Podcast #156 Dr.

Keith Baar

So there's this idea that tendons and ligaments are really entertain shoes they don't turn over very
much. And what we're finding out is that that's completely not true and as were inactive we
decreased the production of collagen sore tendons and ligaments get smaller. This is episode 24 of
the Jack athlete podcast today have on Dr Keith bar to talk about tendons there is this idea in the 10
world of treating the donut not the whole treating the healthy area not the area of degeneration and
this seems to be supported by most tendon researchers but Keith Barr talks about the exact opposite
of treating the injured area getting that back online and doing what we can to make the entire tendon
all healthy and functional so we talk about his different methods of doing that isometric holds short
sessions using collagen supplementation and we talk about different case studies so this is up so 24
with Dr Keith Barr enjoy. Keith if you want to give people a background on how you got where you
are and what you doing right now go ahead sure so so I started as a strength and conditioning coach
with the Michigan football team and you know that experience did did it kind of shaped a lot of
what I did simply because I ate I have that practical background of trying to understand why it was
how to get people better how to make people stronger how to make people better more resilient
more injury resistant and so from there I went on to to do a PhD and and basically I started it and by
doing a masters at Berkeley really what I was looking to do is to try and understand why why
certain people you would want to strength training program they got huge they are strongly they just
change increasing muscle mass and strength dramatically and other people they seem to work just
as hard they seem to do all the same things but they didn't grow at all and so you know I did a quick
masters at Berkeley and then went to a PhD in the university of Illinois and I get to really address
that question by using essentially what was the techniques that we were using at Michigan too low
to one of one of the muscles are all of the muscles of the England so this was an experiment that I
first in rats what we showed is that is it the ones that we're going to grow bigger the increased
activity of this one specific protein kinase and that's just an enzyme that adds a little little that
decorates other proteins with with these phosphate groups which are just negatively charged things
that change the shape of the activity of the location of other proteins. What we found is that there's a
direct correlation between the activation of one of these kinases and the growth of the muscle so if I
looked 30 minutes to 6:00 hours after he did a heavy exercise I can see the activity changing that
one kinase correlated almost perfectly with the increasing muscle mass situasi from 6 weeks of
training and so the so that muscle that protein kinases of protein kinase called M. torn a complex
one and that's also no been shown to be activated by amino acids and it's really kind of central to
increasing muscle mass that happens when you strength train and other people have shown the
exact same thing in humans and so so that's really that was really good finished up there with my
PhD and I went on my wife actually I just followed my wife down to Saint Louis she was doing her
her law degree and I got into a laboratory with probably one of the most famous exercise
physiologists a guy named John Hall Izzy and John Hall is he what he what he had done as he had
years and years and years ago he had been the first person to discover that that exercise was in fact
doing something good to muscle and and what it was doing was it was increasing its mitochondrial
mass and increasing the ability for that muscle to make ATP and while I was in his lab I discovered
this one gene it was activated by exercise that could lead to the increase in both mitochondrial mass
but also the fat oxidation enzymes the the the capillaries in all of these other things that are so C.
within Durrance exercise miss this gene that they call PGC one alpha what we discovered is that
when you do exercise you activated you get more of an. And you produce a smaller version of it
that's actually lacks an inhibitory domain so you produce a lot more of the of the protein and it's it's
more it's conspiracy always active and so that was really cool and then from there went to Michigan
again and what I did there was kind of I got really cocky with my my PC my postdoc I thought I
could do everything with muscle so we we tried to do is we try to make muscle and dish so I've I
figured that I knew so much about it that I can I can actually just make it from cells and and so I
spent some time with a guy named Bob Dennis who is it one of the smartest people in the world and
and you know we had some success making muscles they were all always really small and they
didn't you know we couldn't control the way that we wanted but the one thing that I noticed when I
was making those more trying to attach them to things is that they always failed wherever we would
attach the the muscle to a machine whether it was gonna be a pen or a force transducer or some
other type of machine. When we would kind of attach it that way we make the muscle contract we
measure the force it would always pull out of the hidden because we're missing that crucial part the
tendon and so we started the kind of research how the tendon work so that we could maybe engineer
the tendon so we can add that into our muscle as well and so we started trying to understand
tendons and what we did with with a couple of really outstanding researchers one was owner route
it was now that the chair of engineering at Michigan and the other is an outstanding young scientists
named name Serra county and what we did together as we looked at how the tendon functioned in
you know hold hands and so traditionally what people do is they kind of tenant pulling a little piece
of the tenant but what we did differently as we held on to the bone on one side and the muscle on
either side and we actually as we pulled it apart to tear it to to see how strong it was we actually
used a camera to look down on the tendon to see how the part near the muscle versus the park near
the bone how stiff the different parts of the same tended more we discovered is that the part near the
muscles really stretchy the park near the bone is really stiff now makes sense because what the
tendon is trying to do is is trying to connect the a really stretchy soft and compliant and pliable
muscle to something is really stiff and bone and so what the tendons job is to do is to protect the
muscle bone interface what has to do is ask me stretch on one side and step on the other and then it
gradually changes from stretching to step. Really that was the the first real discovery didn't let us
down to trying to understand how tendons and ligaments and other tissues connective tissues
worked and so over the last say. 10 years we've been spending a lot of time trying to understand
how how these connective tissues work Howard portent Charlie for muscle function for
performance for injury prevention because what we tried to do is we try to figure out how these
tissues were regulated by exercising by nutrition all these things so what we did is we went back to
the same kind of model that we were using for to make these little muscles and dish and we just
modified a little bitten using human cells we started making these human tendons and then what we
did is we developed a way that you could actually make a bone and so we need a bone on both sides
we had all these human cells make this little tissue and the tissue is essentially a ligament because I
got a bone on each end and it's got this connective tissue in the middle and functionally it's almost
exactly the same as a as a developmental ligament and then what we could do is we could see how
different nutrients are different hormones or different things like that would affect it what we found
was really interesting is that when we added things like proline or or glycine or other you know
potentially important amino acids that we could make these ligaments different stronger and so
from that we decided to look into humans to see whether we can see the same thing and people and
so we you know I try to talk a bunch of people into doing studies that looked at dietary collagen or
gelatin and its effect on collagen synthesis because from our you know engineered ligaments we
would expect that there would be an increase in in the stiffness and strength in collagen synthesis of
these tissues nobody wanted to do it because it was it wasn't really a cool study so about 10 years
ago we started to try and figure out how to do it ourselves and we eventually figured out how to do
it I did it together with the game great shot the Australian institute of sport and we show that when
you gave people dietary college. And you have them do some activity like jumping rope you can
actually measure and increasing collagen synthesis in in in people and so all of that together now
gets us to the point where what we're trying to do is we're trying to understand how loading
nutrition can be combined to maximize the production of the best possible matrix because what we
know is that when we make a good matrix that are. Our musculoskeletal system works better our
muscles work better attendance work better leaves our call our our cartilage as well as our bones all
of those tissues together work better when the matrix underlying them is stronger and more robust I
actually found your work you talk about the viscoelastic properties of tendons could you cover the
basics of this classic properties and what this means for training and adaptation sure so so
viscoelastic just means that good a tissue or a substance it doesn't have to be tissue but most of our
most kills kill all over my skills skills tissues are viscoelastic and what it means is that these tissues
behave like both elastic solid which doesn't necessarily explain too much to people but it's like a
steel is an elastic solid if you pull it it's going to get stiffer as you or if you bend it or if you do
anything it gets different you apply more force. The physical component means that that's means it
acts also like a liquid viscosity is is kind of this measure of how how liquid like something is and so
when we say it's visco elastic that means it has the properties of both a liquid and a solid and
importantly the liquid components really important and that's because what happens is that a lot of
the the properties of these tissues that we're gonna talk about. There there mechanics which is their
important component are dependent on how fast you load them if you load quickly the tissues are
all going to be more stiff and if you think about it and you've got city of balloons for example and if
you've got a balloon there's you put a little bit of air into an impolite there's not really much
resistance because anytime we pull on something like a balloon as we pull it apart it actually gets
skinnier it's called radial compression so what I'm doing is defined and we all know this almost
every street coach knows everybody who's ever been to Jim knows this because we want to do if
you want to show people that you've got a big muscly going to flex our muscle when you flex your
muscle what you do is you contract the muscle there's also get shorter it gets fatter in the
perpendicular direction okay so that's what happens when we contract the muscle we get that big
bold sh because it has to as we shorten it it has to expand in some other direction because it it has to
stay the same volume as we shorten also it's got to maintain the volumes that means the volume has
to go out on the on in a perpendicular direction. So now if we do this in reverse with the tendon
that's right pull it as a stretcher you have to get skinnier. If we do that and there's air inside say that
balloon that I was giving an example of then there's not much resistance because the air doesn't
provide any resistance but if there's liquid in the attic as I pull it out the liquid is now going to
prevent you from stretching it any further because it's gonna give resistance. And so that's
essentially what the liquid is doing is as we're pulling our tendons it's going to give that resistance
ticket to the compression the radial compression and that means you're gonna get some stiffness
associated with the liquid now unlikable lunar tendons are connective tissues aren't completely
uniform they're not they don't have a barrier so what happens is I pull on it and all I have is is
collagen matrix I don't have that the the rubber of the balloon so always when I pull on it yeah I'm
compressing the the water and the water it gives it gives it some resistance but because there's little
holes in the collagen the water also moves at. So if I move quickly the water moves at the door the
water doesn't have time to move out as I pull on my end if I move slowly as I pull it the water
slowly seeps out of the collagen and now there's less resistance so there's less stiffness so when I
load my tendons quickly I'm going to get a stiffer tendon when I load them slower I'm gonna get a
less stiff tendon because. You know the other way to give the example is. If you want to think of it
like a pool if you put your hands at the bottom of the of the shallow end of the pool in the lower
yourself down into the pool if you go slowly like that you're just lower yourself slowly you barely
feel the the contact with the water because when you're moving slowly the water molecules just
move around your body because they're acting more like individual molecules as you move faster
and faster now you're gonna hit the water in the impact between the air and water is going to be
much more significant the water is gonna be much stiffer because as you go faster and hit the water
there's not that time for those in the individual molecules work to work as individual molecules now
they work as a sheet the faster you go the thicker the sheep the more stiff the water. So the
viscoelastic properties of of our connective tissues I mean that when we load quickly we're gonna
have a stiffer system we load more slowly we're gonna have a list of system when we talk about
stiffness stiffness is basically the amount of collagen and the amount of crosslinks correct yes so so
stiffness is going to be determined primarily by how much how much college in there is in the
tissue and how well connected each molecule color vision is to the other molecules not stunned by
these little crossings that we make either using the enzyme lysyl oxidase or we make using sugar so
if we're if you have a diabetic athlete they're gonna have higher blood sugar instead of controlling
the blood sugar really well what they're gonna do is you're gonna have stiffer tendons and ligaments
than if you have a a non diabetic athlete if you have athletes who go through a period of an activity
when you're inactive a lot of times were eating similarly to when we were when we were training
constantly because I mean active I'm sitting on the couch Morton either because I'm injured because
our scope and I have to shelter in place now what I'm gonna do is I'm gonna find it I'm gonna have
poor blood glucose control because I am not exercising as much the result is that all actually
increased the number of crosslinks within might connective tissue and that means the connective
tissue will get stiffer and if I'm really an active and I'm just kind of sit around for awhile I'm going
to give both the increasing crosslinks and I'm gonna get less collagen in the tissue and that's when
the tissues get brittle and that's what happened but 7 years ago in the NFL during during the last
NFL players locking. When they locked the players out for 3 to 4 months the players came back to
training in the U. they try to ramp up their training really fast and they had something like 12 to 13
Achilles tendon ruptures after on average they would have one per year they had almost 10 fold
increase in that and that's because. As we load we're gonna increase the production of collagen and
as were inactive we decreased the production of collagen sore tendons and ligaments get smaller
and when we have a smaller ligaments and I told you before that you get more crosslinks because
there's more sugar circulating and we're not controlling their blood glucose as well those 2 things
together make a stiff but but very small tissue and stiffen small is is what we call brittle you can
have a tissue then it's it's extremely brittle and that's what you see when you have people coming
back from long periods of of of an activity I remember in the in the study you talked about
immobilization for I don't know if that was 4 weeks for the calf so that would be the tendon the
Achilles tendon would be brutal but you were talking about the after but actually perform better
correct so so again when we look at this so athletic performance most of athletic performance is
down to our power to weight ratio and our rate of force development so the faster rate of force
development and we've done some studies that we haven't published yet from with USA track and
field team what we found there is similar to what a lot of people found elsewhere is that
performance at the USA championships was directly related to the the rate of force development of
the legs and that was in all of the throwers for for the whole championship didn't matter where
you're throwing hammer with you throwing the shot put the discus or or the javelin all very very
different offense what we found is that. No matter what you're throwing if your rate of force
development in the legs do an isometric squat was higher your performance is better to reinforce
development is dependent on the stiffness of the system the whole system so that means the
stiffness of the muscle tendon and and everything in between and so basically what and it's just like
if you think about it if I have a big heavy weight on my desk and I attach a rubber band to it not
pulling the rubber band always gonna happen is the rubber bands gonna she's gonna stretch out a lot
and eventually I'm gonna move the weight but if I tie a rope to it now what's gonna happen is the
rope is gonna stretch a little bit but not very much and so I'm gonna move the weight much faster
and if I attach a metal rods that we now I move it as soon as I pulled in the middle run the week
moves so the stiffer did the interface between the muscle in the bone the faster you can develop
forced to retire the reinforced government and so yes when we increase stiffness we're gonna
increase right first of all and that means that we're going to be maybe a step faster. And so when
you take somebody out of a group what you often see isn't there a little bit faster and it's a little bit
they have a little bit more speed because in that period where they've been inactive they've
increased the crosslinks within the 1010 and now what you've got is you've got a stiffer tendon you
can transmit the force better now you're a little bit faster but the problem happens when what you've
got during an activity is you're increasing the crosslinking the stiffness the tendon but you
decreasing the size the strength of the muscle and now what you've got is you've got a system
situation with them the tendon is stiffer than the muscle is strong and so now you go to hit the
ground and you and instead of the tendon kind of acting as a shock absorber where it stretches in
recourse to protect the muscle from having to stretch now the tendon is actually stiffer than the
muscle is strong now instead of the the 10 instruction it's actually the muscle that stretches and is
the muscle stretching was trying to contract as hard as it can that's a really high E. centric load and
that's when we see muscle ruptures or muscle pulls and so you you very very often see that what
happens when somebody gets out of a boat there step pastor they seem to be doing really well and
then what they do they pull our calf muscle because their stuff faster because there's different
attendant the Achilles tendon is there for and they pull the calf muscle because they're Kelly's gonna
step for that muscle is strong now they go in they hit the ground and that's that joint opens up and
you have to just load the killings in the gas truck in the in the soul is now what you're seeing is that
the soulless gastric complex or stretching while they're trying to contract as far as they can and
that's when you can get catastrophic injuries to the muscle do you think this speaks to what might
be coming up as athletes are entering let's say back into the sport of football date sure they have met
in a boot but if they haven't been active do you foresee a number of injuries absolutely and and
we've already seen a little bit of this as. The Bundesliga came back you had the first week in the
Bundesliga so that's the German soccer league they they basically had 8 muscle pulls in the first
week if you look at the Australian rules football right now it's all came back from being in
lockdown what you've seen is a steady increase in muscle pulls every week so now we're getting up
into that almost into the double digits for muscle pulls. Again because these guys even in Australia
where they've got really good sports science and it got you're still getting this point where you're
getting that 10 is a little bit stiffer they haven't done enough they haven't done enough like heavy
strength training so the muscle is not is not as strong as it should be you combine those 2 things
with high high velocity movement you've got the perfect storm for pulling muscles talking about
tendon stiffness it seems and I haven't looked at every single piece of research but I've I've looked at
quite a bit it seems that they talk about heavy and slow lifting resulting in a stiffness gain but as far
as I'm aware you've talked about is that you're saying the stiffness game comes from fast
movements so why do you think there's a difference of opinion that's a great question is not really a
difference of opinion it's basically a measurement issue. So we've got a lot of our stuff we've done it
in model organisms and so racks mostly and so a lot of people say this is a human rap different. It's
not really a human right difference because. But the real difference is is they were not using were
pulling on the bone and pulling on the Muslim we're watching what happens to the tent so we're
directly measuring the stiffness of the tendon what you have to do when you take a measurement in
people is you have to use alter sound and you have to use muscle contraction to load the tended to
load that that muscle tendon unit so we do a heavy strength training session or we do we train using
heavy heavy slow lifting what we're going to see is that's going to change both the stiffness in the
muscle it's going to change the rate of force development in the muscles gonna change this it's
gonna change the strength of the muscle as well as changing the stiffness of the muscles and the
tendons so now we've got to try and integrate all of these different things into a measurement where
we're taking some optical measure of the safety teller tendon and we're trying to watch how the
fascicles of the patellar tendon are moving relative to the contraction of the muscle and after doing
your heavy slow lifting your muscle is now a lot stronger and it's a lot stiffer so it can develop force
within the muscle faster and so as a muscle tendon unit what you would potentially see isn't there's
an increase in stiffness within the day unit but if you look at the muscle into the tendon were
absolutely convinced it from our database in animals and and a lot of Howard Davis translated into
humans as well as other more non non direct measures of performance we would almost guarantee
you that what's happening is the muscle and tendons getting listed on the web the best piece of
information or the best piece of data that's out there that goes together with that is if you take people
in you do only have a slow lifting. Everybody knows what's happening to performance to rate of
force development what happens you know Jake what happens when you just when you've got an
athlete who goes away and all they do is they lift heavy set up a running back the classic thing is a
running back goes away for the summer they train using heavy slow lifting they don't run they don't
spring they don't do a lot of things what what happens to their performance when they come back
they'll be slower than the slower the reinforced it only goes down every single study shows that.
And so if tennis dismisses going up you actually expect that their counter movement jumps will go
up there all of these things that you actually see go down we have a study that's coming out right
now where we've given out we've taken our football team during their 3 weeks of training. What
they did is they either had a placebo and they had dietary collagen. And we just talk about the
placebo group what you see in the placebo group is that maximal isometric force goes up and rate of
force development goes down everybody sees the same thing and that's an isometric rate of force
development so that means that it's it's just telling us that when we train have been slow we
decrease rate of force development largely because we're decreasing stiffness of the muscles and the
tendons it doesn't have to be that way simply doing our our collagen and vitamin C.
supplementation we we show that we can prevent that decrease in rate of force development
completely and so what you've got now is you've got a system where. People tell us is the same this
this is the same thing that actually comes up with aging research when we're looking at 10 and
stiffness you know all of the model we're gonna sins so in rats and mice in in in primates every
organism that's been tested as you get older you get stiffer if I look at money daughter when she
was 3 months old and she was sticking her foot in her mouth and I looked at that time and my
grandmother who is in her nineties and could barely move her foot up to tie her shoe I would say
that we get stiffer as we get older but the research looking attendance deafness actually says that our
tenants difference goes down as we get older. I can't. I can't figure out any other way to explain that
other than this is a measurement error. We're not measuring what we think we're measuring in that
situation yeah for me looking into it not being a researcher but being a straight coach the been pretty
frustrating because yeah the terminology and then hot actually measuring it is it is it an involvement
of the muscle you know so this is going to kind of circle back there's this idea in the 10 in the world
of treat the donut not the whole but I remember you with you talking about the scholastic properties
that you can affect an area of degeneration what are your thoughts on this idea of treating the donut
treating the healthy area of the tendon right so so that's that's you know that's a classic thing where
it it seems to make a lot of sense because it's it's really hard to fix a tendon problem. Well it has
been really hard because we haven't really necessarily understood what's going on. If you if you
don't understand what needs to happen in order to fix the whole. Then yes treating the donor is fine
it's not foolproof I've had one orthopedic surgeon who was performing a patellar tendon repair on
NBA athlete tell me that. Did the outside edge of the patellar tendon was black and the incident no
green in the inside part was black so so that actually had such advanced patellar tendinopathy date
yes they had a whole but also that the donor was completely was completely useless as well so it
there's this inherent. Believes that that we can we can treat that doughnut and that that's gonna make
everything better but that's really just seem we can't fix a sweet so we have to do this other thing the
reality is that that's not true what we understand what causes the whole we can actually come up
with a strategy to fix the whole and the best series of the best series of experiments that show this
are from this guy professor hai Arshi in Japan he did this beautiful set of experiments yeah I was
done and it was done in rabbits because what he did was he took the Patel but we we actually see
the same thing in human all explain that as we go what he did is he took Robinson he put he put on
a wire the connected to the telephone so the knee cap to the to the tibia and he pulled on the wire
just so enough so that the patellar tendon didn't get any load through it. And this is what's called
stress shielding we know that this happens in bone when you put when you do a knee replacement
or hip replacement as you put in a really strong piece of titanium what happens is all of the other
bone around the titanium begins to die because it doesn't feel anything alone because all of the load
goes through the strongest possible route. So when professor hi Ashley did this to the patella any
unloaded the patellar tendon he didn't touch the patellar tendon what happened to the tendon is it
suddenly got smaller collagen molecules it got about 100 fold increase in cells the collagen became
not aligned basically those are the 3 symptoms of a scar so what he was able to do by unloading the
patellar tendon was he was able to produce a scar without actually having injured the tent the tissue
at all and so what that tells us is that this this car itself is a result from this process of stress
shielding and if we can figure out a way to overcome the stress shielding we can completely reverse
the scar and the other piece of really cool information about this is is if we look at again another
model organism here and she. If you take a she she could still in embryonic sheep when you go in
and put a you put in you damage the patellar tendon he put a hole in the middle of it and then you
look after it's born after is walking right you take the patellar tendon now you can see no score at all
but if you do the exact same injury to the sheep to an adult sheep you see a big scar in the middle.
And then this really cool experiment they did so this is loosely slough skis lab and what he did was
he actually took out the the injured patellar tendon out of the out of the embryonic sheep and he put
it into an adult sheep to see whether. If you just put it into an adult environment is there some seen
circulating that causes it to not repair and what he found is that the embryonic tendon in the adult
actually repairs completely so it's not anything about the environment that we don't have that we
don't have a certain hormone is not about it seems to be about an adult tissue is stiffer than
embryonic tissue so if you don't have much stiffness in that tissue you can't shielding can stress you.
And so the result is you know for a cigar and so all we have to do really is trying to figure out ways
to overcome that stress shielding and we can now fix that score so we can you know I like to say
that I am I grew up in Canada on the Canadian. So in Canada we have these things called timbits
that are better than donuts and they're basically the doughnut hole and so maybe it's because I I
grew up in Canada and I didn't really like the don't have but I like the whole that I actually figured
that this is a great thing that we can actually fix the hole we can treat the whole and we can fix it
and we can make it back to a normal tissue getting up practical on treating the whole what's exactly
do we need to be doing. Yes it goes back to that property that you asked about before which is this
idea of visco elasticity and so this call us this the is and we all know this because if you if you
reached out to you trying to get your toes and and you get to your shins and you hold it there for
about 30 seconds and then you reach a little bit more suddenly you can reach a little bit further
because what's happened is. Tendons these viscoelastic issues if I pull on them. And I measure how
much force it takes me to pull on them and then I measure how much force it takes me to hold it in
that long position. They go what's called through through this process called stress relaxation in
during stress relaxation what happens is the load across that whole tendon decreases and it actually
decreases along way if I take a whole 10 and I pull it I can see about a 60 percent decrease in the
load from the earth from when I initially pulled it too when I measure 30 seconds later. We all kind
of know this if you ever were in gym class and you didn't wall sits because well since it is
incredibly painful thing or are you just doing is you're sitting against a wall and why is it painful
was painful because your quad tendon your patellar tendon or going through stress relaxation so
they're getting longer and in order to maintain that position your muscle has to keep shorten shorten
shortened until your muscle has to keep doing all this extra work because the tendons are relaxing
so if we take advantage of this because what I told you before is that an embryonic tendon doesn't
get this car because it's not strong and I just told you that if we pull in the hold on intended it
becomes less strong so if we combine those 2 things together and we actually go in and we hold the
contraction added pretty good angle what's going to happen is the tendon is going to relax over time
and that's it relaxes it's not going to be able to shield the injured area from the strange from that
from the tension from the low. Unless you're holding it there it is you're holding it not position
what's going to happen is the tenants gonna relax and then load is going to go through the injured
area. And the injured area has been shielded from low for so long that it didn't know the direction
that it needed to make collagen because attendant is directionally oriented collagen so as I pull and I
hold my tendons they're gonna begin to relax the can't shield the injured area now the injured area
feels the load I think also the lotus in that direction that's the direction I need to synthesize collagen
and so it starts making collagen and making it directionally oriented and because you're getting low
through that area. You've given the signal to the tissue to that scarred areas that hole which is not a
whole because it's got cells and. I'm not signaled gives the necessary information to those cells all
we need to make more collagen because now we're under the work undergoing this stretch and the
stretch is going in this direction so we need to make more collagen and given the stretch we need to
make it in this direction so now those cells all have all of the information they need. To make a
normal happy scar free and just like that embryonic tended. And so that's what we're looking to do
is we're looking to use these holes and so what we do is we look at things that have worked for 10
Opeth in the past slow heavy isometric or slow heavy you centers or slow heavy strength training.
What we always see is that word slow. And so what we did was stress relaxation is that the slowest
contraction is isometric contraction no movement of the joints at all and so if we do it as an
isometric contraction we're gonna hold it for 30 seconds because that's when we're going to get to
about 60 percent relaxation in the tendon collagen and if we were to hold it for another 2 minutes
we only get about 5 percent more relaxation so we're at the lowest point by that 30 second time
points we're gonna hold that isometric contraction for 30 seconds. And not stimulus is going to
cause stress relaxation in the strong aligned collagen and as it relaxes it's gonna provide enough of a
stimulus well as you it wouldn't be able to shield anymore because it's relaxed so much of its
strength so now that little scarred area undergoes that tension feels the tension gets the singles that
means and now it knows okay I need to synthesize a lot of collagen in this direction and now
becomes part of the actual tendon again so you're stark filling in the hole immediately from that
period do you have any clue on the amount of time someone had to do this I know you had a case
study with a basketball guy that showed after like one year up to 18 months that the whole was
cleared up on his on the MRI what do you have any idea how long this might take for someone who
might have a hole in their tenant yes so so the the quickest we've seen and again we've we've seen
people who really have positive effects on on pain scores and things like that but that can be there's
an analgesic component Tyson metrics where it's actually working on the central nervous system
and and some of the peripheral nervous system. When we actually start to see. The whole being
filled what was the pleasure of working with this discus thrower in New Zealand and he had
bilateral patellar tendinopathy for a long time it got so bad that he was the national level Jim discus
thrower but he was unable to train anymore because of the pain and so I I didn't interact with he and
his his group there and and he started doing isometric said he would do if you don't 5 days a week
because he wasn't able to train other ways and he would do the 5 days a week he he that's nutritional
components in there there that we can talk about later but what he would do is he would do kind of
all you would do is take go to LA extension machine and put the put the pin at the bottom one leg at
a time trying to push as hard as he could to lift that weight hold it for 30 seconds pushing as hard as
he could. The nice thing about this case was that he had gotten on the altar sound right before he
started. Where you can clearly see the hole in his patellar tendon. Really go on 7 weeks later and the
whole was completely gone. Not only was the whole gone but if you look at the collagen in the
patellar tendon that should that was closest to the ultrasound probe. Actually it become thicker and
more line in so this does not take months and years this can actually happen quite quickly we know
that the tissue is extremely dynamic and the collagen synthesis increases very quickly after after
exercise so Dan Morse when he was in Stu Phillips laboratory did these really nice studies where he
took muscle biopsies to look at the extracellular matrix so how much collagen synthesis happen
after you did exercise after did heavy weight lifting what he found is by 1.5 hours he had tripled the
amount of collagen synthesis it was happening in that matrix of the muscle. So there's this idea that
tendons and ligaments are really entertain shoes they don't turn over very much. And what we're
finding out is that that's completely not true there might be kind of a central core that doesn't
normally turn over simply because it doesn't feel the load but what we're finding is that if you
loaded properly you can get turnover throughout the tissue when you turn over throughout the tissue
you can get that to you and you can maintain the functionality of that tissue much much better for a
much longer time and so we've got a whole teams now that that I've had really good success about
almost completely eliminating patellar in quad tendinopathy he's from teams that have had his
historically have had rates of between 40 and 70 percent of their athletes. With patellar
tendinopathy or quad tendinopathy yeah so when we talk about loading you said he put the pan at
the bottom it always has to be a heavy load correct. The lotus just it makes it easier it makes it
easier to get the load through the discard part because the heavier load you're pushing against
remember as you're pushing really really really hard and you get straight you get stress relaxation in
order for us to get that load through that scarred area it has to feel low so if you do a light load and
you get stress relaxation you're still not going to get the kind of. Level of relaxation allows a load to
get through this car. So we use a heavy weight simply because what we think is happening there is
we think is dead after heavy load as you get stress relaxation the relaxation of the strong part goes
below the stiffness of the of the scar and it set up where the stiffness of the healthy part of the tissue
has relaxed so much that this car is actually stay for the rest of the tissue then that's when the
scarred the cells within the scar begin to feel that tension and that's the tension signal that we need
to get them. If you don't have a damaged tendon and you're just looking to keep a tenant healthy
you don't need as much weight we can do I. Symmetrix at the side of the field where you just push
against you just push against something that's you know again you can push down into the ground
we've got exercises a lot of people used to Copenhagen for the growing to decrease growing strains
those things are gonna affect on the muscle into the tendon stiffness without really having to lift
huge amounts of weight so it depends on what you're doing as to how much load needs to go
through the system if you're trying to fix a tissue that is is telepathic yeah it helps to go with as
much load as you can go what do you stand with the Spanish squad exercise for 8 talked up the
okay so Spanish one is fine it's it's a good way to do it again it's not gonna be a heavy load so it's not
going to be as effective as it would be at patellar tendinopathy as it would be for other things the
way the place we really use the Spanish what is if you've got athletes and you're like oh we've got a
lot of hamstring pulls let's do so Nordics well if you're gonna do Nordics you better do escape
Spanish squad because if you don't what you gonna do is you're gonna have stiffness differentials
between the the hamstrings and quads which are going to accelerate ACL ruptures what you saw a
number of years ago now it's about 5 years ago now everybody started doing Nordic stood to
decrease hamstring pulls hamstring pulls went down and then what happened ACL ruptures went up
because the forgotten co contraction of the quad and hamstring is essential for stabilizing the knee.
Now what you have is you have all of these exercises to decrease stiffness within the hamstrings but
you haven't done anything for the quad now you're quite a stiffer so the rate of force development
quite as faster so now you go to jump in you go to land and now your quad contracts faster than
your hamstring and that accentuates the the the entire door mechanism for Tracy rupture and so you
saw that quite clearly in European football for example everybody was doing Nordiques yeah
hamstring pulls are down great ACL ruptures are way up I'd rather have a hamstring pull an ACL
rupture. So if you're gonna do something like a Nordic you better do something like a Spanish what
to make sure that you still have that balance between the 2 between the 2 antagonistic muscles that's
interesting it seems like the whole the whole world talks what hamstrings ratio of prevention but I
never thought that way so in that sense you in the study I forget actions and maybe we're talking
about the 30 second holes in them the records and whatnot you had talked about it doesn't matter
how long the stretches it doesn't matter how much it is for the adaptation of the tendon let's talk
about the patellar tendon if we wanna get estimates on the top 10 and does it matter if we're going
like let's say a sissy squat where like you're on your toes and you just pushing the needs super far
forward or doing a squat with a vertical tibia does the stimulus on the patellar tendon change much
between those exercises. It will change and again it's it's whether whether that's going to be enough
to see a difference I don't know yet so I can tell you that we've I've got a PhD student and she's a
former pole vaulter here at Davis and and so she's an NC double a athlete who had a lot of tendon
problems and so so now this is the focus of her PhD and what she's doing is she's actually creating
the patellar tendinopathy in rats. And what she's actually going to do is she's actually going to tell
me and tell you and all of us what whether the joint angle that we are exercising it makes a
difference so what what she's already done which is really important for this idea of the donor the
whole is she's done an experiment and we've submitted the paper now and so what she did is she
created the patellar tendinopathy we came back 14 days later when we had a good scar in that in
that patellar tendon and then she did either for isometric so for 30 seconds to metrics with
contracting the quad maximally or she did the exact same time under tension the exact same
exercise duration but using a more dynamic contractions who was at a point 3 second long was a
third of a second long contraction and she just to to get the same amount of time and attention she
did 360 instead of doing for 30 seconds what we do is we take out the injured patellar tendon and
we can look at the gene expression within the scar and what you see is that when you do the 430
second isometric the genes that are associated with tendon development so there's a famous tendon
development gene called score axis and gene goes up about 2 fold in the ones that do the isometric
contraction and it doesn't change maybe goes down slightly in the in that wants to do that dynamic
contractions. And then if we look at college one you see this tendency for the genes for college you
want to go up in the isometric. But the interesting thing did she saw was the collagen to gene
expression so that's what you find in cartilage it actually goes up when you do the dynamic loading
and it goes down when you do the isometric loading and collagen to saying that it's cartilage so how
would you get this well again remembers I talked about we're putting a hole in the center of a
patellar tendon so I was like pulling a patellar tendon it's going to do what we talked about earlier
which is radial compression and is it compresses in if there's no attention being felt where we put
the whole. It's still going to feel the compression it is feeling more compression and tension it thinks
it's cartilage so it makes more type 2 collagen and so what we find is if we do dynamic loading so
for running jumping doing these types of things. It's exactly what you'd expect is it we actually
make the problem worse. We actually increased the expression of genes like collagen to which
cartilage like jeans other cartilage like teams are gonna be increased as well like the ones that are
holding the water in the tissue and now we're gonna do is we're gonna develop what's called a
central core tendinopathy and that central core 10 up as he is is what you see a lot of jumpers as
jumper's knee and that's when we get. More compression on the center part of the patellar tendon
we do get tension because the whole doesn't feel tension but it still feels compression and that's
where the problem was classically that led to the idea of treat the doughnut hole because as you
treat the doughnut you can make that part stronger but if you're treating it was dynamic movements
you're making the whole bigger because you're still you're increasing the compressive force in this
car and that's going to make the whole worse and worse and so. That's where we get to this point
where understanding how we're doing the loading is going to be absolutely essential to fixing that
problem and so so not looking at that gene expression study. That's her first study as I said the next
thing she's going to do is tell us whether the joint angle makes a difference so if I do it with us if I
do my isometric leg extension with my with my legs straight with my late 90 degrees of Miley get
60 degrees is one of those positions better how many contractions should I do should I do one
contraction is that enough or do I need to do do I need to do 8 to 10 contractions so she's going to
actually go through in and trying to get a prescription for reversing tendinopathy using the gene
expression within the tendon the injured part of the tendon as the marker that she's trying to
optimize them when she optimizes this developmental phenotype within this car. Then when she's
gonna be able to do is she's gonna be able to say okay this looks like the best way to exercise and
then she's gonna test that in a separate group of animals where she's gonna make the holes she's
gonna test the best loading protocol the worst loading protocol and she's gonna have a control group
that doesn't load and she's gonna see over time what happens to the mechanics of the tissue and
what happens to how the tissue looks what whether it's telepathic or whether it's completely normal
for now we've got some insight we've got some some things that we've done that just anecdotal but
that are suggestive that of greater joint tangle might be might be beneficial but at this point we don't
know so our our our discus thrower was obviously using a really a really flexed joint angle of the
knee so he was probably more like 60 degrees when he was doing it so that's a really big joint angle
and so it's possible that that is having a benefit simply because you're starting with a longer tendon
as you go through through stress relaxation you're gonna get more load through the scar from a
longer position in a shorter position that's the idea at least when you you're talking about the the fast
movements being basically bad for tendon 80 pretending they're bad for attendant has an injury
yeah yeah that's what yeah if we're talking the isometric are on the far other and what about the
heavy slow resistance could that possibly be doing that's a similar thing or would it only really be
benefit to the normal healthy tissue. I think it's gonna be it's definitely doing something that's going
to be positive we've seen Michael cares done some beautiful work where he looks at heavy strength
training versus versus versus say any centric protocol that says slowly centric so the outfits and
style protocol and what he sees is that the heavy strength training is is really good again we know
from looking at meta analyses on on musculoskeletal injury rate they didn't if you do have a
strength training it decreases injury rate by about 2 thirds musculoskeletal injury by 2 thirds and if
you go back to it it makes sense because when we say we're gonna gonna do heavy strength training
we're gonna make the muscles stronger we're gonna make the muscle stiffer we're gonna make the
muscle and tendon a little less than. And now the tendon is no longer stiffer than the muscle is
strong so that system is going to work a lot better than one we're doing short fast movements the
pending it's different the muscle doesn't have enough of a load on it to get bigger and stronger and
so now you're getting again this we see this all the time as we get build up to the world
championships Olympic Games for sprinters they know that the faster they move the greater the
rate of force development dubbed that's going to help them with their sprinting so they start
decreasing their heavy loading because I don't want to decrease rate of force development and they
start doing lots of lots and lots of extra sprint team and and. The result is that you see in the men's
into them the men's 600 meters you see lots and lots of hamstring pulls because they've just gone a
little too far they've gotten their tendon a little bit stiffer than their muscle is strong because by
loading with a low load they haven't kept the muscle strength. By loading with a high velocity
they've increased the stiffness of the tendon and now. What you've got is a stiffer 10 in the loss was
strong and that's when you get that hamstring rupture so the heavy strength training is wonderful for
health of the musculoskeletal system is gonna make your muscles stronger can make a little stiffer
muscle impending gets a little bit less than. But if that's all you're doing your performance if you
only do that for a long period of time your performance will go down because you're in for stone
will decrease. That's why it's important to integrate strength training into your on on field or on on
court practice. As the on field on court has all the plan that you're quoting that you need and then
you come into the gym and part of what you do in the gym is you trying to maintain health. The
number one thing that I did as a strength coach. Was my job was to get a healthy athlete on the
field. It wasn't to maximize the performance of the athlete in I don't know a swimsuit competition or
a high jump it was to get healthy athlete on the field and if I did that using heavy strength training
what what what I would see is I would see that their entry rate decreased their muscles killed their
non contact muscle pulls would go down significantly and so so that's where you can easily. Use
heavy strength training as a way to get it's a kind of positive effect on the tenant maybe not quite as
good as an isometric but it's gonna be really good and it's got a great effect on also as well so that
must feels that muscle tendon unit is now gonna be stronger throughout the whole range of motion
so in that one study you were talking about the tendon basically stops adapting after 10 minutes so
let's say for example someone goes to basketball practice for 60 minutes what will be the points at
the tenant level to doing like an isometric session at the end of that would there be any point at all.
So it wouldn't be we wouldn't use it as a as an adaptation section we would be so if we're gonna be
doing if you've got practice if you got basketball practice in in your installation your basketball
practice 3:00 in the afternoon. We wouldn't go at 5:00 in the afternoon and try and do some
isometric loading for you we would do probably would. If you're if you're playing football we
would because what you've done is you've increased the plyometric load over the over the practice
now what I'm gonna do is I'm just gonna do it but I'm gonna do it for muscle health not for tenant
health. And it's not designed to give a stimulus to the cells within the tendon is designed to decrease
the stiffness if you build up any stiffness of the my tennis junction so you can either do. Yeah
isometric after you do it or just one heavy heavy like press if you just want to target the legs and
you would actually see that you're you would decrease the long term muscle injury you would
actually decrease their the feeling of heavy legs in the first few weeks they come back. So what I
would do in that situation if I was practicing I had an athlete was a basketball player volleyball
player will give so you see we've got a women's volleyball player who's practicing every day at
3:00 in the afternoon she's got chronic patellar tendinopathy. What I would do is that I would have
read it a clock in the morning. Do you are loading system are isometric loading for patellar
tendinopathy. As we've got data from 10 then there's also a beautiful data from bone and other
tissues they show that unlike muscle the connective tissues only have a short period where they
need a short period of activity to get a signal that okay we've we've been active and we need to
adapt. And it takes about 8:00 hours before they get another they can handle another signal so so if
I've got that athlete who's got a practice at 3 I'm gonna count backing is say okay that's new that's
gonna give me 3:00 hours and then 5:00 hours before that or th so we're looking at 6 to 6 to 8:00
hours so I can go with 3 to 4:00 hours before noon that's when I want to do my isometric loading
session and I'm gonna do that isometric loading session and it's gonna be a short session it's going to
be done in less than less than 10 minutes and it's really gonna be targeted at. The patellar tendon
into do all the things we talk about you stress relaxation get the load through the 10 and then an
hour before that I would have given her some sort of hydrolyzed collagen together with with
vitamin C.. An hour before that is the timing for that because by or 30 minutes to 60 minutes before
she's gonna do that session that's when I want to have to call you because you can digest and absorb
all those amino acids and those amino acids are gonna peak between 40 minutes at around 40
minutes to 60 minutes after you take the collagen supplement into now those things are circulating
around now I'm gonna do my isometric loading protocol my patellar tendon while I'm doing that the
whole environment around my patellar tendon all the fluid around it is rich in all of the amino acids
that I need to synthesize collagen specifically glycine and proline and so now as I'm doing my S.
metric loading I'm giving the signal to my to that's the cells within the scar that they need to
synthesize correct direction oriented collagen and I'm giving them all of the amino acids they need
to synthesize collagen and so together it that's giving us a stimulus that's gonna actually according
to an Australian study that looked at runners who had who did loading alone with a placebo or
loading together with hydrolyzed collagen what they found is the runners return to play twice as
twice as fast if they took the hydrolyzed collagen it was a double blind crossover study as well so so
in the first half of the study. One group is on the CBOE and the other groups on college and you
saw that twice as many individuals on the collagen group got back to running then they did the
crossover where now that the placebo group is taking collagen collagen groups taking placebo and
still when they did the switch over still the collagen group had twice as many people going back to
running so there does look like the collagen is having some effect we don't know exactly what it's
doing it but it does seem to be having an effect that is supporting what we're doing with our loading
and so providing that to stimulate together is going to give us exactly what we need to try to
maximize the positive adaptation and the and the and really just to fix that hole within the patellar
tendon doesn't matter what type of calls into that and make them aware they sell like I don't know
type one type 2 type 3 doesn't it doesn't matter what type of calls and we're consuming absolutely
not so so it would matter if you took in the collagen as a whole molecule when you used it to sent
you just packed it in to to the tendon or the cartilage or whatever but what you're doing is you're
digesting it down to 2 amino acids and peptides in the gut so it doesn't matter if it's take to college
and you start with type one collagen or you know collision 22 if you wanted to be you know
extreme and and try to find trying to find the smallest bit of college you could. It doesn't seem to
matter in the end we haven't seen any difference between the different brands it just all it is is it's
providing substrate because what we think is that when you you know because we all had appeared
of time where we had these pains associated with growing people call growth growth growing pains
or whatever and they're always at like the end pieces so that they can actually between the bone and
the tendon or within the tendons are and what we think is happening at that time as the glycine is
becoming a conditionally essential amino acids if you don't have enough lysine and you have this
huge stimulus for adaptation within the matrix but you don't have enough substrate because every
third amino acid in collagen is glazing. If you eat milk protein you don't actually see an increase in
glycine you'd actually see a decrease in glycine after exercise with no protein so it doesn't look like
there's this potential for the glazing content of the collagen to be come something that allows the
tendon cells to use to produce more collagen. Even though glycine normally is not an essential
amino acid there are situations where we we do think it becomes a conditionally essential amino
Watson keep if you want to tell people where they can find you anything else go ahead. No I'm I'm
happy for people to to to reach out to me the easiest way is is through Twitter I have muscle
sciences my Twitter name right I got in very early not because I was actually doing any anything
with the with the with Twitter at the time I was just had to do it because for my logo that was the
only way that I can reach the artist who who did the logo that I use so I got in like you know almost
12 years ago something like that I'm so I got a really good handle so I'm out muscle science on
relatively easy to find there and people can can shoot me a message is there asking questions and
that's probably the easiest thing to do and I do use that as a way to kind of highlight different
research that I think is an interesting and exciting and talk about different things that are within the
science area that that I think are really important cool our kids thanks for being on yeah no worries.