https://podcasts.apple.com/us/podcast/jacked-athlete-podcast/id1462537296?i=1000695065247
Diagnosis: “I just realized none of the findings of the testing really changed anything. The treatment was always the same, no matter what you found. And that was an early realization in my career. And then I’ve just doubled down on it where for the vast majority of things, unless you’re a surgeon or maybe unless you do injections, the diagnosis really doesn’t tell you what to do.”
“If you’re in like the multiverse with a 24 year old woman or say 38 years old and she, she plays the same sport, volleyball or whatever it happens to be. And she has kneecap pain, IT band pain, patellar tendinopathy, maybe a meniscal strain, early knee OA. None of those things would change what you do in rehab. It’s sort of her and and the sport that tells you what to do… You just build people up to do what they love.”
“A bone injury. That’s actually one of the few areas where maybe knowing the tissue kind of matters. Because with a bone stress injury, you probably have to back off and let it heal. And what sucks is initially it’s just time.”
“What people might say is maybe that tendon needs to get stiffer… is the lack of stiffness, which is just a manifestation of how strong the tendon is. Yeah. Is that lack of tissue strength, something that’s inhibiting someone from getting back to their sport? So that’s like a very specific physical attribute and an attribute like that, you have less options in what you do in rehab.”
“The measurement of stiffness is a surrogate that you’ve changed something about the tendon itself… Because the theory of stiffness, of why we would want to change stiffness is that it implies that the tendon itself got stronger.”
“We don’t really see a lot of changes in tendon stiffness. We don’t really see a lot of changes in the tendon at all from what we’re able to measure. And so after you do a plyometric program or a hopping program, so you’d be like, well, has that done nothing to the tendon? And that doesn’t make any sense. We must have done something to the tendon if it builds people up to hop and skip. We’re just not able to measure it. That’s sort of the problem right now.”
“So like a hopping program could be fantastic for tendinopathy, but if you think people need to increase their stiffness to get better with tendinopathy, then you would say, shit, don’t ever do hopping. So we gotta be careful with these surrogate measures, assuming that we know how people have to change to recover. And that’s what we do way too often. We shit on things, because we make an assumption of what has to change for recovery. Just gotta be cautious.”
“They looked at a heavy loading program, which was pretty consistent, the classic like three seconds on, three seconds off, 80 to 90 % max, you know, four sets, three to four times a week. And then they compared a medium load, which be your classic painfully centrics done daily. And then they had a manual therapy group. Right? And people have been shitting on manual therapy for years. I think it’s unfair. And of course, the heavy loading program was the only program to increase tendon stiffness. So it definitely made the tendon stronger. It underwent, you know, less strain during functional activities, which was the goal. But it didn’t outperform the other two programs in terms of pain or even function… So like in terms of the things that matters to people, the manual therapy or the low load medium low program was just as good. I laugh because I’m so sheepish. I’m like, fuck what the hell are we doing? It’s not a comfortable laugh.”
Tendons healing on their own: “Less so with sort of like the athletic tendon stuff with Achilles tendinopathy and all that. More so with things like plantar fasciopathy, greater trochanteric pain syndrome. I think these things are like local manifestations of systemic issues, right? So it’s like something’s up with the health of the person and it has to show up somewhere. It’s the canary in the coal mine.”
“Right, so it would be someone who’s maybe overweight and has metabolic disorder and diabetes and they get Achilles tendinopathy. Like it’s just got to go somewhere. So that’s how I view like that lateral elbow pain for a lot of people. It’s like they’re not even really that athletic. So maybe the heavy loading isn’t necessary. But I’m not willing to say that for like the runner or the jumper with Achilles tendinopathy. I still think we do something there. I think we step in and intervene and somehow change the course of it. We’re just not sure how.”
“Any type of mechanical intervention that improves, and I’m gonna speak really loosely here, cause I don’t know the mechanisms, but it’s like, we improve the local metabolic machinery to somehow make that tendon healthier and have less of an inflammatory profile locally. So any type of exercise could do that. That’s why the medium load stuff might be so helpful. That’s why even stretching could be helpful. You just sort of made it healthier metabolically.”
“When you look at why people get better like after when they have tendon related pain we don’t always make it stiffer but something must like just with nociception just means like if the nociceptive fibers they get triggered with inflammatory mediators pressure or like you know temperature so if we did something to change the inflammatory mediators locally then it could certainly make the tissue less sensitive. And so what could do that? That could just be any type of activity at the level of the joint and system.”
“The compression is a function of the angle of the pull, how much it wraps around it, how much the tissue spreads out, so the concentration of force, and the force applied, the tensile… So there’s definitely compression, but I just find it’s possible that it’s a really is a bad thing for tendons.”
“Like if compression is sensitive, great, avoid it for a bit, but what do you gotta do eventually?… You jump, right? Like if you have a jumping style where your knees are going past your toes, then you have compression at the Achilles and the calcaneus. What are you gonna do? Wear high heels every time you ball?”
“Sometimes you work with a runner and they have kneecap pain or iliotibial band pain and it hurts when they’re running slow and then when they run fast it feels better. So speed will increase the load per step but sometimes it feels better. So it’s just different so it may not be about the magnitude just that it’s a different load and you can handle it.”
“Yeah, it’s actually really tough when to push into pain and when to fully back off. But really, I mean, it’s the same as everything. If their performance starts to suffer, or if like their quality of life elsewhere outside the sport starts to suffer, then you think of backing off. You know, but if their goal is to run a really fast 10K and they’re still progressing and getting their workouts in and all that stuff, then we keep pushing. As long as we know that they’re safe and we understand what’s going on.”
“So my favorite for minimum effective dose is out of the Arampatzis lab. So that’d be Sebastian Bohm and Mersmann stuff where it’s essentially four sets of four to five three second contractions three times a week. It’s so good.”
Tendon rehab: “So this is where I’m kind of embracing options. I’m like, hey, for some people, if you just say, would you rather do it every day as it’s the thing you do before you go to sleep at night or wake up, or could you just put aside three times a week? Some people would rather just do maybe two to three sets every day or something like that. Or maybe take like the Keith Barr protocol, which I know less is like, well, you do one minute three times a day, separate at every four hours… Or, you know what I mean, like give people those options. Like, so rather than getting frustrated with like, God, what works or nothing works or everything works, be like, here, it’s all on the table, here’s your choice.”
Jake (28:36)
Yeah, the you said the muscle, the Merzman, the Merzman podcast you did, but you had commented on one of my one of my posts on Instagram about one of the Merzman. I had never heard of him until you said that. So I looked up all his work and this idea of the muscle tendon imbalance. It’s still to me, I’m like, I feel like how how can we know that the muscle is is stronger than the tendon is stiff?
and the tendon is overly stiff and the muscle is weak, like how?
Greg (29:06)
so
Yeah, I think he’s only worried about the less stiff tendons. this is done in kids. their hypothesis is that originally it was like kids develop really fast in their teen years and get really strong really quickly. Right. And that would probably be like, you the reason people, you know, your bench press can go up, you know, 20 pounds in four weeks, primarily because of neurological adaptations. Right. So I think that was sort of the idea with kids.
And then they thought maybe they’re producing too much force for what their tendon can tolerate. Cause the assumption there was it’ll take longer for tendon to adapt, you know, like cartilage or something. So I think that was the impetus for the idea and how, how they would measure that is they, they’re able to, they have a system set up where they measure plant say plantar flexion. they push against something almost as hard as they can.
So they have this peak force that they can measure, but at the same time with an ultrasound transducer, they’re measuring the strain in the Achilles tendon or the patellar tendon. And if you’re doing like a really heavy loaded calf raise, which would be not even the type of strain you would get during the sport. And if you’re, think their cutoff is 9%. If you get 9 % strain in there, that means your tendon is stretching a lot.
during the force that you’re able to produce. And Mersman’s idea, and I know you’ve questioned this because we see more strain in other activities. Mersman’s thought is at 9 % strain is when the tendon actually starts to damage and break down. That’s sort of their cutoff. that’s what they thought. then, so what they did really well was that was their hypothesis. It had the biomechanical idea. They then went and kind of looked at it.
during a season and followed kids over the year and they did find that the kids that had those higher active like amounts of strain during functional tasks they were a bit more likely to get injured so that’s a really good like biomechanical research program you can debate it but they did the right right things in there does that make that answer it is that the what you’re wondering
Jake (31:22)
Mm-hmm.
Yeah, yeah, the
it does. Yeah. Yeah, I just got I get hung up on the I get hung up on the numbers because I’m like, if if like what the number was 4.5 to 6.5 % strain is like a healthy strain. But then it’s like that that it was the boss’s Spanish squat study where they had four people and one of them strained like 18%. I’m like, I think if you’ve strained them four to six, what is that going to do for them? And then some of that Achilles some of that Achilles work.
Greg (31:50)
Yeah.
Jake (31:57)
I mean, a lot of it is like modeling and not the actual, because they had an old paper where they had like a transducer in the Achilles, I think, and they saw like a 20 % strain or something like this. It must have been, yeah. But I’m like, that’s why I get hung up on the numbers, because I’m like, if this person’s tendon is straining 20 % and we just get a 4 % in training, what is it really doing? Like, I feel like we would need to get closer to that.
Greg (32:06)
Yeah, isn’t that Pavel Komi?
Yeah
I would guess that Mersen might say it depends how you measure strain, that and where you measure it. That would be the thing. And so they have their protocols that are pretty dialed in and they’re always measuring in the same place, same part of the tendon. That would be my guess with things like that.
Jake (32:40)
Yeah,
I’m gonna get them on actually in maybe a month or so to kind of ask that, it was kind of just something I… But otherwise outside of that, it’s like the Berlin method and the stiffness gain they saw with such a low volume, that was really cool to see that it doesn’t take a whole lot of work to make your tendon stiffer. Yeah, you don’t have to do 15 sets a day. So here’s one thing, you were talking to… I don’t know if you brought this up with Merzman.
So I found this paper like two months ago and then just two days ago I found it again and I posted it on my Instagram story. It’s one of the best stories I ever had. It was on, it took me like five seconds to do and it was just, it was on, it was Aaron Patsis, Mersmin, there was another guy. I think the title was How to Train Tendons in Human Athletes. And they had it, it was all the way at the bottom. I think they were talking about their studies.
comparing their studies to plyometric programs, but they got at it and they said, mechanotransduction. So like to make the tendon stiffer, I think to make the tendon stiffer, the tendon cells have to be stimulated to kick out collagen and then cross-link the collagen. I don’t know how else you would get a stiffer tendon. I think that’s it because the stiffness is coming from the collagen and how it’s cross-linked. And I’m like, that’s coming from the cells. And they were saying that to get mechanotransduction on the tendon cells, you need a contraction of at least,
three seconds time under tension. That’s why I apply metric wouldn’t increase stiffness. What do you make of that?
Greg (34:14)
So, this is where I kind of like, I think I might ask them some of this stuff, like through email or things like that. That’s based on their 2007 paper. I’m pretty sure. Oh, 2007 and 2010. where in 2010 they compared three seconds versus cyclic contraction versus a one second contraction. That was sort of a, it’s not even a pulse. It’s not like a plyo.
What they can really say is three second contraction will get the tendon stiffer, one second won’t. It doesn’t mean that two seconds won’t. They just haven’t tested that. That’s all we could say. That would be the only nuance that we would need in there. However, you know what would, I don’t know her stuff at all, because it just, do you remember, what’s her name? God damn it, Denon. I think her first name’s Stephanie. She works with Keith Barr. She has a similar paper, but they’re looking at like,
Jake (34:54)
You
Greg (35:13)
the gene expression in engineered ligaments and tendons. so remember, because they’re the ones that say hold it for 30 seconds or I’m not even sure what they say. Yeah, I mean, that’s probably overkill, but it certainly would be helpful, helpful. they also found that with the brief plyometric contraction, there wouldn’t be a lot of gene expression to produce, I guess, collagen and all that stuff. So that would support.
Jake (35:21)
Yep, yeah it’s 30, yeah.
Oh yeah, yeah I remember that. it was, yeah I think it was like
a mouse or rat where they punched a hole in it and then they saw that if you hold the contraction it had that collagen one expression, the like linear laid out, but then if you did the plyometric it was like compressing the hole in the tendon and causing like a cartilage expression, like laying down cartilage and water and stuff. Cause it was getting compressed, that was what I made of it.
Greg (36:05)
Yeah, maybe. I don’t know.
Jake (36:06)
But then
Gerard, Gerard McMahon on Twitter, I think he was like, why are we doing studies where you’re punching a hole in a tendon? Because that’s not what’s happening in humans. Why are we taking this to humans? That’s not how we get tendinopathy. We don’t punch a hole in the tendon. We just get it from like overuse. But yeah, I kind of know what you’re talking about. So I’ve had this thought on the tendon strain thing. And I think some of it comes from Mersmin, probably from McMahon too, but.
Greg (36:25)
Yeah.
Jake (36:34)
because McMahon had this older paper on a, it was on a leg extension. And I think he, well, he had a calculation for tendon strain. it was three things. was the joint, the starting joint angle. So like getting rid of the tendon crimp, if you can go to like a 60 degrees or 90 degrees, that’s gonna have a starting strain of the tendon because the knee’s bent. And then the next was the contraction or the torque from the quadriceps.
Greg (36:38)
Yeah, 2013.
Jake (37:03)
And then the third was the co-contraction of the hamstrings. It was just on this exercise. So like if you did something dynamic, it might be a bit different. But I was thinking if the quadricep torque is the main, that’s the main thing that’s going on, that’s going to be straining the tendon. So like if you lift a 30 % load, the quad’s not working that hard. If you lift a 90%, the quad’s going to be working harder. The quad’s going to be pulling on the tendon more. And I just thought that the torque your muscle can produce,
is gonna be pretty high in like a three to five second maximal thing. But when you start getting to 15 seconds, 30 seconds, a minute, you’re getting worse at produce. So I’m like, wouldn’t tendon strain, so like the Keith Barr stuff of 30 seconds to get, wouldn’t that be less tendon strain?
Greg (37:48)
Yeah, that’s my issue. I do have an issue with that. It’s such a, I like him in this space because he’s someone who’s thinking differently, but there’s lot, so many assumptions in there. Because they argue that’s the stress relaxation. So if you hold it and you decrease the stiffness of the healthy tendon, then it’ll stop protecting the unhealthy tendon. That’s the theory on stress shielding, right? I think that’s why he advocates it.
But if they’re right, if they’re right that there is stress shielding going on and that you have to decrease the stiffness of the healthy tendon in order for the unhealthy tendon to get loaded, you could take his ideas and improve upon them. You don’t have to do that 30 second contraction. All you have to do is warm up the tendon and decrease the stiffness in some way. And then you could do Mersman’s Protocol.
Do you see what I’m saying? Then you can make sure that you get the high strain in the tendon to make it adapt. If they’re right, if they’re right that they’re truly stress shielding it and that decreasing stiffness in the healthy tendon will allow the unhealthy tendon to undergo strain. Because that’s what it’s predicated on. But I don’t know how well it’s tested. I remember looking a while ago and I was like, it’s a neat idea, but we have to test this better.
Jake (38:48)
Yeah.
Yeah, I’ve.
Yeah, I’ve thought maybe it’s a healthy tendon versus a very unhealthy tendon that I think if you put the very unhealthy, at least for a patellar, I don’t know what the kill is, if you put the really unhealthy tendon on a three second ISO, I think that’s gonna hurt. Like that’s not gonna feel good. A three second, like 90%. You know what saying? A leg extension versus if you did the Keith Barr 30 seconds, that load is much lighter.
Greg (39:39)
Yeah
Jake (39:43)
I don’t think that’s gonna be blowing up your tendon.
Greg (39:46)
So here’s what you could do. I think you mentioned the McMahon paper, which is… I pulled it up because I find it so neat and I don’t even really understand it. Because are you talking about the one where he trained at different ranges of knee flexion?
Jake (40:02)
I think that was it, but the part I liked was the part where he had the equation for tendon strain. Yeah.
Greg (40:08)
Okay, yeah, just the model.
I don’t know if I trust those because he didn’t actually measure it But but what he did in that paper he looked at people they did leg extensions Okay, and I remember one group did like a full leg extension from perfectly straight and then down to 90 degrees and then straightened out again So that was their their full range of motion with 80 % max and then they had a group kind of like length and partials
Right? So they, it was bent 90 degrees and then they only extended it to 40 degrees and then back down. So was under, it was like a length and partial, but in that group, it, only trained at 55 % of max one, one rep max. And then another group did sort of the knee was fully straight and they only bent it, you know, 50 degrees and then straightened it again. So the idea here is like what he was trying to prove the most important thing that
is the strain idea. The most important thing that will catalyze mechanotransduction is the strain that the tendon feels. And so he’s saying he wanted to compare like high load with not a lot of stretch, passive stretch. That’s the group that only went from zero degrees to 50 compared to the medium load, the 55 % with lots of knee flexion. And so what he found in there, remember, was there was no change in tendon, all the groups increased tendon stiffness.
Right, so that was their big magical finding. So even that group that only trained at 55 % of max, because they had a lot of knee flexion, the tendon would have had lots of strain and then it was able to adapt. And so I’m wondering with what you just said, if you don’t think someone could tolerate a high load, then what we would do is do the medium load, but make sure that they’re training at end range. I don’t know, did we just, did we solve anything?
Jake (41:58)
Yeah.
Well, I’ve had it too. Like a month ago, I had the opposite where a guy reached out, because I’ve kind of, I’ve always said mid range, like 60 degree or like slight dorsiflexion is going to be good to a starting strain of the tendon to start loading it. And this guy reached out, I think he was on the leg extension and…
Greg (42:02)
Should we name a protocol after ourselves?
yeah.
Jake (42:25)
He was like I’m going to pretty much extension like pretty much full extension and just loading it as heavy as possible and I don’t know how many people he had ten people and their patellar 10 has responded very good to it so No, but the load was super heavy because it’s like if you go into yes Exactly, so it’s like but then I’m also I also wonder too if you’re like so locked out I mean probably not completely locked up, but I’m like
Greg (42:40)
So not a lot of knee flexion.
Okay, so that’s how they got the high screen.
Jake (42:54)
I feel like that’s like so much muscle and I don’t know how much tendon. just, you know what I’m saying? Yeah, because you’re not, the starting strain is just not, you’re just, you’re not bent. You’re not bent at all. I don’t, for him, his people felt so much better. And it’s one of those things where it’s like, maybe it wasn’t any tendon adaptation at all. Maybe it was just like getting a huge hit to the quads.
Greg (42:59)
Yeah, yeah, yeah.
And that’s the thing maybe you don’t need it. Do know Jeffrey Vero? He’s a sports medicine doctor of Australia He has an old paper from like the mid-2000s on like I think he called it stretching eccentric stretching like a huge numbers and of 140 I think and he for that Achilles tendon group He would do the heavy the medium loading and then hold at full dorsiflexion for over 30 seconds
Jake (43:20)
no
Greg (43:43)
with like so high strain medium load. And I just realized as you’re talking, cause I was thinking the opposite of what you’re thinking to be honest. I was like, my God, it’s kind of like a Keith Barr program. And he really had.
Jake (43:52)
Yeah.
Yeah, and what did
he test there? That was just for achilles tendinopathy stiffness or what?
Greg (44:00)
Nah, there
wouldn’t have been any mechanical stuff. But that’s not uncommon. Do remember I had Colin Griffin on? I think I followed up with Colin. He had a really pretty heavy loading program and all that stuff. And they didn’t find a lot of tendon stiffness changes in their group either, so it’s not weird. But then he emailed me and told me about a medium loading program, like your classic painful eccentric, three times 15.
that he knew of someone doing and they actually found increases in tendon stiffness. So, but there’s no way like that’s if you’re doing 15 reps, what’s that like 65 % of your max?
Jake (44:43)
Yeah, yeah. I wonder, I wonder the starting. I wonder on the subjects. No, no, no, I’ve thought of this. So I’ve thought of this with the subjects, because I think of a kid. Like you think of a young kid that just got, that was just born and then they mature and they get to like 17 and their tendon’s getting stiffer that whole time. They’re laying down collagen to make the tendon stiffer. It’s getting bigger, but they’re not lifting weights. They’re not doing three second contraction holds.
Greg (44:49)
We’re not helping anyone listening, we’re not giving any solid answers.
Jake (45:12)
So I wonder if it’s just the beginner versus an advanced that if the beginner, could they do anything in the world to get tendon stiffness versus the advanced? Do they need the Mersmin, those type of isometrics to get it? Or if it’s like a very unhealthy tendon, is that then that pocket of that pocket that might be like more fluidy or like it’s restarting the building process, maybe that adapts to the real, to anything.
Maybe that adapts to the lighter stuff and it doesn’t need this really extreme high load. I think that’s a problem I have with the tendon stiffness things is like, who were the subjects coming in? Like what were they like coming in? And if they were very advanced, maybe they don’t adapt to the sets of 15. If they’re a beginner, maybe they advance the sets of 15. yeah, still the, it’s like you’re gonna, the stiffness, they’re always just such tiny changes.
even any change to a tendon is so small always versus I feel like muscle is so adaptable to everything and maybe all the tendon rehab should be focusing on muscles and just laying off the tendon and letting it go about healing.
Greg (46:24)
Well, I think that’s that’s Jeffrey Veral’s idea as well. He’s he wasn’t stretching to do anything to the tendon. He goes, I don’t quite understand his ideas, but it’s more like we know what stretching does. It seems to change this stiffness of the muscle slightly, like it decreases a little bit. Doesn’t do much to the tendon. Maybe it changes the hysteresis loop, but that’s another idea. And he’s like, maybe we just get
the load sharing down where we change the timing of the load that the tendon feels by changing the stiffness in the muscle. Like he talks about damping and all of this stuff. That’s sort of the idea there. So that might all be what we’re doing is we change what the tendons feels by changing the muscle or something like that. And maybe the tendon isn’t even our target sometimes, or it is sometimes, we just don’t know with whom.
Jake (47:18)
Okay, you had this. Yeah, I’m gonna look that up. So there was this idea on the muscle tendon. So you have a tendinopathy, the muscle gets wasted and gets smaller, weaker. And then people have proposed this idea that because that’s the case, you’re now straining the tendon more because the muscle isn’t there to do it.
Greg (47:19)
Just another one that you can read about.
Jake (47:46)
But I think you and probably others have questioned that like, wouldn’t it be the opposite? That your muscle can’t pull on the tendon because it’s so weak. That wouldn’t you be straining the tendon less? Wouldn’t that be protective of the tendon because your muscle is so weak? And then when you talk about an athlete, wouldn’t they just perform slower? Because they can’t have outputs. Their muscle can’t do it. Yeah, could you kind of explain your thoughts there? If I represented what you said.
Greg (48:12)
Yeah, that’s the idea. don’t
know. It’s because it’s… But maybe there’s a complicated physics I don’t understand. Because it’s in series, I don’t see how the tendon can protect the, or vice versa, protect the muscle. I would think if someone has tendinopathy, we tend to see them not use it as much. The load is less. And there is a… I think I have this right, but I’m pretty sure there’s a paper by Pat Corrigan, and they do show that, that the load…
The loading on the tendon is less when people are running. Now you’re bugging me. gotta press pause and look it up.
Jake (48:48)
Okay, okay, I
might’ve been familiar with, yeah, so he was saying that when someone has Achilles tendinopathy, they present less strain on the Achilles when they’re running.
Greg (48:59)
feel like that. I honestly haven’t read that in years and his stuff is weird, hard to read. Not because of him. Yeah. It’s because some of it’s a bit counterintuitive.
Jake (49:12)
But I’ve wondered
if, so like, I think it was one guy on Twitter, like an anonymous account. He’s probably interacted with you too, and he’s kind of annoying to me, because I don’t like anonymous accounts. But yeah, he was having that thing of like, wouldn’t you just, if you’re patellar tendon hurts, wouldn’t you just jump lower and then you protect your knee? But I was like, I guess you would jump, but I’m also like, if my left patellar tendon hurts, no, yeah, say my left.
and I’m a right leg jumper, like I can jump off my right really good and my left knee just hurts. What if I get in this situation where I have to land with my left? It’s like, that’s a load that I can’t just jump lower because I just jumped higher and now I got to take it with the other leg. Maybe in running you can compensate to one side or the other, but it’s like, I think sometimes you have to deal with outputs that you didn’t even produce, like you didn’t produce on that side. So that idea is like, I get it, but is it really?
Greg (49:55)
Yeah.
Jake (50:10)
Do you really see that?
Greg (50:11)
Yeah.
No, I agree. It’s you’re not, you might be fine 99.9 % of the time, but when you actually need that strength and you don’t have it, that’s where you might get injured. I think that’s like the sprinting analogy with hamstring strains, right? Like we assume that the goal sport is enough to prepare people to train their hamstrings. But the problem is people are rarely sprinting a hundred percent of their max when they practice in soccer or when they play soccer.
But when they get into a game and they actually have to sprint a few more times than usual at 100 % of their max, they really haven’t prepared themselves for it. So they have to like consciously sprint 100 % of their max in training to prepare it. I think that’s the same idea. But yeah, I’m with you. I did find the paper. was right. this first, Pat Corrigan is on it, but the first author is Seymour. And this is a newer one, but…
people with Achilles tendinopathy will offload that. So that what you’re saying is it might be fine with distance running, but if you need that in your sport, then it could certainly be an issue.
Jake (51:22)
Yeah, and then with the distance running, they’re probably just like offloading that whole leg, right? Or maybe they’re running in a way where they’re not going into dorsiflexion or.
Greg (51:28)
Yeah, which with-
Yeah. Yeah. It’s just like the…
Jake (51:34)
Yeah, or they’re heel striking. Maybe
they’re just heel striking and not really just rolling over the Achilles. Yeah. Yeah. Yeah.
Greg (51:42)
Well, yeah,
I think the biggest Achilles load with running is at mid stance, related to what you said first with the dorsiflexion. So they might be getting off that foot faster.
Jake (51:57)
Are you, have you seen this? So have you seen this? I’ve talked now, I’ve done a few podcasts the last few days and I’ve maybe brought up this Blazovich, Anthony Blazovich study. So I’ve had this idea for years now of based kind of on that McMahon thing of like the more, the more the muscle is working, the more the tendon is going to strain if we, so like, that’s just, that’s just what I think. If you get a harder muscle contraction,
Greg (51:57)
and not force it
Yeah, I love his stuff.
Jake (52:26)
the tendon’s probably gonna strain more because it’s getting pulled on more. But this study by Blazovich, I think he was doing like a leg extension flywheel. It was weird. And it was such a high contraction of the quadriceps at the bottom. So I’d think a ton of tendon strain, comparable. He compared it to something else that was not as much, I guess, quad activation or something. But the tendon hardly strained compared to the other one. And then he was getting at it at the end, he was like,
In moments where it’s like very high and quick, like I think that flywheel, it was so weird. I had to read it like 10 times to be like, how was this move performed? And I still didn’t get it. But I was thinking that in moments that are very sharp and quick, where you’d think the tendon would strain a lot because the muscles working very hard, he had a phrase where he was like, in moments like that, the tendon becomes a rigid transducer of load. I almost thought of it like a rod. And I was like, it’s…
Greg (53:23)
Yeah.
Jake (53:24)
Is that what’s happening in those really sharp, quick movements? The tendon isn’t actually straining and the whole thing is stiffening up and not straining, but just relaying what the calf is doing to the calcaneus.
Greg (53:38)
Yeah, that’s the viscosity hypothesis, right? If you pull on taffy really fast, it’s really hard to form. If you pull on it slowly, it deforms. It’s why like with bony evulsions, like when you can sprain your ankle, can either tear the ligament or you can rip the bone off. And it depends on the speed, what structure will fail first based on the viscosity and that stuff. I think that that’s, that that’s must be what he’s relaying. Yeah.
So really, really fast, the tendon’s super duper strong.
Jake (54:07)
Okay.
Yeah, so like, could you have a spectrum of like the faster you move, the more it stiffens up?
Greg (54:18)
I think that’s the idea. I think I have honestly, I was taught this 30 years ago. was like 20. No, not quite that long. 25 years ago. I think that’s like when, when bones fail, like very fast. think the bone rips off rather than the tendon breaking because the tendon is so strong. That’s why people have a vulsion, but slower stuff you might get it. But I’m not sure. I think, I think that’s what he’s saying. Now I need like a viscosity expert to chime in on your podcast.
Jake (54:43)
I… Well, yes, yeah. But to me, still, I’m
like, I’m like, if you’re… But then here’s the middle that kind of messes it up. I’m like, if you’re, if you’re jogging, let’s just say your Achilles is straining 10%. But if you go sprint, now your Achilles is straining 20%.
Greg (55:02)
Yeah.
Jake (55:03)
but then you go even harder than a sprint and it’s not gonna strain much. It’s gonna like go less strain because it’s such a quick, if it’s like you’re landing off of a box and have to jump up or so, I don’t know what it would be. You know, so I’m like, what?
Greg (55:17)
It may like I would guess it’s time dependent. So it’s gonna end up still sprinting faster will end up straining more But there may be a few a hundred milliseconds or so whether it’s delayed. That would be my guess
Jake (55:33)
Okay.
Greg (55:33)
Like
I don’t think it would stay stiff the whole time. It wouldn’t go under go strain the whole time of application.
Jake (55:40)
okay. Yeah. Yeah, I need to talk to a VSCO elasticity expert. Cause I can’t get that stuff. then I don’t know if you’ve, I did email, I’ve emailed him and we were going to set it up and then it just never happened. But he’s had some really good YouTube videos. I tried to read his biomechanics book, but I just, didn’t enjoy it. I’ll get to try to read it again. Yeah, lot of terminology that I…
Greg (55:50)
Well you should have Tony on. Tony is really good.
good.
Yeah, I… That’s me too. I’m good as well.
Jake (56:08)
Yeah, a lot of like in-depth terminology and I’m just like, I want things simpler. yeah, what I get, we got a, I’m gonna go five more minutes here to respect your time. The, I was gonna talk about compliance and stiffness, but let’s leave that alone because we’ll probably end up getting nowhere just like with the tendon strain, but the isometric. like for a bit, for a long time, that’s kind of when I got into the tendon space. It was like five years ago.
Greg (56:16)
too smart.
Jake (56:36)
Isometrics from Keith Barr, Ebony Rio. They were like the golden ticket for tendons. I guess people have really questioned that Ebony Rio study. I think it was on like six people and then it wasn’t really replicated again. Yeah, what have you made? I don’t know, can you talk about your experience with isometrics and where you are now?
Greg (56:54)
So, no, I’m where I was. I’ve been around enough not to get too excited of things. Right? And I always go and read the original research. And I remember reading Ebony’s stuff, same with the tendon neuroplastic training, like, okay, we gotta fuckin’ slow down everyone here, Cause I read that and I was like, well, I suck as a clinician. Cause it got, so just quickly for people, this would be 2015.
Isometrics are really touted as, you do a 15 second to 45 second, 70 % maximal contraction, you’ll have a dramatic reduction in pain in the short term. That’s what Ebony Papers found. That’s what everyone was saying to do. Like in her paper, they went from six out of 10 down to zero, based on nine volleyball players. And I would do that with my patients and I would get like random responses and I’d be like, okay, I suck as a clinician. There’s something wrong with.
But then at the time, even if you knew there’s a researcher named Noggle who was publishing at the same time, who would say any type of muscle contraption can give you an analgesic effect. And it’s really not that dramatic with what Ebony found. And so people recreated it, Seth O’Neill, Henrik Riehl, in different parts of the body, Sinead Holden. And they were like, no, it’s random. Some people get a great analgesic effect. Some people don’t. Just like some people get runner’s high.
Others people don’t. So that’s where we should be. We just got way too excited back then. I got so nuts at the time. People were almost arguing. If someone doesn’t get the analgesic effect, it’s not a tendinopathy. Like it was bonkers. Like we just got way too excited over things. so isometrics are great, but they’re no better than any other type of contraption.
I really don’t think your tendon knows if it’s an isometric or not. Your tendon’s stupid. It just feels pulling on it. It doesn’t know what the muscle action is really.
Jake (58:53)
Yeah, I get that probably daily on Instagram about the what’s the best contraction and it’s like, well, the tendon just strains or it doesn’t strain. So it’s not a contraction dependent.
Greg (59:02)
Yeah. So even
with Keith Barr stuff, like to say to do like a 30 second isometric contraction, I would go back to like Bayer’s stuff from 2015, who started the heavy slow resistance program. If you look at that, it’s five reps of three seconds up, three seconds down. It’s done so slowly, it’s quasi isometric. So the tendon doesn’t care. It’s like…
Jake (59:30)
Yeah.
Greg (59:30)
And
then pragmatically, the stuff with Keith’s stuff, the thing with Keith’s stuff, there’s no clinical research showing it’s better. I’m not telling people not to do isometrics. And so it’s one option that you have for people. no one’s, or like, I don’t know if you Pete Malieris on the podcast?
Jake (59:49)
yeah he was actually one of the first i did but i was like four or five years ago
Greg (59:52)
I figured. So
you remember his paper 2013, right? He actually tried to answer the question of contraction type. And he’s like clinically, no difference. So he’s the person to believe there. And I’m pretty sure if he redid that paper, that systematic review, he’d find the same thing. So tenants don’t care, just pull on them. Yeah, that’s simple.
Jake (1:00:12)
Yeah, yeah, that’s exactly. that’s,
I got that too with the, for many years I was like the only way to get that, like the tendon creep and stress relaxation is the isometric hold. But it’s like, well, if you just lift with like a three up, three down tempo, it’s the same, it’s gonna be the same thing. Maybe you have a period if you’re doing a squat, like at the top, there’s hardly any strain. So maybe you would just avoid locking out if you wanted to keep constant tension. But it’s like, yeah, it’s just.
Yeah, strain or no strain, that’s about it. I was going to say more on the isometrics and I lost it.
Greg (1:00:49)
They’re great to try and it’s a good start. And they’re great with what you talked about earlier with like, you found a few patients who didn’t respond well to certain positions. Well, great. Then you just do isometrics around those positions. Or it’s a great way to get into those positions that they don’t like because they can feel safe and control it better. Right? So I’m not saying not to do them, just like we need a little bit of like nuance and not to have like the strongest opinion here.
Jake (1:01:20)
Yeah.
Greg (1:01:21)
I’m do a lot of this profession.
Jake (1:01:22)
Oh, there is a lot, dude. When I got in, I was really behind a lot of like, don’t do stretching, icing, ibuprofen, all these things are bad. Like, I think there was an article that was like a whole I think Jill Cook wrote it like a whole list of 10 things not to do for your tendons or something, which was which was, which was probably kind of good. Some of those things. I love talking to Jill. I love listening to Jill. But there’s always many things where I’m like, I don’t know if I agree with that. Yeah. And I don’t know it.
Greg (1:01:37)
Yeah.
Jake (1:01:50)
For me, because I’m like, I really only care about 10, I can kind of maybe weed through the things that are said, but I think a lot of people take it at face value and they just run with it. And I think that’s probably not good. Yeah.
Greg (1:02:03)
Yeah, we
should recognize those 10 things as being clinical opinions rather than really strongly tested. They’re not that well vetted, that’s for sure. And that’s okay. I like, I want people’s clinical opinions, but we always need an asterisk beside it or else it just becomes dogma and that’s not cool.
Jake (1:02:14)
Yeah. Well, I get, I get.
Yeah, I wanted to say on, I guess one more thing. I just, well, you’ve never talked to David. I was talking to David today and I’ve got in, on Twitter I’ve posted like, so I rehab a lot of jumper’s knees and I’ll just post about like, all right, patellar tendon pain, address squats and deadlifts and then jumping progression and everything. And people will come at me probably from like a physio or evidence-based world of like, you don’t need to do this for patellar tendon rehab. you know I’m saying? Like you.
This is you don’t need to do squats and heavy lifting and above 80 % loads and everything. And I didn’t really know how to answer them for the longest time because I’m like, I understand where you’re coming from. There’s many ways to get out of pain. There’s a billion ways to get out of pain. You don’t have to listen to my way. But I think recently it hit me where I’m like, the reason why I do things the way I do them is because I’m focused on performance as well. These people want to go dunk a basketball. So whether I’m not just trying to decrease patellar tendon pain. If my goal was to decrease patellar tendon pain.
I would just tell them to go sit on the couch. Just stop loading your patellar tendon and the pain’s gonna go away. But because you wanna go dunk and play basketball, I’m gonna have you do 80 % loaded squats, or I’m gonna have you do heavy split squats, or I’m gonna have you do heavy isometrics. And I think, I don’t know if that’s like a thing in the rehab world that it’s like, we’re so focused on decreasing the pain and looking at evidence-based for that, but when it comes to performance, like I’m trying to do both at once, performance and pain, because the people I work with are basketball players.
They’re not some 60 year old lady who just like wants to go for a walk.
Greg (1:03:56)
No, that’s great. That’s patient-centered care, right? Because there’s so many different ways to help people, we choose secondary goals to guide our rehab interventions. That’s what you did there. Someone else might come in and their goal might be bikini season and hypertrophy. And so you’re gonna create a hypertrophy program that’s also gonna help their tendon as well. Someone else might wanna be sprinting more, so it’s gonna be a sprint-based program.
Right? And then with some things that can help their tendons. Someone else might want some manual therapy and they don’t, they have a really rough patch of their life that they’re going through and they don’t want to do any goddamn exercises. So you give them a more gentle program that’ll help their tendinopathy. Right? Like that, that, that to me, that’s good patient centered care is recognizing that they’re options. You, you only get in trouble if you said, this is the only way you can help a tendinopathy. It’s dead lifts, core squats, leg extensions, wall squat. You know what I mean?
Although here,
Jake (1:04:53)
Yeah.
Greg (1:04:54)
let me challenge you a bit here, because this is always my clinical struggle. Do you, like, we talk about movement preparation. So if you work with people who want to jump, right, basketball, whatever, volleyball, why can’t just jumping be enough to rehab your tendons or to get people back to like preparation for basketball? Why can’t it just be a jump? Okay.
Jake (1:05:18)
I think it can sometimes. I always
try to find those anecdotes as well. I mean, even vertical jump development is like the people who jump the highest. There’s obviously a genetic influence, but they got it from jumping for 20 years, and that’s why they’re such a good jumper. It’s not from getting in a weight room and doing all these rehab protocols or pre-hab protocols. It’s just from doing the actual thing.
Yeah, I feel like that’s probably lost in rehab is like, what did they want? Did they want to be a runner? Like the rehab should probably include quite a bit of running and not, not whatever things you want to do in the physical therapy room. But can they come back to jumping from just jumping? Like I, I, I just, I have my way and I sell like a PDF for rehab. So it’s like, I just want them to follow that, but I do entertain that. And I’ve had
Greg (1:05:50)
yeah.
Yeah.
Jake (1:06:10)
professional dunkers on my podcast just to talk about jumping. yeah, they’ve had guys that have had really bad jumper’s knee and they just start jumping every day, maybe on like a lower rim or something. And it’s just like they desensitize to the pain and it goes away. But a lot of people will try that and they’ll just get worse. So, you know, and you got to get the, you probably got to get the frequency and the volume and intensity like perfectly right. Maybe like the biopsychosocial factors, those have to be right. I don’t know, but I.
Greg (1:06:27)
Yeah.
Jake (1:06:39)
Yeah, if you got an Achilles, a person with Achilles tendinopathy, could you just have them play with their running volume, volume intensity frequency and they can get back like that’s great. It’s just, guess I can say that because I’m not insecure, but a lot of people want to make money and they want patients and they want people to buy their programs. So obviously let’s, let’s say that, but the, the jumping, yeah, the jumping, man, that’s such a tough one. Cause a lot of these guys who have the jumper’s knee, you can just look at their quad and it’s like,
so tiny on that one side and I just feel like I don’t think that’s you’re going to get that back from jumping. Maybe when the pain settles maybe the quad would come back but
Greg (1:07:20)
No, I think where I would help you here, because this is my challenge too, like why can’t the goal task just be the only rehab? I think what happens sometimes is we are too good at adapting and we can protect and spare that body part during the goal task of jumping or running. And so unless you specifically address, this is what we started with, unless you specifically address it, you’re never going to get back that attribute that you need.
So have to consciously isolate it. So it’s like Eric Mira in quads. He’s like, you can’t just squat. You need to consciously, cause the body will protect the knee during a squat. You need to consciously do a wall squat or, or actually maybe a one-legged Spanish squat. I don’t know if he’s actually thought about that or a boring old leg extension. Cause we’re just too good at hiding, you know, so that, that would be the idea why maybe you couldn’t, you couldn’t just jump because you’ll just adapt around it.
Jake (1:08:15)
Yeah.
Greg (1:08:15)
Unless you
maybe, but if you did one leg it jumps. No, no, even that. No, that’s the ruler’s work. Even that you’ll get stuff from the hip and the foot and you’ll still protect the knee.
Jake (1:08:26)
Yeah, yeah. Having it be such like a compound movement with so many joints involved, there’s just too many ways to cheat. Yeah. But if you’re willing to give up, like if your left patellar tendon hurts, if you’re just like, I’m okay with my left quad and patellar tendon never doing anything for me forever, and I’m just a jumper, I’m just a dunker, then it’s like, you can adapt and just use your left ankle and your left hip to jump, and then your other leg’s gonna be fine, you know? Like, you could probably do that.
Greg (1:08:33)
Yeah, that’s the redundancy. Yeah.
Yeah? Yeah.
Jake (1:08:55)
But long term, I don’t know, you get in a situation where you need your left knee and now there’s nothing there, you’re probably gonna like snap something.
Greg (1:09:03)
Yeah, that’s the idea. Eric will talk about that too if you ever have him, come on. Good guy to talk.
Jake (1:09:09)
Yeah.
All right, Greg, tell everyone where to find you online. And I know you got courses all the time, so talk about whatever you want.
Greg (1:09:19)
Yeah, well, greglayman.ca, because I’m Canadian, so it’s .ca. Still allowed in the US. Nothing’s changed with those tariffs. then they let me come over. So that’s primarily it. That and Instagram and Twitter. Yeah, that’s where I am.
Jake (1:09:37)
Yeah, perfect. All right, man, thanks for coming on.
Greg (1:09:39)
Yeah, thank you. Bye, everybody.
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