https://podcasts.apple.com/us/podcast/jacked-athlete-podcast/id1462537296?i=1000700933250
Isometrics: “It’s not magic and there’s going to be some people that I think respond really well. And I think other population that’s just not going to respond too well and can’t even make them worse.”
“When programming for people, I don’t necessarily think about the tendon all that much. I think about the muscle function and the nervous system function.”
“When someone has tendinopathy, there’s basically a change in the cell phenotype and the activity levels of the cell. And the cell essentially becomes hyperactive and very sensitive.”
“I think that we do eventually need heavy load… but I think heavy is maybe applied too soon and kind of going back to the point that the cell is a little bit hyperactive. We need to calm it down. We need to allow some of that sensitivity to decrease a little bit. And then for me, like reflecting on how do we train the muscle versus the tendon, that makes more sense to allow the tendon to calm down, but we can still do like slow, concentric, slow, eccentric, and get a good muscle pump essentially. Hammer out the muscle, get some good stimulus there, get some nervous system adaptations, and then that’s eventually going to drive tendon changes but also let the tendon calm down in the early stages”
“It’s trying to balance that thought process of using heavy loads versus calming down and decreasing the sensitivity. And I think a lot of times probably we have to use pain as our best guide in a lot of these situations. Like I know there’s a lot of limitations to that, but we still do have to use pain as our guide.”
“In the early stages, it could be beneficial to keep pain in check and do lighter loads more frequently.”
Early on: “Calm the tendon down while still trying to provide a good adaptation to the muscle and the nervous system… you can use increased frequency every day even to kind of build it up. And then once you get to a point where you can potentially use heavier loads and the athlete can tolerate that, then you can back off the frequency. Then maybe you’re training two or three times a week with the heavy loads and just resting in between.”
“The nervous system and muscle deficits persist first before someone even has symptoms. So there’s muscle weakness present and that the tendon is trying to kind of buffer the loads that are placed on the muscle, but since the muscle can’t help out as much, there’s more stress on the tendon and maybe that tendon is overloaded for the given demands and the preparedness level. And so the tendon’s overloaded and that stress does increase compliance of the tendon, making it not as stiff.”
My personal story? Yeah. Yeah, so for sure. Like I said, I really think at that time it was just from playing basketball every single day. I played in high school and so, you know, thinking I’m still MJ and playing at that level. And it was great. We had a great group of guys out there playing and so it was a blast and you’re playing more than you should. And I’m still strength training, but I’m not…
Jake (22:20)
Yeah, the one you had in PT school.
Alex Nelson (22:47)
probably training like an athlete. I’m training maybe more like a bodybuilder or even powerlifter. And actually that kind of segues into the rest of story here because I had patellar tendinopathy all through my last year of PT school. It was even hard to demonstrate exercises to my patients in the clinic. And at that time when I couldn’t demonstrate a lunge very well, was like, man, I really have to do something about this.
And I was training at that time, but like I kind of touched on, I was really getting into powerlifting and I was competing in powerlifting. Not super competitively, but I did a meter or two and I had a blast. But at that time, my volume, I think this was one of my, I think biggest things I was doing to mismanage the tendon. I had super high volume of back squats, for instance, and I wasn’t doing any isolated muscle tendon loading.
And I was thinking as I was still, you know, I thought I knew a lot about tendons at that time, always, always trying to learn. And I thought, okay, I’ll just do, you know, tempo squats and that’s going to take care of it. But of course with compound movements like that, you get a hip shift, you get a forward trunk lean, even if you realize it or not, your body’s going to find ways to accommodate, to perform the task and offload that, that injured tissue. And, and also, you know, I’m going for PR is I
I’m trying to push through pain that I probably shouldn’t have. I was really letting it impact my, my mood anyway. It just kind of really took me down a rabbit hole because of how much it, it impacted me, not just like training and not just the clinical life, but my, even at that time, like it was impacting my relationships to extent. Like I couldn’t go on the hikes that I wanted to, I would go out on an event and I’ll just be thinking about my knee cause it would be throbbing. So it would just kind of take away some of my cognitive.
energy as well. So at that time I was like, okay, I just got to focus on my rehab and I ended up buying a leg extension machine for home and just so I could really focus on it. And that just kind of took me on the deep dive. And then I had better volume allocation, my intensity was better. I thought about rehab in a lot more structured context and it probably took 10 months, 12 months to
to totally go away. But, you know, happy to say, knock on wood here, that I’ve been feeling really good. I haven’t really had any limitations. I don’t train too hard right now. I’m just a dad trying to stay young and fit, but going a little bit of run here and there, can do some jumps on the playground, play some basketball with my friends, and yeah, no pain currently. So, happy to say that.
Jake (25:38)
With the, I guess I’ll go here, the powerlifters. I’ve had a few powerlifters with Patel or Tandon and you you go to the Jill Cook thing and she’s like, Patel or Tandon is reserved for young, jumping males. And then maybe like elite females. But I’m like, I see it with powerlifters. I don’t know, have you seen it? What do you make of that?
Alex Nelson (25:42)
Mm-hmm.
yeah,
I’ve worked with quite a bit of power lifters that have it. Patellar tenonopathy, maybe more so quad tenonopathy in power lifters. I’m not sure, that’s just kind of a theoretical there based on my limited number. But I would say definitely quad tenonopathy and patellar tenonopathy. I think a lot of it does come down to just the volume and intensity of their squats.
It would be a big one, of course. know, deadlifts are gonna play a role, even the leg drive on bench, like that’s gonna play a role. So you have to look at the whole picture, but probably the biggest factor to manipulate would be the squat volume and looking at the frequency, the intensity. For instance, like I’ve had a few power lifters, okay, they’d hit their top set at 93 % and then they do back offsets at 85%.
basically going to failure and they would do like three, four, five of those and then, you know, then they’d have a heavy deadlift after it. So I think a lot of it comes down to just managing the fatigue, managing the load, of course. And for a lot of the power lifters, what I found to be effective, I’m curious to hear your thoughts on this as well that I really, something else that really interests me other than the tendons is
strength versus hypertrophy data and how to train for those and also around that topic is the minimum effective dose of training that’s needed, especially for strength training. And it’s a lot less than people would probably initially think. So you could still do a top set, depending on their symptoms, you could still do a top set at 90, 93%, and then maybe your back offsets are 70%, and you’re just doing a rep or two.
and you’re just really focusing on, you can still focus on a slow eccentric control, so you’re getting that slow focus, and you’re getting a lot of good fast concentric velocity that’s gonna be great from a strength adaptation, but you’re at like RPE two or three on those back offsets, and so it’s good way to continue to build strength and just managing fatigue. So what are your thoughts around that? What have you seen?
Jake (28:25)
Yeah, not I don’t see too much power lifters just and I always forget stories unless it’s recent and I haven’t worked with a power lifter in a long time but um Yeah, so so is that like a number? I mean that makes a whole lot of sense is that is that number one for you is kind of the the overall volume like during the week and then if you’re looking at them if you because if all they do is a squat and a deadlift or like the big three If you get them on like a leg extension or something isolating the quad even if they squat like 500 pounds Are they still presenting with like a super weak quad on that on that back?
Alex Nelson (28:30)
Yeah.
Jake (28:55)
side.
Alex Nelson (28:56)
yeah, you’d be surprised. the, the athletes that can squat 500 pounds and then you get them on a single leg leg extension and it’s either like very, very symptomatic for them. And maybe the squat was just like, the squat was doable after they got warmed up and took three scoops of pre-workout and all that, you know, the squat was doable, but then you get them on that isolated leg extension and it’s either super weak and it just is, it’s good in a way because it builds buy-in. They’re like,
oh wow, yeah, this is really what’s needed and then it’s ultimately gonna help their strength gains. But yeah, I do see that quite a bit and going back to your first point, that probably is the first thing I look at. Like I do look at the volume and intensity and make sure that we can keep it at a threshold that still has the performance benefit but also calms the tendon down a little bit.
But I do always add in the the isolated leg extension exercises for quad and patellar tendon optic and I would probably shift a lot of that that volume and and allocate it Like as I mentioned instead of four or five back offsets for squats Maybe I would do one back offset and then the rest of the volume for quads that day would come from the leg extension then I actually think it’s
I think a lot of those athletes are surprised because they can still get like three, four sets of leg extension if needed. And it doesn’t necessarily fatigue them out. just, they don’t feel quite as beat up even from a performance standpoint, long-term, even if they keep it in the program like that, once they’re healthy.
Jake (30:41)
Do you see the squat? like, I guess I’ve been, I’ve done a few powerlifting meets and I don’t see, didn’t see too much like patellar tendon pain. And for me, it actually helped mine a lot, I guess until I went back to basketball. But do you see like a biomechanical thing? Like people who have more knee dominant squat, is that more, you, whether you see it or do you think it’s more likely for patellar or quad? And then to ask one more on top of that is this whole thing with like chronic workload, when you have a chronic workload of the 10,
and then usually you’re fine. So like, why are they getting patellar tendon pain to come at you? Is it like a change in workload? If you get their story or is it like, do they have the chronic workload and they just somehow the patellar tendon came up?
Alex Nelson (31:23)
Yeah, interesting, interesting points here. So to start with the biomechanical aspect, I don’t know, man, it’s definitely important, especially for these elite power lifters. I wouldn’t say I’m an expert in power lifting by any means, but I know that technique is very important to hit those, especially elite numbers, right? So you do need the biomechanics and that’s important from the performance aspect. How does that impact?
the injury and the tendon. don’t know if it’s a chicken or the egg sort of deal. I’m not sure if they have always squatted that way and they’ve changed their volume. They’ve changed their workload, not only from like a training standpoint, but hey, they started a new job or they’re kind of at a point in life where they’re out, they’re going to the bars with their buddies and they’re drinking, they’re not sleeping too well. And then they’re trying to hit their squat bench deadlift on a Sunday, you know, afterwards. So there’s still lots of factors that go.
go into it. I don’t know. I don’t necessarily think that it’s that they have improper technique and that’s causing it. mean, especially for the elite athletes, like they got to be elite because of many reasons, but I think that it’s a change in change in something, change in workload, change in intensity, and then the biomechanical factors are important. So
If someone does have like a high bar back squat, for instance, the bar is higher up on their back or if it’s like a weightlifter front squatting and they have to have a more upright torso and they have to have a more positive shin angle, a little bit more interior knee drive, like that’s definitely going to piss off the tendon more than someone has like a really low bar back squat and their…
just naturally more flexed at the trunk and it’s a little bit more posterior chain dominant, I find that they can tolerate that lift better just because of the biomechanics, but I don’t necessarily know if it’s the biomechanics caused it, but it’s something to change and think about during the rehab process, no doubt. And then what was the other question kind of related around workload? Okay.
Jake (33:38)
Why? I know I think you answered it because it was it
was on it was on the chronic workload versus the Whether it’s a chronic thing or if they change something and you kind of you kind of got at it that there is there is
Alex Nelson (33:47)
Yeah, they all kind of go hand in hand, right? It’s
so tied together.
Jake (33:52)
Okay, one thing you said at the start was you were seeing a lot of mismanaged tendons like in the clinic and probably now when people come to you and they tell their story there’s some mismanagement going on. What exactly is being mismanaged?
Alex Nelson (34:10)
Yeah, so when I was in the clinic, a lot of times, man, I’d see these patients and it didn’t matter if it was a younger high school athlete or maybe like a middle-aged weekend warrior athlete or just individual, one to chase their kids around. They would go to the doctor with knee pain or whatever. Doctor would say, okay, looks good, let’s take an x-ray, right? They always take an x-ray. X-ray would show.
show nothing on the x-ray. All right, you’re fine. Why don’t you rest it for two, three weeks? Come back and see me if it doesn’t get any better. And you can take the NSAIDs, can try these stretches, right? They’d give a few exercises on a handout. And all right, come back and see me if it doesn’t get better. All right, person would go see the ortho or whoever it was again, four weeks later. Yeah, it’s not getting any better, doc. And then they’d say, okay, well.
why don’t you go to physical therapy? And so, then at that point in time, they’re already like four to six to eight weeks into the injury and all they’ve done at that time is rest. Maybe they’ve even gotten a cortisone injection. Maybe they went to Reddit and tried to find some different exercises that made things worse. So, that’s just, that’s what I saw so frequently and I don’t, like I don’t blame those profi-
providers. I think they were like very well intentioned of course. It’s just that there’s still a lot of education that needs to be done and you know education for the person going through it that is going to be beneficial. Whereas if they just saw a physical therapist or they worked with you Jake like day three I bet you would get them get them better a lot quicker than someone that kind of goes through the whole gauntlet of tests and
care and then they go to a physical therapist. Again, the physical therapist is well intentioned, but they’re doing straight leg raises and clams for 12 weeks and they’re a soccer player that only really gets pain when they’re playing soccer, right? Like not even during day to day and they’re doing these low level exercises that are just not adequate for them at that time. And man, I’m going on a tangent here, but then the other thing is with
A lot of these physical therapy centers, again, nothing against them, but they have yellow TheraBands, maybe they got a black TheraBand, and they got a 20 pound dumbbell, that’s it. And so, yes, you can get creative, but it’s just hard. They don’t have a lot of the equipment to manage. just your average Joe that wants to get back to just being active. Anyway, that was a little bit of what I saw.
Jake (37:00)
Yeah, so you’re seeing a lot of, I guess earlier we talked about people go heavy, maybe they go heavy too soon, but in these cases it’s like you’re starting light, which is probably good, you know, you can you can feel better initially, but there’s no progression to the heavy and then it’s like we’re going to go try out sports again. So it’s like this whole middle ground of actually getting the muscle stronger, getting maybe the tendon stiffer. That’s just skipped. But you see that quite a bit.
Alex Nelson (37:11)
Yeah.
Yeah.
yeah. And, and then that’s what led me to feel like, okay, there’s gotta be a better way for this. And started training with tenon opathy and like I was just genuinely interested in it as well, like learning and improving my knowledge and started working with a few people and they had a lot of success. And, I think this sort of platform online and digital here is how I work with people. Like I’ll meet with them through zoom.
we’ll have the consult and then I’ll program them their training remotely and they can go do it in a gym. And I can kind of be probably like more attentive and have better care even in this digital aspect because we can talk about that middle ground more frequently instead of all right once a week in the clinic. I can see them.
talk to them every day if needed, see how the squats were in the gym, how the leg extension, talk about the progressions that are needed, talk about the introduction to plyos and the criteria that are needed to get to plyos. So that whole middle ground definitely is something that is needed and has been really successful, I think, to work with people through that middle ground.
Jake (38:44)
Okay, well I have some I want to Before I forget I was gonna earlier your your page training time an op day I kind of remember when it came out and now you’ve grown it quite a bit Was it pretty difficult to get a get a I don’t know get it going get a bunch of clients remote Or was it like just pretty easy because everyone’s has has tendon pain and they’re mismanaged
Alex Nelson (39:07)
Yeah,
and I went into this with like not a lot of expectations in terms of I’m just gonna do my best, have fun during it, do my best to help people as best I could. And so that wasn’t really my goal to like get a lot of clients early on. It was just to try to educate, work with a few people here and there because I started it when I was still working in the outpatient clinic and it did allow me.
a nice avenue to work with the select few people with that approach I was just kind of referring to. And I would say that relatively it happened quicker than I would expect reflecting back on it. I’m very grateful for that. I’m very grateful I’ve worked with some amazing people that have been nice and helped promoting the page and promoting their success. And I think that gave
people a lot of trust in this avenue and now with just life becoming more digital in general, people are seeking avenues like this. Insurance was a big limiting factor for this population as well. So that’s a whole nother thing that goes into it, how insurance would limit care. And now we don’t have to deal with that, but it did probably grow quicker than I imagined. And I went full time, you know, treating tendinopathy here through this.
through this outlet full-time quicker than I imagined. And yeah, I’m very grateful for that.
Jake (40:37)
Okay, when you got your patella tendinopathy, it sounded like you just kind of went and rehabbed yourself, but then you talk about these people that get mismanaged, they go in, they get an x-ray. Other types of imaging, like you never got an MRI, you never got ultrasound for yourself. What is your take when people are going and they’re getting these things like immediately and they’re giving them all this language about how messed up things are?
Alex Nelson (41:03)
Yeah, man, I’ve actually really found this topic interesting in particular because in the past I was probably more black and white in terms of like imaging doesn’t matter. It doesn’t correlate to pain. It doesn’t correlate to outcomes. And I think I’m wrong about that. You know, now as I’ve learned more, like obviously tendon structure does matter for function. mean, especially for these elite athletes.
you need a healthy tendon, the tendon structure matters. But for a large majority of people, like you mentioned, they go in, they get an x-ray, okay, they have to go fail PT to get the MRI. These patients want to fail on purpose because they want to see what’s wrong. So you know that they’re not going to get better when their whole goal is to fail physical therapy. They want to see what’s going on. And to your point though,
there still is like a really complex relationship between what the image finds and someone’s symptoms. So someone can find something really scary on the MRI and have zero symptoms and vice versa. Like I have a couple people right now that I’m working with that had nothing shown on the MRI, but they’re having a lot of symptoms. So it’s such a complex relationship. then oftentimes you find these
diagnoses that maybe have nothing to do with the pain you’re experiencing. So a doc’s like, the common one, you have, you have the knees of the 70 year old, right? With the, with the 20 year old athlete and they, the, the athlete is then freaking out cause they think they got arthritis or they’ll find a meniscus tear in there. And then now it’s like, okay, well how much is that relating to
my injury and my limitations? Do I need to get surgery on the meniscus tear when that may or may not have anything to do with what’s going on symptom-wise? So it definitely is challenging, I think, for the prognosis. When someone comes to me, they’ve had an image, they have all these scary words. A lot of times they find a tendon tear, right? Like oftentimes it says tear or something similar to the words and patients then are
even more scared and uncertain of the outcome. there’s a lot of challenge around that. But I’m still looking and reading and reflecting on the value of imaging because kind of what I said in the beginning of this chat here that tendon structure does matter and there’s newer studies coming out and maybe even a few older ones too that if someone
Has maybe a poor-looking tendon on their MRI. Let’s say a soccer player Poor-looking tendon on MRI. They’re a lot higher likelihood to injure their tendon in that season So structure matters. It’s just for me, you know and and most physical therapists and in most Health care providers in our settings. It’s like how do we how do we measure that and? How frequently can we measure that and when is it important? So there’s still a lot of thoughts around it, but
Most of the time it’s what I said earlier, there’s a lot of fear around imaging.
Jake (44:27)
Mm.
Yeah, what have you seen with the partial tears? Because I mean, the call I just had yesterday, 25 % got the surgery and then like in hindsight, he talked to other people. They’re like, you shouldn’t have got the surgery probably. another case to girl, woman’s basketball player, like, I guess high level to have gathered diagnosed partial tear. And it’s like the pain had been the same for like many years. It was like an event that happened. And I’m just like, well, conservative management, see if it settles. And I think it just settled naturally. So it’s like,
I don’t, I think what is the, unless the partial tear is like huge, I’m like how, I don’t know. Do you use that, do you use that information at all or do just tell them like let’s just say it’s tendinopathy and let’s try rehab.
Alex Nelson (45:02)
Yeah.
Yeah,
yeah, it really depends on the size of the tear. And then when it comes down to that conversation, a lot of times it’s already had with like the ortho and the patient. if the ortho says you need surgery and there’s a patient that comes to me and most of the time if the ortho says they need surgery, they’re not gonna really go based off of what I’m saying. So I’m not gonna try to convince them that, you shouldn’t get surgery. Don’t listen to the ortho.
There’s lots of times though where they will have the partial tear, whether the ortho kind of left it open or whether they said, Hey, yeah, try the conservative route. I, do try to, I don’t want to dismiss it by any means. I don’t want it to sound like I’m dismissing their fear with that or the severity of the injury, but also kind of generalize it and say that, you know, tearing and what’s found on MRI is common with just tendinopathy with the label of, of tendinopathy.
in general and so I would definitely go the conservative exercise therapy route and it would be a case like this where right especially keep reflecting back on elite athletes just because they typically have more resources but I hear Seth O’Neill talk about this and I’ve learned a lot from him especially the Achilles and he’s he’s really taught me a lot around imaging and
how they would use like UTC, which is a different type of imaging other than like an MRI. And that is probably better at maybe finding some of the subgroups of tearing that can occur and just being more detailed with that and potentially using that as a criteria or measuring stick to return to sport because maybe, right, the athlete could be strong, you know, neuromuscularly.
But if they have a still have a damaged tendon, well, they’re probably going to go out there and maybe later in the season, there’s probably a higher likelihood that they have an injury versus if they’re still a little bit weak and there’s still some deficits there, but hey, their tendons looking good. It’s repaired. It’s regenerated. There’s probably a lot higher likelihood that they can, they can cope. They can perform well. And especially the level that they’re, they’re playing at that may be the right decision for them to
to go out there and play, especially if the image is showing a healthy tendon.
Jake (47:41)
What have you seen with surgeries? People that go, well, I guess if it’s a full rupture, you need it, unless it’s Achilles and you can go non-operative. Yeah, what kind of things have you seen with people that go and get an operation done?
Alex Nelson (47:48)
Yeah.
Yeah, I’ve seen, you know, I’ve treated many ruptures over the years, like you said, Achilles, quad, patellar, and man, it’s just so individualized. Some people can cope and respond really well and get back to a decent level and some, unfortunately, they have deficits that persist for many years. So it’s challenging, man. I don’t think I have like a solid concrete
answer for you just because it man it just really depends on the age too and the goals and what level they’re trying to compete at and what do they want to get back to but they’re definitely more more challenging they’re definitely more challenging what what have you seen
Jake (48:39)
Yeah, I mean probably the same. The thing I was gonna ask is the pain. So I guess when you go to the full rupture, guess the partial, I usually tell people when they get a partial, if they are diagnosed partial tear and it is confirmed, I’m like, you kind of would prefer to have done a full because the partial, you get it, what are they even gonna do surgery on? Like clean some things out and you’re gonna have a ton of pain in the rehab process because that sucks. But when you get the full, you gotta get surgery.
Alex Nelson (48:58)
Yeah.
Jake (49:09)
Anyways, again, Achilles non-operative, can do that. you have to get the surgery and I guess there’s not much pain associated with it. So, you like you repaired the Achilles, I kind of talked to David Gray about this and I heard Peter Marleiro’s too. It’s like, so I kind of want to backtrack to the whole thing of like letting pain guide. How are you working with them if pain can’t guide? Because there is not, there isn’t pain.
Alex Nelson (49:36)
Yeah, it’s, man, this is again very case dependent and now, now being in this digital setting here, when I see a surgical case, a rupture, I don’t treat them early on, I’ll say, I’ll try to refer them to a different physical therapist in person, because I do think they need that in-person care, they do need more hands-on, whether that’s hands-on mobility work, they just need that guidance, they need that structure.
in person early on, maybe the first three, four months, really kind of dependent on the location. So right now at this point time, I don’t see him quite as early and quite as fresh, but yeah, when I was in the clinic, it’s tough. We’re definitely going off the orthopedic protocol in terms of like timeline and I’m listening to that. If I ever have any questions, I would call the ortho up and maybe have a conversation about it. I would try to use other
objective markers is best I can. Outside of pain in the moment or even that delayed onset of pain, I’m kind of looking at life impact, I guess. this is, maybe in this situation, we’re talking about someone years down the road, but let’s say they return to, they’re playing soccer and they’re able to get back and play soccer and they have a five out of 10 pain playing soccer.
Hey, well that kind of makes sense compared to if they’re walking in target and they’ve only walked a couple minutes and now they have a five out of 10. So again, I know I’m still using pain as a guide, but just kind of looking at life impact, but other objective markers, definitely trying to look at strength if I can range of motion, if I can swelling, if I can the incision healing, like how is that going? Especially for the Achilles. Cause there’s I’ve seen
Unfortunately, a lot of cases that you don’t want to get infected and a lot of the patients, they don’t keep it as sanitary as you would think, especially if there’s man, metabolic factors that going into play, obesity, diabetes, high cholesterol. I’ve seen a couple of those patients that rupture. And so now they have all those factors of delayed healing going on, on top of the challenge of the surgical procedure itself.
Yeah man, it’s tough. You try to do the best you can.
Jake (52:05)
I’ve heard that once with the Achilles, guess if they can do smaller incisions now, but like, why is that an area that can get infected? I think I heard Carl and Silverknuckle talking about that, but do you know anything about that?
Alex Nelson (52:20)
I have probably pretty limited knowledge there. A lot of times from what I’ve had, it’s just like very superficial. It’s very superficial, one. Two, it’s down right on an area where there’s gonna be a lot of friction, whether it’s from like a sock or the boot, and there’s a lot of moisture in that area. There’s a lot of sweat going on or just moisture accumulation with the boot and with the sock and where they try to rest their leg.
And just of course with the edema that is present as well, especially people that even had an ankle sprain, it’s crazy how long the swelling can last just with an ankle sprain, right? So with a surgery like that, especially if they got all those other comorbidities, it just takes a while to get that, the bad swelling out of there as well. I know we need some, but so that would be my hunch. What have you heard? did she teach you?
Jake (53:17)
I mean, that was it. just said it. She does it. That was it. That was it. She’s like, I think, I think she just said like infection is a big concern and I didn’t address it because I wanted to bring up other things. But now that you said it, I was like, I remember saying that I just never really got into it anymore. But yeah, we’ll leave that as it is. So what have you seen with injections? Because people, I mean, there’s the story of like you get your patella tendon, you use self rehab and you get better. But all these people are going to go in and get the x-ray, get the
Alex Nelson (53:18)
Okay, perfect.
Yeah.
Jake (53:47)
opinions from doctors and often they’re just going to be referred for an injection. What have you seen? Is it a good thing, a bad thing?
Alex Nelson (53:51)
Yeah.
I’m staying hopeful. Like I’m staying hopeful because again, lot of the clients, patients that get the injection, right? They want that. They want the hope. They probably tried a lot of things and maybe they didn’t have success. Maybe the loading was correct, right? And it was great rehab and maybe they just didn’t have success or maybe it was mismanaged and they got an injection too soon. I’m staying hopeful and staying up to date as best I can and wanting it to have a really positive.
effect and I think we’ll probably get there. I’m not sure that the PRP is super effective. think you had Peter on the podcast recently and I think he’s put on a couple blogs talking about, did he talk about PRP or was that shockwave? Maybe both of those and maybe he’s changed his mind on it and I don’t know. I don’t want to put words in his mouth but.
Jake (54:45)
Yeah, he did talk about both. Yeah, yeah, he talked about he talked about
he talked. Well, shockwave, he’s like doesn’t work. But for like insertional Achilles, because it’s like calcification thing. But he’s like they did they did some recent studies. They’re coming out that it doesn’t work. then he’s been a big guy, like a big maybe anti PRP guy because of the research they’ve done to not see to see things. But yeah, yeah, that’s what that’s what he was saying.
Alex Nelson (54:57)
Yeah.
Yeah.
Yeah,
you know what, I don’t know if I’m like anti just because you know, it’s their decision and I don’t know what harms it could cause. I guess it would, the harms would be around the narrative of why they need it and the narrative of, what’s ultimately going to get you better? Like I think if there’s the narrative that
Hey, you can get this injection. It’s going to help supplement and provide a good environment for healing, but you still need the proper loading and you need the proper progression. And this may not necessarily like speed up your timeline, but it’s going to maybe allow you a little bit of pain relief during and, maybe just better outcomes long-term.
You know, I don’t really necessarily see a lot of harm in that. Maybe there is that I’m missing, but I think it’s like the narrative is kind of the important key rather than if they’re like, hey, you need this injection. This is kind of our last hope. You’ve tried everything. If this doesn’t get you better, I’m sorry. I can’t help you. And then those people, unfortunately, are probably set up to fail just because they, yeah, many, things go into that. But that’s my thoughts.
I don’t find them super effective, but hey, there’s people that told me that it was huge for their prognosis, so that’s great.
Jake (56:29)
Yeah,
yeah. Another thing, it reminds me earlier we talked about the inflammation thing and I think it was, like Jill Cook was on that whole thing, like there’s no inflammation in tendon pain, tendinopathy, and then maybe more recently, Neil Millar, Stephanie Dakin are like, there is inflammation and it’s the immune cells in the tendon. But another piece Jill, I think Jill was talking about was like, do not stretch the tendon. And that was a big thing, maybe for me too, I’m like, okay, it makes sense, don’t stretch the tendon.
Alex Nelson (56:35)
Yeah.
Hmm.
Jake (56:59)
Where do you stand with that?
Alex Nelson (57:02)
Yeah, so I agree. probably lean on the side of just minimize the stretching, especially early on, just because I’m trying to minimize the variables. At least from my programming standpoint, I’m trying to figure out, was it the loading I gave them that pissed it off? Was it the walk they had to do, you know, to and from work? Was it the extra stretching we’ve added on every day? So I just take that away. And then with some of the evidence, especially for like proximal hamstring tendinopathy and
insertional Achilles tendinopathy with stretching, adding potentially another compressive sort of load that isn’t needed and potentially irritating in the early stages.
I tend to stay away from it more so with like I said, the hamstring and the Achilles. Quad and patella, I kind of avoid it early on as well, but then if people want that stimulus, they want that sensation, they’re like, man, my quads are tight. Just keep it gentle and it’s probably not too harmful, especially as they progress and we kind of get their symptoms low and stable enough. And eventually, I kind of think about it that eventually we want to put these people.
Not that it’s necessarily gonna come from stretching, but we eventually want to put them in like the dirty positions, right? Where they’re gonna be in for sport, that step back to drive, whatever it may be. So they’re gonna need that exposure to, if we’re talking the Achilles here, compression, extreme ranges of dorsiflexion. So we’ll probably train in those positions with loading, with isometrics, with whatever it may be. I don’t.
I would have a hard time seeing that, they can do all that, but then at that stage, stretching’s gonna be very harmful still. So I’m kind of more in the early stage, maybe early middle. I avoid it, but then it’s cool later on.
Jake (58:54)
Okay, I got one more for you in our notes from when we talked a couple weeks ago. I have VPC in there, VPC 157. What have you seen? Have you seen any, is it just anecdotes or what?
Alex Nelson (59:02)
Ooh.
Yeah, man, I’m really interested to learn from you on this, especially over time, because I almost feel like you’re gonna see a lot of this maybe before me and you’ll be able to keep me up to date. But I’m still learning about it because I think that quality of studies are limited. A lot of the studies, almost all of them I’ve read are on animals. And so it’s hard to take that and then apply it to…
my clients and recommend it to my clients. I don’t know the dosage, I don’t know what brands, I don’t know what’s quality. And so I just don’t really have a lot of good information to say yes, you should definitely do it. A few of my clients have done it though. And again, this kind of shows the continuum of what you can choose. Because I have one client did it.
man, now can’t remember if he did the injectables or oral, because right, there’s another factor, what’s better there, injection or the oral, but he was paying like $700 a month, I think, for this product, and then I’ve had another client that was maybe paying 50 to $100 a month for the product. so like, was one more pure, was there better quality, and…
I wouldn’t say that there’s a big difference between how those two people responded between the 50 and the $700 product. And the one that was actually on the more expensive product, he said, yeah, probably helped a little bit. It probably helped, but he couldn’t say for certain. And I think he did it for a few months and I don’t think he’s taken it anymore. I have one client says he’s going to continue taking it because he noticed maybe he recovers better when he’s on it. And, you know, then I probably have everywhere in between.
maybe worked with like 10 or so people that have taken it consistently or trialed it. So I guess that’s probably not big of a case study or study to run, but that’s my experience with it so far. Have you learned anything recently since we last talked?
Jake (1:01:15)
Yeah, did. Well, yesterday, yesterday I had a call with I think he tore his, yeah, he tore his patellar tendon a few years ago, maybe. And I talked, he asked me about BPC towards the end and I was just like, well, I don’t know, it’s all anecdotes. And then I’m like, well, I don’t know if there’s harm. Maybe there’s harm, but I don’t know if there is. And I was like, it just, it just costs a lot of money. And then he was like, well, he’s like, mine’s pretty cheap. And he’s like a healthcare guy. He’s like, I got it out of China, which doesn’t have like good, good quality
Alex Nelson (1:01:38)
Yeah.
Jake (1:01:44)
the shirt I don’t know so he said it was really cheap so I’m like okay I guess if you want to do that it’s not a problem there but it’s it’s it’s either like someone says it’s magic or it doesn’t do anything it seems like and I I’m just gonna wait I’m just gonna wait until there’s there’s more information on it but yeah anyways that’s my little bit there okay we’re at about an hour tell everyone where to find you online if they want to work with you
Alex Nelson (1:01:55)
Yeah, exactly.
Yeah, thanks man. pretty much Instagram is the only place where I’m active and social there. You can find me at training with Tenenopathy on Instagram. can shoot me a DM. You can send me an email at twt.nelson at gmail.com. I’m pretty slow with emails depending on the day and the week, but yeah, Instagram is really where I’m active and posting and networking.
Jake (1:02:40)
And you’ve done all the tendinopathies. Do you have ones that you’re really specialized in?
Alex Nelson (1:02:46)
Yeah, no,
I wouldn’t say I’m more specialized in one over another. do more commonly work with individuals that have patellar and hamstring and Achilles tendinopathy. I would just say that’s more frequent in my caseload and that’s probably just due to the general epidemiology of those tendinopathy’s in general. But I do work with a fair amount of people with golfers and tennis elbow, various shoulder tendinopathy’s.
Even though I’m training with tendinopathy, kind of consider myself training without tendinopathy as well, because I have, that’s the goal, right, to train without eventually, but then also, I treat back injuries as well, shoulder dislocations, I have a few, so I have experience just with other general orthopedic injuries.
Jake (1:03:36)
All right, great. All right, man. Thanks for coming on. Yep.
Alex Nelson (1:03:39)
Hey, thanks so much for having me, man. Appreciate it.
Alex’s links: https://stan.store/training_with_tendinopathy
Alex’s Instagram: https://www.instagram.com/training_with_tendinopathy/
