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See MintMobile for details. Welcome back to the Barbell Medicine podcast where we bring modern medicine to strengthen conditioning and strengthen conditioning and modern medicine. I'm your host, Dr. Jordan Fygenbaum joined by the second most handsome doctor in North America. Today, we're going to be talking about high intensity interval training. I guess I should also actually remember to mention your name as the second most handsome doctor in North America, Dr. Austin Barocky.
What's going on, man? I mean, it is just an honorific that now I think people clearly associate with only me. So maybe you don't need to mention the name. People just know who you're talking about now. People just know. Also, people assume that I consider myself number one. It's just like all that does is speak to the new audience that we've garnered because they aren't privy to the insider joke that was out of the bag long time ago, hundreds of episodes ago. But I am not number one.
Clearly, clearly, I don't think poorly of myself, but just as far as like number one, that's not me. So anyway, if you know, if you get that joke, if you get that reference, hey, man, we're really excited to still have you listening to the Barbell Medicine podcast. But again, can confirm I'm not number one. We've got an interesting podcast today. And again, we normally split up something like the mystery case. We're going to do one of those. We got quack watch.
We also are going to talk about high intensity interval training because it pertains to the quack watch segment. And so that's going to be fun. Also, some new research has emerged. So we're going to get into that. But before we do, Dr. Barock, any sort of life updates, anything going on on your side of the of the country? We recently got back from a brief trip to Mexico City. My first time there had a good time exploring that city.
And then back in the hospital, I handled 15 inpatients this morning after a pretty busy call shift over the past day. Saw some interesting cases. Did some good work and then managed to squeeze in a training session. And now here we are. Nice. Yes, I also returned from a trip. I have beaten jet lag. So no longer that is not a problem for me anymore. The trip to Paris and France was excellent. Save for and this, this may be a hot take. This actually may get me into trouble.
I don't think that French food is like, it's worth the hype. Because I don't know maybe I made up this hype in my brain that like Parisian food or French cuisine in general was like, you know, day record. Like I was going to love it. Or I should like, it's an aspirational goal to go to France and have the French cuisine. I'm convinced that people in France do not eat food. I'm convinced I think they smoke cigarettes and drink wine and they just don't eat.
And I just, look, if you're listening to this and you are, you do live in France or you are French, I'm not meaning this in any sort of derogatory way. Like great. I love your country. I love your culture. The food on the other hand, save for your pastries. I think I'm out. Like I just, like how much pigeon can one man have? I like lifetime quota of snails. I took down, you know, I'm just, I'm all set. All right. I mean, that is a take you can have. That's a take.
Look, when I landed into JFK, you know, you ever feel, because I'm sure you've had this, especially in residency and maybe even sometimes like in the hospital or whatever, you're like, I can feel myself much lighter than I normally am, right? So I lost seven pounds over there. I didn't know that at the time, but when I landed in New York, I go, I'm light and hungry. There's only one way I can, I can play it myself. I need to go to Shake Shack.
I went to Shake Shack, Burger, Fries, Shake, Aided, all of it, cleaned it. And then I was like, I need a second burger. That's, I mean, and I don't think that that is in my normal wheelhouse as far as food consumption, but I needed that to get back up to some level of satiety that I was comfortable with, especially if I was going to fly back to San Diego. But anyway, that's probably all the people want to know about my Parisian experience.
Other sort of announcements that we have, Barbell Mason Plus, we have no announce that a few weeks ago, and it's going strong. We're uploading summaries and podcasts, actually early access to our podcasts, ad-free, existing to our podcasts, in addition to transcripts and some other exclusive content. So if you want to be a Barbell medicine Plus member, that you can look that up on our websites, also linked in the description below.
We also, I did this while I was in France, released a brand new template, Power Building 1 Generation 2. And I know what people are thinking, they're like, well, didn't you guys already have like a Power Building 1 template? Yes, we did. It was a three day version. It couldn't pick your own exercises.
And the reason why I selected that originally, it's because my thought was in the like lifetime of a train, you know, career of a trainee, if you're doing, you know, an entry level template, I don't know if you have enough experience at that point to pick your own exercises. And so the idea was, well, I'll do it for you. I've done some tweaks, I've done some modification of our template offerings, and I figured out a way to make that work where people can pick their own exercises.
In addition to giving people not just a three day version of the template, but also a two day and four day versions of the template. It's also got brand new programming that I think is a little bit better suited to folks who will be in that sort of that market for a for an entry level or like their first four day into Power Building. And additionally, kind of rewrote the entire company in text. It's very specific now to this new template. So it's a completely new sort of template offering.
And yeah, it is up on the websites on our app as well. So you can pick that up if you are interested. All right, well, let's pop into the mystery case here. Dr. Baraki, as is my custom, I have to predict whether or not you are going to identify the correct diagnosis. And you know, I was thinking about this the other day, it's going to be really hard for you to get one of these cases completely wrong.
And one, that's a testament to your sort of workflow, you know, and how you think about these things, you got systems large to small like how could anything possibly produce these symptoms and you kind of consider every different system. So it's going to be tough for you to like arrive at the wrong system. However, if there was a case where you were going to arrive at the wrong system and completely miss the diagnosis, I think this one is it.
And I've intentionally selected one that I think is going to challenge you. So let's get into it. That means this might be a good opportunity for me to learn some things. Let's go. Yeah, let's go. All right, here we go. It's a 19 year old male presents to the emergency department with the three day history of worsening left arm pain. Three days ago, the patient was doing biceps curls when his left arm became painful mid rep and he immediately stopped doing curls and went home due to pain.
He says that the arm has remained sore for the last couple of days. But the reason he came to the emergency department was because he thinks he felt a sudden tearing in the middle of his biceps when he was closing a drawer at home. He has pain and swelling in the left arm at rest, which is made worse with movement. He denies any other symptoms in his time. He has no chronic medical conditions and does not take any medications.
He also has no surgical history and denies use of supplements or recreational drugs. Of note, his mom reports that earlier in life at age five, he was diagnosed with a quote overgrowth of cartilage near the growth plate in his left arm, but it was minor and asymptomatic and no care was rendered further. All right. So before we go any further on the case report, Austin, do you have any thoughts on this particular patient?
Sure. So a 19 year old male with unclear, not any like glaring medical history that you gave me aside from whatever that congenital concern was, which I don't know much about at the moment. Coming in with acute sudden onset left arm pain during exertion. And I suspect that even some members of the audience who have listened to a bunch of these cases where we've had kind of extremity pain come up as a relatively frequent concern in some of these cases.
So I think that we'll be ready for this breakdown of thinking about kind of like the structural compartments of the limb. And so I think about the muscles and soft tissues as one component, the bones or the osteoarticular component as a second compartment, the vascular compartment as a third, and then the nerves as a fourth.
And so those are the big four kind of sets of structures that I think about when there's something going on in an extremity before I kind of move more proximally to think about more systemic causes and issues. And so in this situation, we have kind of acute pain that onset during exertion, the sensation of tearing. I'm not really at this point ready to start thinking of super rare esoteric diagnoses until I have a reason to pull me in a different direction.
I'm most concerned about a muscle or a soft tissue type injury, especially with that acute pain and then some swelling. That would be characteristic of something like that. Of course, in the back of my mind, I'm wondering is there's some reason, some predisposition to this? Was it purely due to the fact that he was doing some curls, maybe under fatigue, the eccentric loading, maybe more than he was ready for?
Or was there some structural kind of vulnerability or predisposition, either in his muscles and his soft tissues? Apparently, maybe something wrong with his bones that could have predisposed this. I'm not getting the sense at the moment that this is very likely to be a primary vascular problem, like a blood clot that we've dealt with before or a vascular dissection or something like that.
Or, nor am I strongly entertaining the possibility of a nerve related issue causing extremity pain, like a ridiculous pain syndrome or a neuropathy that onset suddenly or something like that, because that doesn't really make a ton of sense. So at the moment, my preliminary evaluation would be just doing an exam in the area, consideration of whether there is any signs that would merit or justify me pursuing additional evaluation to include lab studies or imaging, which their may or may not be.
And at the moment, I'm most concerned about a soft tissue injury or a severe muscle strain, perhaps a muscle tear, something like that with some consequence swelling afterwards. All right. Well, let's get to examining this patient's arm. So on physical exam, in the emergency department, a focused, musculoskeletal exam was performed on the left arm. It was significant for a very swollen and bruised left arm, predominantly in the mid-brake arm. So that's like where your biceps is.
Also the antacubital fossa, which is a fancy way of saying the crook of your elbow, like if you were going to get an IV started or blood drawn, for example. And then also the forearm, which is also, they're all very tender to palpation, particularly the mid-brakeum. He is able to flex and extend the elbow, as well as supinate and pronate the forearm with some pain.
Strength is diminished, left compared to right, with your senior resident giving it a rating of 3 plus out of 5 for supination and elbow flexion. With elbow flexion, there's a notable soft bulge mid biceps. Strength and range of motion of the intrinsic muscles of the hand, and also the extrinsic muscles. Sorry. Strength and range of motion of the intrinsic muscles of the hand are normal, and capillary refill in the hand is also normal. Sensory exam of the left upper extremity is unremarkable.
It also got an x-ray performed in the emergency room of the left upper extremity. It showed thickening around the epiphysis. That's the growth plate of the humorous, but is otherwise unremarkable. So now, before we go any further, Dr. Baraki, any thoughts on this particular patient? Yeah, most of this is kind of what we expected based on the history. There's not a ton of reason to deviate in a different direction based on what we have here so far.
I mean, we have this kind of focal or like a pinpoint area where the injury happens. Some expected consequence swelling and bruising, as you might expect after something like a muscle tear with some bleeding and edema into the area. The strength exam is suggestive of a biceps injury, which again, we could tell by history since this happened during curls and is having difficulty with supination and elbow flexion both of which are actions of the biceps break. Yeah, hands are fine.
The rest of his vascular neurovascular exam is fine. The other arm is fine. And then on the imaging, whatever this thickening of the epiphysis is, maybe related to what was described in the pediatric situation. I mean, when I think about bony overgrowth, cartilaginous overgrowth, things like that, especially if he was a child and he's now 19, it does, it seems like it would be unlikely to be something malignant growth or a cancerous growth going on for, you know, 15 years.
And so there are benign, you know, proliferations of cartilage like incandromas and osteocondromas and things like that that I don't really tend to see or deal with very much in the older adult population, but that the presence or absence of that at this point in time isn't really factoring a ton into my diagnostic thought process as far as this acute injury goes.
So yeah, the patient was diagnosed with a biceps tendon rupture placed in a sling and discharge home told to follow up with orthopedic surgery. Two days later, he did follow up in the orthopedic surgery clinic. And on exam there, the patient still had weakness of the left arm and it was still swollen although the neurological and vascular exam remained normal. They did an MRI of his left arm and it showed that there was a hematoma between the brachialis and biceps brachy muscles.
There was also a large tear within the biceps muscle itself that was noted directly over the area of thickened cartilage. He was given a compression wrap and a sling for comfort and sent home. One week later, the patient suddenly developed excruciating pain in the posterior elbow and anterior forearm that was associated with numbness and tenderness, particularly in the forearm and hand, along with weakness in the flexor muscles of the hand.
Repeat MRI of the left upper extremity was performed and it demonstrated a mass with a ring around it at the level of the thickened cartilage that was previously noted which, or though, now called an osteocondroma. Ultrasound and angiogram were performed showing blood flow out of the brachial artery into the mass which measured about 3 by 3 by 3 and a half centimeters which was adjacent to the now osteocondroma.
Unfortunately, that's all the information that you get about this patient before you have to come up with a diagnosis and tell us why this whole thing happened. Again, I told you I really thought I had to go into the weeds to figure out a way to get you thinking about the wrong system. This is what I came up with. Nice job. Going into the world of benign pediatric bony tumors is definitely not an area of strength for me. If I can do the best that I can here.
This individual has seemingly a long history of some sort of overgrowth around the growth plate that may or may not actually be an osteocondroma. That structural defect, if we can call it that, I can envision a way in which that might predispose his muscles to tear if there is strain applied across the muscle in a particular way, maybe when it's compressed or stretched across that bony overgrowth that would not otherwise normally be there.
Perhaps that can predispose to a tear and the hematoma and that might explain his initial presentation. It sounds like for the first half of this, we were on track with the diagnosis and what he presented with and what that preliminary diagnosis was for his biceps injury and the consequent hematoma. The second part with now consequent pain in the forearm and the posterior elbow is definitely unusual and a little bit harder to explain.
If I'm understanding correctly, they repeated his imaging and he had an angiography, which is interesting. He had blood flow into some kind of a structure that was adjacent to the cartilaginous overgrowth that was being called an osteocondroma. Is that right? Yes. Effectively, if you were looking at it, you'd see this bony overgrowth.
You'd see the torn muscle and you'd see the artery, the brachial artery, and then out of that is where this new structure is that's round and about three by three by three that has blood flow flowing into it from this brachial artery. Interesting. So he's getting a bunch of nerve-related symptoms as you can tell weakness and sense. Okay. Interesting. I'm going to try to, I don't know, use my knowledge of other areas of the body where other things can sometimes happen in an analogous fashion.
So there are situations from a vascular standpoint, for example, where patients can develop vascular kind of malformations and those malformations, like what you seem to be describing here, blood flow into a structure that's enlarging and now compressing on other things. When those happen very slowly and gradually, you can have an aneurysm. That's something that can form in a vascular structure. But those don't typically form suddenly.
There are analogs or cousins of this that can form in a much more short term fashion called pseudoaneurysms. And we sometimes see those in other contexts. I see it sometimes in cardiac patients undergoing heart catheterization and certain other kinds of procedures.
And so I'm wondering whether because of the flow into this structure, because it's too quick for it to be an actual new solid mass, like a new solid tumor that develops over the course of a few days that wasn't seen on the previous MRI. But a vascular development like a pseudoaneurysm or something like that can happen.
And so I'm wondering whether this just accumulating mass effect, the mass, the hematoma, potentially something like a pseudoaneurysm in the area, all of which is leading to maybe compression on the nerves that then feed his forearm and his hand, leading to worsening pain. He almost has like an acute compressive neuropathy of his forearm, leading to pain and weakness as a result of this vascular complication adjacent to his prior benign bone tumor.
That's probably about as good as I can do because again, pediatric benign, bony, overgrowth and cartilage is I do not know very much about it all. You know, I have to hand it to you. I did think that this I finally did it. But you said all the right words. And I think that I have to give you full credit for this.
So the patient was diagnosed with an osteocondroma that subsequently weakened and punctured the wall of the brachial artery in the left arm causing a pseudoaneurysm that mimicked biceps tendon rupture. Wow. He subsequently underwent surgery to remove the pseudoaneurysm and repair the brachial artery, along with removing the osteocondroma that actually had a sharp triangular point to it.
The case report at this point said that when the surgeon's palpated the osteocondroma intraoperatively, it actually cut the surgical glove. That's how sharp it was. Patient subsequently did well with pain relief, sensory function and strength recovery that was fully back to normal in one year. This podcast is sponsored by NCOGNI. Anyone who has been on the internet knows that online privacy and data protection is a big problem.
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Paid non-client endorsement, compensation provides incentive to positively promote Acorns, investing in involves risk, Acorns advisors LLC, an SEC registered investment advisor, view important disclosures at acorns.com slash BBM. So when I read this case report, I'm like, pseudo-annurism, osteocondroma, mimicking biceps, pen and rupture, I got him. Game over.
And then you just bingo carted your way to the diagnosis and I don't know what I'm going to have to go even more, you know, I'm going to have to reach even further into weird stuff to I think that has to be associated with exercise. That's the problem. If I went into like, you know, un stuff unrelated to exercise or activity or muscles, I, you know, I'm sure I could find something. But this was, yeah, I had higher hopes.
Well, really interesting educational case because I still would say that I learned some stuff because this is not something that I've ever seen or thought about. I feel like I kind of got there by way of reasoning using like analogs that I see in other parts of the body, I suppose. And so like, you know, a pseudo-annurism complicating somebody who has like vascular access for heart catheterization or something like that or other types of vascular access is like a known thing.
I'm trying to think of like what sudden thing can cause a vessel to do that because it has to be vascular since there's blood flow into it. And it wasn't there, you know, a couple days ago. And that's that's kind of the way that I ended up getting there, I suppose. But yes, I am impressed by this case that is very, very challenging, enjoyed doing that.
And so yeah, I guess the only other point of feedback is you can open it up to the audience and see, do they want you to limit all of your cases to exercise stuff or do we want to do what we want to get weirder and broader. But yeah, that was a great one, very, very challenging outside of my scope. And I had to stretch quite a bit to get there.
Yeah, well, let's talk a little bit about pseudo-annurisms and osteocondromes and also biceps tendon rupture because I, the latter ones obviously related to exercise, particularly resistance training as most of our audience is interested in. But the pseudo-annurism and osteocondromus stuff, that's opportunity for education, I think for not only both of us, but certainly most of our non-ortho, non-vascular related audience members. So let's start with pseudo-annurism.
And I think you described it perfectly. You're like, oh, it's not a true aneurysm, right, which includes the, you know, of the vessel itself. It's kind of like a brother or cousin to it. So pseudo-annurism is, you know, typically referred to as like a false aneurysm. It occurs usually at the site of an arterial injury can be from trauma, could be from an infection and sometimes as a result of medical treatment, so eye atrogenic sort of causes.
In the case of a break-yield artery, pseudo-annurism, so break-yield artery is the one in the upper extremity. It is admittedly rare. The most common eye atrogenic or medical treatment related cause would be like dialysis access, for example. We're also like surgical fixation of a fracture or similar as a few case reports on like humeral fixation, you know, people who fracture their humerus and then subsequently develop a pseudo-annurism around some of the hardware that was placed in there.
It can also happen with IV drug use, but unlike true aneurysms, which the blood vessel wall balloons out to various degrees, a pseudo-annurism does not involve the vascular wall. Instead, blood's like leaking out of this injured vessel, a punctured vessel and is contained by a wall that's basically from the clotting cascade factors. So you have like a, it's like a false wall, so just pseudo-annurism.
Resumes of pseudo-annurisms are related to the mass effect of the sort of blood collection, pressing on things like nerves, vessels, muscles, etc. They can subsequently cause nerve-related symptoms and swelling as an R patient, as well as both bleeding and clots that can affect function of the limb and will put it at risk for like, you know, limb survival. So sometimes if it gets really bad, they'll have to actually amputate due to the effect of the pseudo-annurism.
Typically, repair to surgery, usually requiring graphs, but that's well beyond our particular podcast. That's kind of the story on pseudo-annurism. Moving on to osteocondroma. This is the most common type of benign bone tumor, comprising about 30% of them. As you said, most common in pediatric patients and it kind of regresses later on, not regresses, but sort of matures and doesn't cause issues later on.
It's the result of abnormal outgrowth, an abnormal outgrowth of the surface of the bone, usually starting as a cartilage-capped bone-bonus burr, which can mature or ossify into a sharp rigid projection in the case of our patient, which likely weakened the wall of the brachial artery. I mean, if you think something sharp enough to puncture a surgical glove, this is just terrible luck all around for this case. Yeah, your brachial artery doesn't stand a chance.
It's actually a wonder to me that if it was in fact that sharp always, that this was like the first time, you know, we had a problem from it. So osteocondromas occur spontaneously, typically during childhood, as Dr. Baroque mentioned, as in this patient, usually around the knee or the proximal humerus, and generally stop growing when the growth plates are closed.
They may be palpable, though they are often painless unless they are sharp or large, and subsequently harmed nearby tissues like our patient. Most require no treatment, though if they're large or cause symptoms, surgical exitions, typically the treatment. There's a small risk of transformation of osteocondromas into a malignant tumor, known as a condrus arcoma, which is often signaled by a change in the size of the mass after the somebody's matured.
Yeah. Yeah. Lastly, we're going to talk about biceps tendon rupture. And honestly, this probably does deserve its own podcast topic, because I spent way too much looking at this. And there's some interesting stuff in there that I can't relate on this particular case report. So maybe we will do a full podcast on it. But when you think about the biceps, it's always biceps, by the way. You're never just training a bicep. It's always biceps.
I look, the anatomy nerd within me, I don't want to be that person, but I made this mistake. And now anyone else that makes this mistake, you have to say biceps with the S. You also always also have to say triceps, for example. But anyway, the biceps break out muscle has a short and a long head, both originating from different spots on the scapula. The short head originates from the coracoid process. That's the bird's beak looking thing on the scapula.
Whereas the long head originates from the super glenoid tubercle. The glenoid fossa is basically your shoulder, the bone ball and socket. So above that super glenoid is where the long head comes from and the superior laborum of the shoulder joint. That's where it starts. Now, the distal biceps tendon attaches to the bicepital tuberosity of the radius. That's a bone in your forearm. And the biceps tendon is a pretty strong supinator of the forearm.
And it serves to, it serves as a weak elbow flexor. So it is interesting that people do biceps curls all the time, just elbow flexion to like training the biceps, which you certainly are to be clear. But you're also training the brachialis a whole bunch. So that supination component is pretty important, which is why supinating your hands to train the biceps curl while doing curls is pretty important there. The long head of the biceps also contributes to the stability of the glenohumeral joint.
It's a fancy way of saying shoulder joint. The majority of the biceps tendon ruptures involve the long head, okay? Proximal rupture. So up by the shoulder can't often be treated conservatively. But without surgery, it's often correlated with rotator cuff issues and is more common in older individuals. Again, that's the most common type of biceps tendon rupture. Distilled biceps tendon rupture from the forearm is typically a complete avulgin.
That means it basically ripping bone away with the tendon or a partial detachment from the radius. Again, it's in the forearm. It usually needs surgery for correction. It's more common in younger individuals. When the long head of the biceps tendon rupture is proximally so by the shoulder, it can produce what's known as a pop-eye deformity.
Effectively, the muscle moves down into the arm and you see this clearly demarcated or delineated muscle belly and it looks like pop-eye, the cartoon character. On the other hand, if the distal biceps tendon ruptures, the muscle belly retracts upwards and they call that just as you would predict a reverse pop-eye deformity. This assumes that people know who pop-eye is and then reverse pop-eye doesn't mean anything. The point medical students are going to be too young.
They're not going to know who pop-eye is. Probably already there, honestly. Will it be like a sea bum deformity? Will it be like a Ronnie Coleman deformity? What are we going to do here? The most common way of rupturing the distal biceps tendon is due to applied forces on the biceps while it's lengthening, typically during weight lifting with elbow flexion or abrupt elbow extension otherwise. Sometimes people see this deadlifting, tire flipping, strong man also in arm wrestling.
As far as how often this happens, the incidence data is not great, especially for proximal biceps tendon ruptures. Those are way more common than distal biceps tendon ruptures, thankfully, though we don't really know the incidence. There's just not great data on this. But again, this mostly occurs in older men's secondary to degeneration and maybe some rotator cuff pathology as well. Dental biceps tendon rupture again, far less common. It's about 3% of all biceps tendon ruptures.
That's like the split here with an estimated incidence of about 2.5 per 100,000 persons per year. This is mostly in active middle age men and again, it's mostly the dominant arm. As far as risk factors for this biceps tendon rupture, it's mostly underlying factors such as smoking, for example, increased BMI, overuse and age, in combination with forceful biceps movement, causing this rupture biceps tendon.
Smoking is a significant risk factor for this sort of issue, basically due to decreased blood supply to the biceps tendon itself. Obesity tends to reduce the immune response to tendon injury leading to anywhere between one third to two thirds of biceps tendon rupture cases, being in individuals with excess anapocity. Corticosteroids are another risk factor for biceps tendon rupture because it tends to reduce tendon strength by reducing the activity of the fibroblast.
Those are useful for actually creating new collagen and making sure your tendon is not only strong but also resilient and extensible. Anabolic steroids, so those are different types of steroids. Also they're thought to be a risk factor. Mostly due to their relatively rapid increase in strength, along with tendons diffening that may occur secondary to some anabolic agents, as far as deadlifting, because that's what people are going to ask about. What about deadlifting with an alternate grip?
One hand is prone, that's palm down, and one hand is supinated, that's palm up, so that mixed grip. There was some interesting studies on this. People are actually ripping videos off YouTube. Researchers are ripping videos off YouTube of people who rupture their biceps tendon and looking at various mechanical things. Was there elbow flexed? Was it extended?
This one study, which is in my estimation, one of the more elegant ones that was done, is 56 biceps tendon rupture events that they reviewed videos on. In 71% of these cases, the elbow was fully extended by their eye. Now granted, these in YouTube, I don't know how many pixels were on there and how they ascertain whether or not it's fully extended.
But when most people think about biceps tendon ruptures during deadlifts, they seem to say, well, it's because the elbow was flexed a little bit beforehand. Well, apparently in 71% of the cases, that was not visible. It was only flexed in, in fact, in 24% of cases. And the forearm was supinated in 96% of cases. In fact, only one distal biceps tendon rupture was seen with a prone hand. The most common activity was deadlifting, sorry for all of our deadlift lovers, including us on the line.
But the second most common was biceps curls, and the third most common was arm wrestling. And all but one of the cases were men. There was actually another study that found a biceps tendon rupture on both arms at the same time when a person was doing a double underhand grip deadlift. Which yeah, you know what? I've only seen like a double underhand grip deadlift done with like an AI image generator. If you're like, generate a person doing a deadlift and they have like both hands supinated.
And there's also one case report of somebody tearing their biceps in the prone position. Well, they were doing a particular pose in yoga. So I don't know that that's on anybody's bingo card, but I did find that interesting. We'll have to do maybe again, like I said, a full podcast on biceps tendon ruptures because people want to know.
But I guess, you know, if it has to be a takeaway from this as far as biceps tendon rupture risk, yeah, I'm going to have to say that using a mixed grip likely increases the risk of biceps tendon rupture compared to deadlifting with a double overhand grip or hook grip where they're with both hands or prone or using straps even. But I don't know that that's like a hot take.
I think it's more just like, okay, you're putting the arm in a position where the biceps tendon, particularly a distal biceps tendon is more exposed and more vulnerable. But if you are a competitive lifter, I don't know that this should change what you do because effectively, you've tried to deadlift with a double overhand grip. You've tried to deadlift maximal weights with a hook grip. And the reason why you went to the alternate grip was because that's the only thing suitable for you.
I mean, maybe like there's plenty of people who just come into the scene. Yeah. And they just like, that's the way they learned to deadlift from the beginning. And they think that's just how you do it. And they never actually considered trying to learn how to hook grip or something like that. And you know, I can't even honestly remember when I started deadlifting, whether I started out with a double overhand or whether I started out with a mixed grip.
I certainly didn't know what a hook grip was for a long time after I started lifting because I wasn't exposed to that. And so there's probably a segment of the population in that way who it's like, well, they'd be open to trying to train hook grip and maybe they can get the hang of it and make it work for them.
But there's also some people who are either unwilling like you and I or unable to also probably you and I to get our deadlift up to, you know, where we've been at maximal strength with a hook. Yeah. I just wonder, you know, if the biceps hand in rupture, they mostly occurs during deadlifts, I haven't seen it at many tested federation meets.
And so I do think anabolic play a role, whether it's direct or not, I don't feel confident in saying, you know, but I do think that as people gain strength very, very rapidly to be that seems more of like a training load or physical task load mismatched to what they've been, you know, trained for so far. If your deadlift goes up 150 pounds in like three months, because, you know, because you got suddenly stronger, well, it's not like you're going to hold yourself back with that scene.
You have people aren't going to do that just generally speaking. So that makes some sense to me. Also it's interesting that these are mostly in men. And so and there are plenty of women out there using anabolic as well and deadlifting with a mixed grip. And so is this like more of a load related thing to like, I don't see a lot of biceps tendon ruptures in lighter weight or middle weight individuals. It's mostly heavier weight individuals.
So there's some like mechanical studies that granted mostly from cadavers that are like, oh, this is like the load required to rupture the biceps tendon at various degrees of elbow flexion, for example. And so it's like, is this only once you're over 600 pounds on the deadlift, like it becomes a real risk. Don't know that. Or maybe there's a genetic difference in like tendon integrity.
Maybe there's a 10 gender related or sex related difference in like elbow carrying angle due to like shoulder width, hip width. There's a lot of potential stuff in there. So overall, I think this is an interesting topic if you're into resistance training. But I don't know that any like sports medicine doc, if they're listening to our podcasts, it's like, yeah, dude, you guys need to go hard in on biceps tendon ruptures from dead lifting. But I'd be interested. I don't know. What do you think?
Yeah, there's no way that it's a simple one way street. Like if it's just above this load, then that's the risk. It's always and this applies to just all injuries. There's some kind of a cute mismatch combined with maybe an element of stochastic, just bad luck between the integrity and capacity of the structure and the load being applied to it.
So to your point, like, you know, yeah, sure, maybe risk goes up above 600 pounds compared to below 600 pounds, but there's also going to be a component of the tendons capacity. And so somebody with a tendon that has been gradually built up and adapted to that load over time versus somebody whose tendon has been catabolized by being on prednisone or something like that. Like those are going to or on a floor of quinoa or something like that.
You know, there's going to be different, you know, tendon capacities to tolerate. And so maybe that threshold is lower for somebody with a lower tendon. That's just that's not anything earth shattering here. Like a hot take, as you said, that just is like general concept of most, you know, acute non-traumatic injury is a component of the load capacity mismatch plus stochastic bad luck happening all at once.
And there yeah, other variables to like you said, medication, maybe there's some like radius morphology, you know, where the insertion is slightly different, you know, a lot of stuff is possible could be possibly contributing. So I do think it's interesting enough for us to dig deeper, but I thought I would talk about it because, hey, look, man, you did the thing. You diagnosis as a biceps tendon rupture or biceps injury right off the jump, just like I wanted you to.
I just didn't expect you to get to the pseudo aneurysm thing, which yeah, that was hard. Nice job. Good job, Dr. Baraki. If you win yet another round, we'll see what kind of esoteric thing I can come up with next time. Hey guys, before we get into the podcast, I wanted to let you know that we're launching Barbo Medicine Plus so that we can expand on what we're doing with the podcast, the website, and beyond.
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