Principles over tactics
“There’s a lot of saturation right now with exercises and tactics and X’s and O’s, but perhaps not these principles and concepts around decision making. That needs to be part of the landscape as a clinician, to help you filter and funnel through the noise and know what the actual signal is.”
“There’s a lot of links in the chain. And if there are a lot of links in the chain, it makes it more challenging to find the truth. It’s almost like a game of telephone, where the message and the signal get lost.”
“I was posting things early on that I’m sure I don’t agree with anymore. But I would hope that’s the case, because if it weren’t, it would mean I probably haven’t evolved as a thinker.”
Variability and robustness
“If I can broaden the range of their affordance landscape, I give them more solutions. Which to me sounds like variability.”
“You can be super precise and super focused, but the downside is that you’re hedging your bet that this one thing is the key ingredient, potentially at the disservice of the rest of the ecosystem having what it needs to do its job in a variable, highly emergent, chaotic environment.”
“Manipulate space and maintain pace. Metabolic variability probably means we don’t need to have these arguments over whether zone two is best or high intensity interval training is best. Perhaps they should do both, particularly in the offseason.”
“Robustness is best served for the offseason. Once you get into the season you need to be a little more precise, because the margin of error is smaller.”
Efficacious is not the same as effective
“The research could say this is the most efficacious solution. But just because it’s efficacious doesn’t mean it’s the most effective, because it’s efficacious under the conditions the research was manufactured and curated for. It might not be what’s most effective for the athlete in front of you.”
“You probably can’t get there until you build the relationship, so that when you get into the discourse, it’s from a place of task conflict and not personal conflict.”
Why the tissue is usually the bottleneck
“Basketball preferentially biases the biology being the bottleneck, just based off the mechanical fatigue that accumulates. Not everything is high intensity, but submaximal intensities done repeatedly at a high frequency can slowly degrade and depreciate the biological substrates.”
“It’s not often that you find athletes who have insufficient neurological capabilities. They’re not usually weak individuals. What usually fails is the tissue.”
“If I can increase the margin of error by giving the tissue more buffer, then when I’m fatigued and that does affect the neurology, at least there’s a backup, an emergency brake on the biological architecture.”
Pain, structure, or function
“Are we talking about tendon pain, tendon structure, or tendon function? Which of those are we trying to manipulate and change and influence? Is it all three? Is it one of the three? That probably at times mandates a different type of input or solution.”
“You continue to read and learn, and now you’re unlearning things, and then you get into areas where you realize you really don’t know a lot. Being able to grapple between the trivial many and the vital few is quite important.”
“The tenocytes don’t know what contraction is happening. They sense tension and strain through mechanotransduction. So you could just do whatever. And then you start to realize there’s nuance with that as well, because if everything matters, then nothing matters.”
“Pain changes someone’s movement solutions. It constrains and reduces what they had available. The beauty of the human body is degeneracy — there are a lot of different ways to get to the same destination. But if I keep rerouting, at some point the other tissues that haven’t built up enough chronic workload get into a capacity-exceeding stress.”
What the tendon actually does
“Most people subscribe to the premise that the only function of the tendon is the stretch-shortening cycle, energy return. And if that’s the only function, then when there’s no depreciation in stretch-shortening capability, we say the tendon is mechanically competent and they’re fine.”
“A mechanically competent tendon is one that has an appreciable, relevant, task-specific level of stiffness, as well as one that can moderate impulse for the contractile tissue.”
“The tendon also has power amplification and power attenuation. Those look quite different, and they may never rear their head in energy conservation or stretch-shortening capability.”
“On deceleration, the tendon acts as a shock absorber so the fascicles can stay relatively quasi-isometric in a more favorable length-tension position.”
The compliant tendon and the sore quad
“If the tendon isn’t mechanically competent for that task, there’s more compliance, less stiffness, more strain per given unit of stress. There’s more give, so it doesn’t buffer the deceleration, and now the muscle fascicles have to go through more deformation and elongation.”
“An athlete says the outside of his quad has been really sore lately, more than usual. So I reverse engineer it. Deceleration means a higher external knee flexion moment, which requires a higher internal knee extension moment. The vastus lateralis has the highest contribution to that. If the patellar tendon doesn’t have sufficient function, perhaps the vastus lateralis has to do more eccentric lengthening, and now they’re getting more soreness.”
“It’s a lot of speculation. But speculation is what breeds different conversations and research.”
The five Ps
“Player’s perspective, pain, past medical history, performance decrements, and pathology. Those are the five Ps you’re navigating between to discern whether this is lending itself to a tendon problem.”
“Are there multiple domains in which this quality, or the lack of it, is emerging? That helps me hedge my bet that this is a constraint we need to pay attention to and service.”
“Jump height and RSI are output-driven metrics, but they’re high-order constructs derived from low-order constructs. Don’t just stop there. Because of degeneracy, they can give you the same jump height by staying in contact a little longer to develop more impulse.”
Via negativa
“Via negativa is a big principle of mine — addition by subtraction. If somebody has a tendon issue, we think we have to insert some tactic to drive a change. I actually think there are more times where we can remove the provocative stimulus and let it settle naturally.”
“If you reduce it to an appreciable level, you can usually know within about two or three days.”
“It depends on acuity versus chronicity. If it’s chronic, that just means it’s persistent. It’s happened repeatedly over the past few years. So it’s incumbent on me to create a loading paradigm they can be consistent with.”
“I never say you’re never going to have tendon pain again. But instead of having it for four or five days, perhaps you have it for two, because you’ve built a more robust system that doesn’t need as long to come back down to homeostasis.”
Keep the same vehicle of loading
“I’d rather not change the exercise for the sake of changing it. What are the levers I can manipulate within the vehicle of loading they’ve already been exposed to? It gives you better information about whether you’re actually making changes.”
“It’s equally beneficial for them psychologically, because they’re still doing the same exercise with a subtle change in one parameter, as opposed to overhauling it and starting with something novel that comes across as, man, am I really that messed up if I can’t even do this?”
Stiffness is an outcome, not an input
“If tendinopathy is a performance-limiting disease, then imparting more stiffness is important for reversing that and promoting more of a performance-enhancing structure.”
“I look at stiffness as a high-order construct. It’s an outcome. We aren’t adapting stiffness. We’re adapting the lower-order determinants — the morphology and the material — and having those converge into stiffness.”
“Stiffness has a behavior, and that behavior is contingent on the task or the environment. It isn’t a quality that exists at the same magnitude during all tasks.”
The chasm before plyometrics
“Let’s say we did improve stiffness. What happens is we jump straight from that into plyometrics. I feel as though there’s a large chasm we’re circumventing.”
“Dynamic effort methods — the ability to produce force fast — can shrink the chasm between isotonics or isometrics and something where you’re projecting your center of mass vertically or horizontally.”
“Early on, let’s get a high magnitude of strain and improve the morphology and material for stiffness. But then we probably need to go to a high rate of strain. And then a high rate of strain with our momentum being displaced.”
“If they’ve been sidelined, it’s not just the tendon that needs to be restored. Rate of force development lags behind quite a bit after ACL reconstruction and Achilles ruptures, and I think that applies to Achilles tendinopathy reconditioning too.”
Seated versus standing calf raises
“Standing is directionally correct, and for most people it’s the most satisficing option. You can use a higher absolute load, and some of that is the summation of torque across the ankle, the knee, and the hip.”
“The soleus subtendon, being anterior and deep, has a very intimate relationship with mid-portion Achilles tendinopathy. There might be times where I want to add more volume or frequency there without exposing the gastroc to more cumulative stress throughout the week. If I can remove that from the equation with seated, that might be a favorable solution.”
“The gastroc helps project the center of mass forward more than the soleus, whereas the soleus is more involved in creating vertical impulse and supporting body weight in steady-state running.”
“With a soleus strain, standing can give you a false positive. They generate appreciable force and it looks like the soleus is sound, but it’s an illusion, because the gastroc might be taking more of the onus.”
“Dull, diffuse, and delayed. The three Ds. That makes me think soleus, as opposed to something that happened acutely and instantaneously.”
Biarticular tissue and soreness
“If it’s biarticular, there are more joints the tissue is responsible for handling. If there are more joints it has to handle from an eccentric perspective, I wonder if that induces more fascicle elongation.”
“The total work is just more. Not the force per se, but the distance, the displacement, because it’s a biarticular tissue.”
The enthesis question
“You go from tendon to unmineralized fibrocartilage to mineralized fibrocartilage to bone. It’s a transition of mechanical behavior. Could we be precise enough, surgical enough, to impose more stiffness at that specific aspect? And is it actually more compliant there — is that the reason for the enthesopathy, a mismatch between the mechanical properties in that location?”
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