at a larger length Okay so whether pre pre-exercise or post exercise I&amp;#39;m not clear on and this seems to work with um a lot of people do do it with pain is that so is PNF used for mitigation of pain a muscle or yeah it&amp;#39;s used it&amp;#39;s used in rehab so it&amp;#39;s it&amp;#39;s it&amp;#39;s used by physical therapists and atc&amp;#39;s and other people who um who will rehabilitate patients so it&amp;#39;s definitely part of it when I design uh Physical Therapy protocols for patients I I like eccentrics for lengthening so once again Ecentric your your muscle is Contracting periodically or mitigating that um the the elongation process I think that could be very beneficial the stretching component is interesting because once again we&amp;#39;re not just stretching the muscle we&amp;#39;re not just stretching the tendon we are also gliding the fascial layers so here&amp;#39;s another love that you brought this up so here&amp;#39;s here&amp;#39;s fascia another that&amp;#39;s a would you consider that an organ system uh it&amp;#39;s interesting it&amp;#39;s it&amp;#39;s part of the muscular skeletal system but it&amp;#39;s so richly inovated and so large it could be its own category what what is fascia fascia is interconnected connective tissue that can run the entire length of the body incredible here&amp;#39;s why we don&amp;#39;t get taught about fascia as much as we could we should be a lot of it is almost as if we during the process of medical school when we dissect k um dissect kabers it&amp;#39;s gross it&amp;#39;s necessary and it&amp;#39;s absolutely disgusting it&amp;#39;s it&amp;#39;s also um important it&amp;#39;s important and thank you to everybody who donates there who donates their body abely incredible that people are willing to do that when we dissect a aers most fascia dries out so much so that it aderes to adjacent structures and becomes incapable of dissecting it off of now I&amp;#39;ve spoken to some scientists in Italy about this specifically you did you were just hey I wasn&amp;#39;t in Italy it just happen you were just thinking I spoke to I spoke to somebody um basically because ultrasound is one of the main ways to evaluate fascia in the living specimen so there is specific cavic preservation techniques for preserving fascia but one of the reasons we don&amp;#39;t crit really understand it or appreciate it to the level that we do is we just don&amp;#39;t see enough of it so fascia can adapt fascia is if not the most richly innervated structure in the body one of the most richly inated structure in the body that means the most nerves does it have pain so does it feel you feel pain people feel mile fascial pain I believe it is a con it&amp;#39;s part of the diagnostic spectrum of pain so you can have a muscle that hurts you can have a tendon that hurts you can have a joint that hurts you can have a ligament that hurts um in fact also can hurt in my op you feel it if someone were to say would that have anything to do with um fibromyalgia or it&amp;#39;s interesting yeah so the the the concept around fibro is um I think it&amp;#39;s part of it the the fascia is part of the issue um but we also see my fascial pain in people who don&amp;#39;t have fibro you know and so we see M fascial pain and overuse syndromes a very common mile fascial pain that perhaps some people will experience is if if they have a pretty large asymmetry in their head hips how their hips move and function they feel a lot of mof fascial pain in like the top of their glute low back area now it&amp;#39;s tough to discern and I it&amp;#39;s been my job doing this every day Discerning what the main pain generator is and then describing how we can appropriately rehabilitate it and and treat that pain now fascia specifically do adapt to exercise and one of the best books I&amp;#39;ve read about this by a guy by the name Bill paresi so um and he the forward was written by Stu McGill so talks about fascial adaptation to training and that basically this fascia system that extends in some circumstances the length of the body connects your glute on one side to your lat on the other is a lot of the reason that we don&amp;#39;t move like rigid robots so allows us to move much more coherently now the question be in this circumstance is how much of a role is that in in pain how much of how much can we do about it now we know that it adapts some circumstances because there are some athletes that when you take them and train them a certain way they get athletically worse at what they&amp;#39;re doing now there&amp;#39;s changes at the neurokinetic level there there&amp;#39;s changes at the muscle level there presumably there are some changes at the fasal level as well one of the accounts that bill talks about in his book is about um an elite quarterback who was training like an offensive lineman so basically they were putting the quarterback through the lifting protocols on offensive lineman and the quarterback all the numbers around throwing got worse spiral got worse velocity got worse worse arms started to hurt so maybe everybody needs to train towards towards a specific goal because on some level or another your entire body is adapting to that stressor so the you always have to keep that in mind of when you&amp;#39;re training an athlete they can&amp;#39;t all be treated the same not any exercise is uniformly the perfect one for everybody um for their specific needs you have to you have to do an individual needs assessment for that patient so FAS is very interesting um we do visualize it on and specifically where fascia are where the small nerves like say for instance the nerves that talk to the the muscles of the back fascia are the fascial layers are where they travel so the thought is behind my fascial pain is could you have these layers that are not appropriately gliding on each other and patients who have chronic pain there&amp;#39;s some evidence that suggest that they don&amp;#39;t Glide that well rounding this back up to the initial question around stretching um stretching also Glides fascia and so does that have its own therapeutic benefit could that actually be helping produce these proteoglycans these lubricant that are present in the body the same way that they&amp;#39;re in tendons so is is it a lubrication problem and can we facilitate that with stretching so then there&amp;#39;s also the question of Mile fascial release and what we do for individual people my I&amp;#39;m less concerned about the modality we use to get people Mobility so much as I am more concerned with us restoring stability through that Mobility really well said I&amp;#39;m learning just so much can we talk a little bit about training yes I&amp;#39;ve learned quite a bit and you really have helped me reframe in fact we&amp;#39;re working on a second I&amp;#39;m I&amp;#39;m working on a second book proposal and I&amp;#39;m hoping you will be so gracious as to um impart some of your wisdom in in part of that process and I&amp;#39;ve learned a lot about think thinking about how we train the current Paradigm the current narrative is all about zone two M it is um that zone two is where we need to focus and then we have other groups that we talk about resistance training do it three to four days a week There&amp;#39;s and understandably so there is only so many ways that we can make Global recommendations yes that being said I would love your take about um you and I have spoken about minimal amount of movements exercise kettle bells more effective ways to utilize our body I&amp;#39;m just gonna leave that for you to take it wherever that you&amp;#39;d like to sure so the concept of Zone 2 is an interesting one I think that a lot of the excitement around it is that it&amp;#39;s helping to promote mitochondrial function and that mitochondrial function appears to be absolutely essential as we age and can we improve mitochondrial function to decrease things like insulin resistance improve metabolic Health improve our athletic performance and the concept there it&amp;#39;s interesting to see how depending on what you look at these different terms that describe similar phenomena so submax V2 training Zone 2 moderate intensity continuous training I did a presentation a while back um specifically as it regarded patients who were recently diagnosed with cancer undergoing cancer treatment or finished cancer treatment and what exercise recommendations we could make for them because their V2 Max and Muscle Max muscle mass help predict how they do and we know that quality of life mortality morb morbidity the more fit you are from a cardiorespiratory and muscular aspect the better you will do with treatments so how can we help people and so the question was in the presentation should we be engaging in high inter intensity interval training um or moderate intensity continuous training and the answer is of course both can be helpful per uni time high-intensity training might be more beneficial to your V2 Max upwards but what are we really thinking about with V2 Max one is if we&amp;#39;re going to test V2 Max in somebody they should be familiar with the movement of which we are testing them it&amp;#39;s not fair to say somebody has a suboptimal V2 Max but it&amp;#39;s their first time doing a certain athletic activity they&amp;#39;re never going to be you&amp;#39;re going to be gassed if if I even if even if I&amp;#39;m I&amp;#39;m a marathon runner if you throw me into a boxing earring I&amp;#39;m going to be Gass in two rounds because now you might be amazing but a normal person yeah but um the truth is as I would be guessed and the it&amp;#39;s because I&amp;#39;m not familiar with the movements is the way that I should be so it&amp;#39;s important that&amp;#39;s important caveat don&amp;#39;t get down in yourself if your V2 Max is not where you think it should be because you did some modified Bruce protocol in a gym it might not be where it should be because you don&amp;#39;t have a familiarity with the movement if you&amp;#39;re on a bike there are so many determinants of how your performance on a bike absolutely your positioning your familiarity with it what muscles you&amp;#39;re activating your shoe angle with with with with the actual pedal um and I&amp;#39;m out of my league there I know that that&amp;#39;s that the very very surface layer of it so we&amp;#39;re looking at substrate utilization fats versus carbohydrates versus creatine phosphate and we&amp;#39;re looking at what can be done um to maximize fat oxidation so this concept around Zone 2 as I understand it is fat Max like we&amp;#39;re trying to maximally use fat for fuel while we exercise to teach our mitochondria to metabolize fat more readily to decrease insulin resistance that&amp;#39;s what makes sense to me at least now uh with high-intensity interval training there&amp;#39;s no I think the downside of zone two is time I think that&amp;#39;s it I think you have two children and a beautiful wife and a full practice yes and time is tough so I I don&amp;#39;t engage in a ton of Zone to myself if I had more time in the week perhaps I would but then high intensity high-intensity interval training appears to be as beneficial for v2 Max as as the zone 2 but you&amp;#39;re training it two different ways from high intensity interval trading you&amp;#39;re like raising the ceiling of your house higher right you&amp;#39;re just you&amp;#39;re getting better at pushing it higher but the V the the zone two training appears to be that like you&amp;#39;re solidifying the foundation you&amp;#39;re getting better in the lower levels that predict success at the higher levels so we might be describing it this way but athletes have intuitively known this for decades when they run they&amp;#39;re not gassing themselves every workout they leave a little bit on the table and the body goes through a period of compensation to basically mount response to that stressor and then when they do peak one or two times a year they&amp;#39;re in really good shape so same principle applies to weight training so are should we or could we be going to neuromuscular failure if our goal is muscle hypertrophy should we be focusing on just muscle hypertrophy and specific muscle segments or generalize strength and instability I think these are good questions but the um I find the way I trade with kettle bells um is I want to be number one thing for me is don&amp;#39;t lose stability in all three planes of motion sagittal transverse and frontal like we spoke about before when you work a kettle bell um most of the time it&amp;#39;s in one hand and that by Nature destabilizes you and you&amp;#39;re not going to get destabilization if you&amp;#39;re working only with barbells so if you&amp;#39;re you&amp;#39;re not going to get destabilization working with bar balls only you know as it relates right as it relates to the frontal and the transverse plane so you&amp;#39;ll be stable as all heck in the sagittal plane if you work with the barbell I was the sagittal plane hero I went to the gym and I did well done bench lats I did squats I did deadlifts and I became very proficient in those areas but then I would go play golf and like things would hurt and i&amp;#39; be like well well that&amp;#39;s interesting you know I&amp;#39;m not the world&amp;#39;s best scaler but it shouldn&amp;#39;t hurt as much as it did and I thought it was basically because I wasn&amp;#39;t as proficient in translating force in rotation so I like to use a kettle bell I think you can get a lot out of it I think the the work from the strong first organization and um and Dan John on online and his own uh Endeavors have done a great job elucidating the cardiorespiratory benefits of kettle bells that you can get strength and conditioning um and so I try to follow that I I also do something and we spoke about this this term exercise snacks which I don&amp;#39;t particularly love but I don&amp;#39;t either I I but I can&amp;#39;t think of we&amp;#39;ll we&amp;#39;ll find a way to Rebrand it but um definitely yeah um I call call it farm hand strength so like if you&amp;#39;re working on an outdoor let&amp;#39;s say you&amp;#39;re not a farm hand let&amp;#39;s say you&amp;#39;re just somebody mulching your yard you&amp;#39;re not going to um basically go to the point where you&amp;#39;re falling down every single time you&amp;#39;re going to leave a little bit on the table you&amp;#39;re going to come back to it you&amp;#39;re going to go do a different activity for a short period of time and you&amp;#39;re going to come back to it and so what I do what I&amp;#39;ll do is I&amp;#39;ll intermix like some sets of kettle bell swings throughout the day I might do a set at 9:00 a.m. and do a set at you know 10:30 I&amp;#39;m not looking to build a sweat I&amp;#39;m just looking to get better at at the movement so I&amp;#39;m really stressing that neurokinetic element am I getting more am I getting better at the movement am I doing a little bit of stimulation of muscle but by no means am I getting a you know a skin ripping pump out of it but potentially you could build a workout like that yeah there&amp;#39;s the a com there are you know when we look at some of the really good uh people who are training um and what they do and a lot of Rehabilitation from injury sometimes it&amp;#39;s three five 10 minute rests you know and so question become I think in there is do you want to be really do you want to be super proficient with a movement or do you want to get as much training in in a short period of time as possible so there&amp;#39;s different strategies there but we move throughout the course of the day it&amp;#39;s not like we only move for 30 minutes and then we&amp;#39;re immobilized for 23 and a half hours so the concept of going to the gym I think is something that needs some work where we we we think about going to the gym we dedicate time but should we be interspersing movement throughout the day I think some people fortunately in their jobs can do that and some people unfortunately can&amp;#39;t do that um but I like like you I saw you both do a set of push-ups before as its own little stimulant prior to the podcast our that&amp;#39;s our um pregame push-up there you go we we do a a podcast ritual now is is that not helpful because you only did one set of course it&amp;#39;s helpful you didn&amp;#39;t know that we&amp;#39;re doing some after this well I&amp;#39;m happy to do it um but you did you did one set in isolation and you benefited from not overloading your tissues you benefited from a short-term increase in your heart rate you learned how to become a better push uper and that has something to do with it too so I think the coming back to the concept around zone two it&amp;#39;s if you were to train I think the the probably what makes sense for a metabolic corollary with weight training is like if you&amp;#39;re going to neuromuscular Fair your muscles are on fire you&amp;#39;re not in zone two right I think we can comfortably say that right yes so your probably in zone five or four or five so you&amp;#39;re you&amp;#39;re really getting there now if you train and you say you do 10 repetitions of something explosively and then you wait a couple minutes and do it again could you still be in zone two and that&amp;#39;s the this concept that has come up called anti-g glycolitic training which is um a way to build endurance and strength um which has been subject to my own personal Fascination I&amp;#39;m not in a position where I could speak from an educated perspective on it a lot of the literature behind it is in Russian so so I can&amp;#39;t read get learning but I&amp;#39;ve read pavo&amp;#39;s work and pav does a great job with that um and I&amp;#39;ve I&amp;#39;ve recently read a couple of his books and I think it&amp;#39;s something I&amp;#39;ve experimented with the same way that we might all experiment with Zone 2 or a hit training or powerlifting or whatever it might be I a lot I think one of the benefits to my patients is that I I&amp;#39;ve gone through the process of experimenting a lot with this played baseball and football I was a personal trainer um I did a good bit of just you know casual powerlifting I tried to be you know a a crappy bodybuilder for a period of time and I wasn&amp;#39;t great at it but uh and then on top of that you know I might not have I might might not be running a marathon like Shane in a couple weeks but I did run a half and you learn so much going through those through those individual experiences so I try to maintain a radical open-mindedness about what could be helpful and and try it myself when if I can and that&amp;#39;s really valuable a physician that sees patients and also walks the walk and experiences it and I I do think that you bring a very unique perspective um in your practice how do you incorporate some of these things so you practice in um where are you in practice right now I&amp;#39;m in Floren Park New Jersey I work for Summit Health okay and people could make an appointment with you if they would like to I so let me just tell you guys something every guest is incredibly vetted before they come on the podcast I have so much respect for Dr Gerard I send patients to him if you are in the area if you are not he is definitely worth the trip I would love to hear a little bit about what makes your practice different unique we&amp;#39;ve heard a lot about your philosophy and how you think about things from both a biomechanical aspect I know where you sit from a nutritional aspect but also um you&amp;#39;re Fellowship trained yes I I&amp;#39;d love for you to expand upon your training and just your individual practice so my my practice is a Sports and Spine practice I did a Sports and Spine fellowship at the hospital for special surgery which by the way is one of the best in the country if not one of the best places in the world yeah it&amp;#39;s a great place to train a great place to be I&amp;#39;m I have been I think the very important take-home for anybody who&amp;#39;s listening outside of me kind of speaking about myself for a moment is if you can find mentors that are really good for you really pursue their mentorship yes um that&amp;#39;s how that&amp;#39;s how you and I have developed this relationship I have um a mentor almost at every different phase of the career so I kind of have mentors that are closer to me in age I have mid-career people I have later stage career people and I also have mentors who are non-clinical or not even doctors you know who who are out people in different fields getting their perspective has been so important and anything that I do is is the great Fortune of having a great family and a great upbringing and great wife and kids at home and parents and brother and friends so I I&amp;#39;m fortunate that that every day I go to work I feel like I bring the best version of myself because I have a great backing amazing now from my perspect for my practice my practice focuses heavily on the biomechanical determinance of pain and when we patient comes in let&amp;#39;s say I see a back pain patient it&amp;#39;s less difficult to make the diagnosis of a pinch nerve in the back from a herniated disc and more difficult to discern why that disc herniated and to unravel in a relatively short time frame what determinance in that person&amp;#39;s life or in their training predispose them to that injury and how are those things going to be encumbrances to them getting better in the future so that takes some refining and I&amp;#39;ve gotten better at it with time but uh every day we try to build a little bit and I try to find what is motivating this person what are your goals and I ask every patient what are your goals for this visit some people just want Clarity of diagnosis well the first thing we need to do beyond anything else is Clarity of diagnosis from a biomechanical element and from a tissue layer element do you have a herniated disc yes why repetitive flexion movements without appropriate lumbar stabilization insufficient HP mobility and then they didn&amp;#39;t have the appropriate brace from the obliques that&amp;#39;s a good starting point now let&amp;#39;s use this inflection point of injury and let&amp;#39;s build you back to a point of antifragility so the concept of antifragility is one that I borrowed from Nasim talib&amp;#39;s book uh which is one one of four books in the inero which are very difficult and fun to read um I love I very thick book yes very thick there are books about everything if you ask me what they&amp;#39;re about they&amp;#39;re about everything but this concept of anti fragility is actually a concept that is exhibited in muscle and tendon and Bone which is you provide a stressor to a structure it doesn&amp;#39;t break but in time if the stretcher is adequate stresser is adequate the Str the structure can actually get stronger so I branded myself antifragile MD because I love that concept I love that&amp;#39;s the essence of my practice can we use stressors rather than hurting you and disabling you to make you stronger yes sir so well said and I know that&amp;#39;s you too I know that&amp;#39;s you too so um I look at is can we get people from a point of injury to back to a state of athleticism and what are the goals do you want to be on the the ground plane with your grandkids are you somebody who&amp;#39;s going to run a marathon in a couple weeks and we kind of look at all these things in the variety of treatments that I can offer and when there is an Evidence Bas to draw from we will draw from that evidence base if there&amp;#39;s no evidence based to draw from an area we&amp;#39;ll extrapolate based upon the knowledge of my bi biological foundations so but I I my practice is is a Sports and Spine practice so I see a lot of hip pain back pain um shoulder pain neck pain to a li Li extent elbow and then of course um knee and some ankle ankle foot as well and the two main three or four main conditions I treat are back specifically low back pain tendinopathies around the body and then a lot of neck pain and you&amp;#39;ll find that patients who have low back pain have tendinopathic problems as well and you&amp;#39;ll find in the in shoulder it&amp;#39;s it&amp;#39;s a whole sling so the whole whole sling can have problems but I I think it&amp;#39;s you&amp;#39;ll find specifically that there there are insufficiencies in the in the pelvis and the peripelvic muscles like the glutes and so it&amp;#39;s not uncommon to find a tendon problem there so I like to uncover what the root cause is and that&amp;#39;s really what gets me out of bed every morning is root cause diagnosis and then if your diagnosis is accurate and you can correlate it with the diagnostic testing we have x-rays M ultrasounds Etc and it matches up with a good physical exam well now we have CL CL ity of diagnosis then the treatment everything we provide from a treatment aspect there out is much more beneficial and what I love about what you&amp;#39;re saying is it&amp;#39;s not about the end pain or the end symptom it&amp;#39;s a root cause approach which traditionally medicine is not about a root cause approach and that&amp;#39;s what I think what makes you and your practice so exceptional is that what is at the foundation so that you can get people better where do you see the field going so I think that there&amp;#39;s uh a good interest around regenerative medicine and there are a variety of regenerative therapies that we have now PRP um you know we spoke about the athletic accommodation curve there&amp;#39;s also the you know the Innovation curve of companies and products and I&amp;#39;m instead of like being on the absolute first phase of stuff I&amp;#39;m probably one phase delayed I I feel the same way we have to make sure that things are safe effective while for patients to spend their money yes agreed um and first rule of medicine is Do no harm that&amp;#39;s right so Do no harm anything we do we want to understand what we&amp;#39;re doing we want to put it in the right place um so I think there&amp;#39;s some very interesting work that&amp;#39;s going on from a stem cell aspect um fat concentrate procedures further subcategorization of PRP when to use it when not to use it and I think the field will continue to develop that I think as we evolve um as a field going forward we&amp;#39;ll begin to understand a little bit more about things like fascia we&amp;#39;ll begin to understand a little bit more about mechanics other than just isolated joint range of motion and whole body movement um I think that the it takes a lot of interest in that and study to do it but I think we&amp;#39;re getting there and I think the the Last Frontier is in in a lot of ways the first most important which is prevention ounce of prevention is worth a pound of cure and how can we prevent these injuries or you know you see this word circulate on like bulletproofing like we going to bulletproof your shoulders bulletproof your knees um and so that&amp;#39;s where a lot of my own self- experimentation comes in and trying to learn that as well as watch people do it and experiment with that but as a field um I hope we I hope we study more of that and then of course predictive U Predictive Analytics around who who is going to wear a joint in a specific pattern based upon their bony development we have some evidence to understand that now particularly in the hips but in the we&amp;#39;re starting I think to in a greater degree to look at that in the shoulders and surgeons specifically are doing a great job of looking at that and then from a tendon aspect you know like we said are there exercises we can engage in I&amp;#39;m certainly going to do my best to find out and I think and to and to figure out what is the most effective ones I think the the question becomes minimally effective dose of everything yes training medication yes how much is too much and are we overtraining tissues and that&amp;#39;s why we&amp;#39;re seeing so many muscles skeletal problems or are we just inefficiently training and is it because we just don&amp;#39;t know how to do it if you can restore you know quote unquote normal mechanics it varies from person to person but if you can restore normal mechanics a lot of things get better and I think what we&amp;#39;re seeing now is people like yourself are doing a great job of highlighting well we need power we need muscle mass we need cardiorespiratory potential um what movements can get all of those in a in a minimal dose of time because we&amp;#39;re all busy and then what nutrition can Empower those goals and what sleep you know determinants can help us so I love how holistically you look at everything because you can&amp;#39;t look at one thing in isolation the body is not isolation everything works everything works together and it&amp;#39;s funny we we have this concept of organ systems and things like this and it&amp;#39;s uh when you look at the the muscular skeletal system it&amp;#39;s like well B cells are present in chronic tendonopathy does that mean it&amp;#39;s now part of the immune system you know it&amp;#39;s they all work together they&amp;#39;re all constantly connected and and communicating with one another to generate our homostasis so hopefully we understand more about the aging process what we can do in the prime years to to to arm ourselves to that and then what activities we can really get back people back to as they Age and and age gracefully Dr Gerard denafo thank you so much for spending time with us you are a wealth of knowledge I&amp;#39;ve just been very impressed with you over the years and you continue to impress me thanks for having me on where can people find you so I&amp;#39;m on uh Instagram as antifragile MD and then my um my website is with my employer Summit health so if you search my name Gerard denafo you&amp;#39;ll find that I have a web page there and you can book appointments from that point and over time I think um I&amp;#39;m also on YouTube at antifragile MD and uh we&amp;#39;ll be publishing more content in the coming months and years yes sir thank you again thank you

Transcript for:Dr. Gabrielle Lyon Show with Dr. Gerard D'Anzafo

Transcript for:
Dr. Gabrielle Lyon Show with Dr. Gerard D'Anzafo