Where tendon practice was in 2012
“This is 2012. The concept of tendon management is foreign to the majority of the profession. The use of tendon-specific adaptation was foreign. We were avoidant. We didn’t push people into pain. If it hurt, you don’t.”
“RICE was still how you managed conditions. Rest was the first word.”
“I’m not saying tendon adaptation changed the practice. I’m saying the practice of physical therapy, writ large, changed because of the way we started to manage tendons.”
“Now we have people loading their Achilles in the cast in the post-op suite. If you’d told somebody to do anything after an Achilles repair fifteen or twenty years ago, they’d have looked at you like you were insane.”
The patient who changed everything
“She’d had proximal hamstring tendinopathy for five years. She couldn’t run more than a quarter mile before it was so excruciating she had to stop. She’d been picked up on the side of the road by her husband, in tears.”
“I’m three seconds out of school and I think I’m going to fix this with glute training. We do this for four weeks and nothing changes.”
“My mentor says, just load that thing up. Put her on a hamstring curl machine and blast it. And I say, Dave, I’m going to rupture this poor woman’s hamstring.”
“She does five sets to utter failure and starts crying around set two and a half. Actually crying in the clinic. Everyone is looking at us. My face is beet red because I’m embarrassed.”
“Thirty minutes later the front desk says she’s on the phone, and I think, oh my god, I ruptured her hamstring. She says: Chris, I just ran four miles. I am completely pain free. What in the world did you do?”
Calling Jill Cook
“I decided, because why not, young dumb kid, I’m just going to email Jill Cook. Jill, tell me everything you know. She emailed me back within forty-five minutes and gave me an hour and a half of her time from Melbourne. I cancelled everything in my day.”
“She spoke about tendons like there was one sitting in the room with us. It felt so real. I could feel it, I could see it. Like it was talking with us.”
“It blew my mind that maybe I’m not loading people up enough, and maybe pain is not as deleterious and catabolic as I thought it was.”
Pain and stiffness are not the same problem
“If something hurts, you can’t load it heavy. High strain seems to be the vehicle by which stiffness is transported. But good luck getting somebody with rip-roaring patellar or Achilles tendon pain to load something heavy enough. So your initial intervention is an analgesic intervention. The problem is we conflate the two.”
“Heavy is for tendon adaptation. I don’t think it’s true for pain modulation. There’s a whole profession of people not loading anywhere near these strain percentages, and people still get better.”
“Pain doesn’t follow any rules. You can do it with thirty percent of your 1RM, or seventy, or ninety.”
“Even if I’m confident you need ninety percent of MVC, that’s ninety percent of your tolerated max, because your Achilles hurts so bad you won’t push. You’ve rate-limited the force output with pain, and now I’m taking a percentage of that.”
“If my goal is tendon pain management, do whatever makes the tendon hurt less. Once you’re out of pain-limited, then you go chase the strain stuff.”
Rigidity is not stiffness
“There’s a difference between performance stiffness and protective stiffness, which I call rigidity. If somebody lands stiff, they’re stacking their joints and hammering the ground. Ask them to jump again as soon as they land and you’ll figure that out real fast.”
“Performance stiffness is spending the least amount of time on the ground and jumping as high as you can. If you spend a bunch of time on the ground, you feel like a flat tire. It just dissipates. Welcome to your tendons.”
“An explosive isometric is still concentric. You’re not getting a stretch shortening cycle out of that. And stretch shortening is the whole reason we have these things called tendons.”
How he doses
“Greater than the minimum effective dose, less than the maximum tolerable dose. Don’t break it, do enough to make a change.”
“I don’t have a magic book that says Jake’s here, flip to page forty-five, Achilles, got it. That doesn’t exist. I give you rules, you give me feedback, and we recalibrate until we find the entry point.”
“I’d rather miss conservatively. Missing cavalier could end up in a bad place.”
“I tell you to kick and stop when you feel a three out of ten. What’s a three out of ten? I don’t care. That’s your tolerance. Then we program fifty, sixty, seventy percent of that.”
“We chase this until you say, man, I’m having to try hard to make it hurt.”
The isometric era
“Go do a leg press isometric for forty-five seconds and let me know how that feels. I don’t care what the load is. It’s going to be brutal.”
“What it did well is it forced PTs, who were going to underload people, to hit intensity. Not through strain, but through time under tension. It just didn’t hit the dial we now think matters more.”
“I was Mr. Isometric for years. Then people got bored, or they just quit.”
Why he went looking for heavy
“I could manage acute symptoms in spicy tendons really well. What I struggled with was resolution. They were still slow. Still boggy. They didn’t have the spring.”
“I’d get your pain better, we’d strength train, then I’d add plyometrics and running and the symptoms came right back. What am I not doing here?”
“Heavy slow resistance — emphasize the word heavy. Actually heavy, and tissue specific. Not squatting with someone who has Achilles pain.”
“Where we’re heading now is: how much? What volume? In whom?”
Partials and joint angles
“Your force production plummets once you hit neutral. Plantar flexing from about twenty degrees of dorsiflexion is the highest by a mile. At twenty degrees of plantar flexion, it’s an eighty percent reduction.”
“If you can do a full range standing calf raise, you have underloaded the bottom. Fact.”
“For the knee I use 110 to 60, and 45 to zero. Those are separate exercises, because the dose is based on your ability to move that load at that range.”
Good enough is good enough
“If I can’t do ninety percent, then I’m lost? Looks like I’m not adapting my tendons today, sorry tendons? Of course not. You’d go backwards and progress. And if you eventually tolerate ninety percent, the tendon adapted. It had to have changed.”
“Somebody will say, but I work with elite athletes. Great, squeeze that lemon. But that’s an outlier. Everybody else is not that person, and good enough is good enough.”
“You went out last weekend and played pickleball for the first time in fifteen years and now you’ve got Achilles pain. Do I need to be that specific with this person? Probably not.”
“You were fine before. The thing that changed wasn’t that you weren’t strength training. The thing that changed is that you did something egregiously beyond your capacity.”
“Good luck getting somebody out of pain and then convincing them to keep doing whatever it is that got them out of pain.”
Performance and risk are not the same thing
“It’s an inverted U. If I’m very weak, I can’t run fast enough to hurt myself. If I’m really strong, I can do more that may hurt me.”
“Performance and injury risk are not the same thing and they should not be spoken about as the same thing. The higher you jump and the faster you run, the more momentum you have to manage.”
“You know who’s not rupturing their Achilles? Somebody sitting at home on the couch. If you’re looking for a solution: stop playing sports. I’ll reduce your risk instantly.”
“The whole risk is associated with a task and an exposure. If I’m not doing the exposures that anchored the risk, my risk is low.”
Force testing, and the two-times-bodyweight number
“Single joint, tissue specific force testing is the keystone to this whole operation.”
“Put a bar on your back, stand up tall, and squeeze your glutes. You’ll feel the bar go up. Now imagine I’m measuring your plantar flexors and all you do is puff your chest and squeeze your butt. I’m getting force from the axial skeleton that isn’t plantar flexors.”
“That two to two and a half times body weight is measured in twenty degrees of dorsiflexion. That is not a low number. You will not get anywhere near it unless you’re rigid, fixed, and in dorsiflexion.”
“You’re going to get a bunch of people running around saying my people are weak, you’re a risk factor because you’re not hitting this number. That’s a research number entering the clinical space, where people do a pretty terrible job of testing.”
“People still do a terrible job of measuring knee extension strength. They didn’t strap them down, so the person leaned back and turned an isometric into an eccentric. Yeah, all your numbers are higher.”
“You’re not going to out-recipe bad ingredients. You can do all the stats you want, but I saw how you measured that, and I can assure you that you didn’t measure what you thought you did.”
“First and foremost, do something repeatable. We don’t actually care what you do. Do it consistently, and know what everybody else is doing.”
“Imagine giving somebody a risk ratio based on a force number and misidentifying them. If that’s an athlete and you tell them they have a high risk of rupturing — that could be a very dangerous thing.”
Closing
“I love it because it’s been one of the most influential things on the healthcare side and people don’t even know it. They don’t know they were a part of it. But they were, because we all do this now.”
“Somebody hurry up and figure out how to do in vivo, in clinic tendon strain measurement so we can start having some fun. Let’s start a GoFundMe.”
Where to find Chris
Instagram: https://www.instagram.com/cmj027/
Dungeons and Dynamometers: dungeonsanddynamometers.com
Twitter: https://x.com/Chris_Juneau3
Email: cmj027@gmail.com
Podcast: https://ptinquest.com