24 Tendon injuries

But we need to be aware that there is an overlap between the kind of injuries that do happen in sport and the t uh the kind of strength training programs that we are writing. So what we're going to talk about today is the kind of two main uh types of tendon injury that you're likely to see, which is tendonopathy and tendon rupture, and how that might happen as a result of what's going on inside the muscle tendon unit. And the types of uh exercise and training that we're doing.

So broadly speaking, um Tendinopathies are often assumed and I'm gonna make this assumption in this podcast. So um if people don't agree with this assumption then you can basically just ignore everything that I'm gonna say about tendinopathy. But um we're gonna make the assumption or I'm gonna make the assumption that Uh tendonopathy follows naturally from large amounts of tendon damage.

So that's kind of my starting assumption. So if that assumption doesn't sit well with you, then that's totally cool. Um you can stop listening now I guess and um you know follow whatever protocol you think is most so the protocol we're going to work with basically is that tendon damage causes uh if it's uh you know reaches a sufficient sufficiently high level it's going to cause a tendinopathy

And therefore we can kind of look at tendon damage, which is actually relatively well understood, uh whereas tendonopathy itself is a little bit harder to get your arms around. So we're gonna work with tendon damage as being the thing that we're kind of focused on.

And the same I'm gonna make the same assumption regarding uh tendon ruptures. I'm gonna make the assumption that um it's essentially a tendon rupture is an extreme case of tendon damage, either acutely or as we talked about last time with muscle strain injuries.

That is the accumulation of large amounts of damage leading ultimately to a rupture in the same way that muscle strain injuries ultimately are the accumulation of tiny uh damage uh kind of areas that ultimately lead to a entire muscle strain.

So those are the assumptions that I'm making. Now as I say, um I think these assumptions are pretty good assumptions, but I'm not going to sort of argue with people who say that they don't um agree with them. I'm just gonna say, Cool, fine, then use a different model. That's totally cool.

So assuming that is the case, then tendon damage actually is relatively straightforward. We know from um uh a number of uh very vr very well done uh laboratory experiments that um the cause of tendon damage is excessive strain and recoil of the tendon. So this is really, really important because what you tend to find when it comes to tendons is that people assume that higher forces are the problem. And actually because of the way that uh because of the fact that tendons are viscoelastic.

Um, tendons actually tend to strain less when you expose them to really high forces in vivo. So if you're doing oh not only in vivo, but in practical situations in vivo. Because you can kind of create a scenario in vivo where the tendon will kind of strain uh in response to large forces, but generally speaking it's not really normal for us to behave like that.

Um, in strength training where you're kind of grabbing the bar and and and lifting it or and you're in sport and you're producing a high force at a slightly slower speed, then generally speaking the tendon is gonna behave in a very stiff way. That's viscoelasticity.

And as a result, it's not going to have that very large strain. In contrast, if you're doing a lighter kind of low movement or body weight style movement, generally speaking, the tendon will strain, it will actually strain and recoil quite a lot. Now in most endurance activities like um

Uh for example a classic one obviously is endurance running. In endurance running you will see that people who have a more compliant tendon will display a larger movement of that tendon um in the kind of uh running gate cycle. And as a result, that ends up creating a large number of events, every footfall, in which your tendon is moving backwards and forwards, straining and recoiling. And that's going to create um, you know, successive uh damage with every footfall that you'll create.

you do some strength training and you start stiffening the tendon, you start to see less stretch and recall of that tendon, and you start to see less uh obviously tendon damage occurring and then obviously you can kind of predict what's going to go uh on from there.

So um the interesting thing is as a result, when we look at the incidence of tendonopathies, again, working with the model that tendonopathy is kind of following on from us uh from tendon damage. Um, ultimately you tend to see that the biggest incidence of tendinopathies is in the uh endurance. kind of activity a community. You sort of say, you know, long distance running, you're going to get Achilles tendonopathy. Um but you also see in the context of um things like uh kind of

track and field where you or or or say for example team sports where you have a lot of uh vertical jumping. That's why we've got things like jumper's knee in the kind of vocabulary that we use because people who do a lot of jumping tend to end up with um kind of patellotend up. The interesting thing is that we're starting to see then that tendinopathies are very common in circumstances where people are doing a lot of repetitions of these very light load or body weight uh type load activities.

Where the tendon is actually stretching, recoiling. You don't see the same thing in situations where people are doing high volumes of. Heavy strengthening activities. It's not so common. Yes, you can find people who've got tendinopathies associated with those kind of things. I don't think it's the same thing.

But I think what you're seeing here with the endurance activities uh or pli large volumes of plimetric activities tending to be associated with that tenopathy is literally just the large amount numbers of strains and recoils of the tendon creates tendon damage which then creates uh a a kind of situation where you end up with a tendon.

Now, tendon ruptures are a little bit different. I think that's probably more likely something where you've accumulated uh a lot of damage. And then you've probably exposed the tendon to a high force and but being damaged and accumulation of damage, you end up with a rupture situation.

Interestingly, the most common uh tendon ruptures, the most common situation with tendon ruptures happening is actually in the usage of anabolic steroids. So, um I went through the literature a while back, I was shocked, really shocked, I brought a table together with all the data because Um they use uh a number of different statistical comparisons to talk about um group.

of people who then go on to experience an injury and then you kinda do a ratio of the number of injuries in one group versus the number of injuries in the other group. And when they're looking at tendon ruptures, it's really interesting because sometimes when they're comparing a uh

a non user of anabolics group and a user of anabolics group. Sometimes they can't do a statistical comparison because there are no incidences of tendon rupture i in the group that's not taking anabolic steroids. You kinda go, Okay, that's quite suggestive. So ultimately anabox door is a really, really big kind of contributor towards a risk of any kind of tendon rupture.

Uh and that's really interesting because when you start to look at what steroids are actually doing, they're tending to upregulate synthesis of things and down regulate breakdown of things. So if you look at the I mean, that's fundamentally what they're doing.

So if you look at the muscle itself, then you upregulate muscle protein synthesis, you downregulate muscle protein breakdown. Um generally speaking, on a muscular level, both in terms of hypertrophy And also in terms of damage repair, that's generally a good thing.

because you're increasing the amount of um myofibula proteins that you're making and you're decreasing the amount that are being broken down. Now I think that probably has got a tiny pathological element to it because I do think the breakdown processes are important and actually serve you know, an im you know, a key uh sort of um actual activity inside the muscle and we need that. But I think that the

the balance of processes does lean heavily on the synthesis side of making new proteins. I think that's why anabolics fundamentally don't create huge problems on a muscular The problem is when you look at tendons, when we actually experience tendon adaptions, especially after strength training, we're not actually adding any more collagen. So the balance of synthesis to breakdowns

Very, very different. So now we don't need to add loads more collagen to create the extra stiffness. We actually don't create more stiffness in the tendon from adding more collagen. We do it by restructuring the tendon, and that relies much more on breakdown to do the restructuring than on the synthesis.

So essentially the uh anabolics is making it much harder for the tendon to reorganise itself because it's stopping you using the breakdown processes that are actually essential to actually doing that reorganisation. So ultimately I think that is why we see much bigger problems with anabolic steroids in the tendon context compared to the muscle context. I don't think it's because they don't exist in the muscle context. I think they do exist in the muscle context.

I think there's the balance of problem versus kind of benefit if you like. No moral judgment implied whatsoever. But but like the the kind of physiological level, the kind of the the kind of what you're getting positively and what you're getting negatively are kind of skewed in favour of positively, at least as far as recovery and hypertrophy are concerned.

But in terms of the tendon, I think it's the opposite. I think you're skewing much, much more in the direction of it not being a good idea. Um now, just to be clear, a lot of um very kind of um influential voices regarding tendon uh kind of uh adaptations don't kind of follow these um ideas. And a lot of people talking about anabolics similarly don't follow these ideas. They say that ultimately the reason that the um

uh kind of anabolic uh usage causes tendon rupture is because the muscle grows uh in strength faster than the tendon. I'm not fundamentally opposed to that specific idea, but I don't think it's the main reason why things go wrong.

um, I think that you see these kind of issues irrespective of whether the I mean, ultimately the only way for in my view that that would happen would be if the tendon rupture happened very, very early on in someone's uh kind of bodybuilding career when they started using anabolics, when the strength gains uh the muscle size gains really, really fast.

Um, or alternatively, if the bodybuilder was exclusively using um relatively light loads and wasn't able to create tendon adaptation at all. I think in those scenarios, sure, you might end up having an imbalance between muscle strength and tendon stiffness. Such that you start ripping the tendon literally off because the muscle's too strong for the tendon, okay, fine. But I don't think that is what is happening normally.

I think what's actually happening normally that that the anabolics are fundamentally disrupting the breakdown uh processes and therefore disrupting the the reorganization that allows the tendon to restructure itself. And that's why the data we've got shows that tendons just don't structure themselves, restructure themselves properly.

in peop in in in subjects that are using anabolic terms. I nearly said people and most of the data is obviously in animals. So you know, it's not going to be ethical to get that kind of thing through, uh, you know uh research environment. But you know, basically that's kind of uh the the the problem that I think we're seeing with with anabolics. Anyway, um so what I'm saying, just to wrap this up, is tendon damage I think is the ultimate base cause of both tendinopathy and

uh tendon rupture, that's my assumption. Um in that case we can just look at what causes tendon damage. It's basically lots and lots of repetitions. of body weight or light load type activities involving a large amount of stretch and recall, so stretch shortening cycle uh type activities. So any kind of endurance running type activity, something like that. Um

any kind of plyometric activity done in sufficient volumes, that's going to create problems. On the other side, stopping that from happening, or at least m moving in the direction of helping ourselves prevent that from happening, what we're going to want is to make the tendon a lot stiffer so it doesn't

stretch and recall. Alternatively, which is obviously not do those things in the first place. But but like assuming you are going to do those things, let's assume you are like for example an Endurance runner and you want to do a lot of running, you want to avoid Achilles tendinopathy. Or let's say you're a kind of a I don't know, a basketball player

or, you know, someone else uh trek and field is using a lot of vertical jumping, then yeah, we want to make sure that tendon doesn't move around quite so much. Um, accepting that

having a good straight shortening cycle means that you will want it to move around. So we've got that kind of balance to uh work around and we talked about that in the straight shortening cycle episode that we did previously. But fundamentally What we're saying here is that um, you know, we could use the strength training as like a way to stiffen the tendon, but we need to use a load that is at least ten max or heavier.

Now I think that as the athlete progresses they're gonna start to need a heavier and heavier load and I think it's gonna come down to five rate max before you start to see changes because we do see very, very uh kind of strong plateaus in tender stiffness changes after only a couple of months of strength training. So ten rate max I think is the kind of the starting point. We need to be heavier than h as heavy in that as heavy as that or heavier.

But fundamentally, uh, you know, kind of as athletes progress I think we probably need to go slightly heavier than So that's kind of where we are. Basically, there's a type of activity that increases or exercise that increases tendon damage, and there's a type of activity that decreases it. And you can kind of therefore see where we're going in terms of uh balancing uh when athletes have got to do a lot of polymetrics.

uh or a lot of biometric type activity in their sport or their endurance runners or something like that, then we can use that heavy strength training as a way to start to reduce the risks of uh tendon damage happening and hopefully therefore, assuming the model works,

um, reducing the risk of a tendonopathy or a tendon rupture as well. Subject to the tendon actually being able to adapt because the person is not taking anabolic steroids. I mean, obviously there's some things we can't actually work around. I mean I Um that is just a problem that people are gonna have to accept and, you know, think about ways in which they can mitigate that. Um, but fundamentally uh, you know, assuming that's what they wanna do.

Um that's that's kinda where we are. So that is uh the physiological introduction, relatively long one this time, lots of stuff for us to work through. But now I'm going to ask Rob. Um there's lots of things going on here, Rob. So um I've got a number of questions I want to ask you about the programmes that you're writing and in no p in no particular order.

Um, obviously one of the things that is a risk factor for um uh tendon damage happening, or one of the things that does cause tendon damage happening, is the plymetric movements themselves. So Um we've talked about how um a high performance physiology

kind of work out plan. We'd start with speed, then do him strength training. The method. Yeah. So we'd start with um, speed, then do heavy strength training, then do um kind of plymetric activities, then finalise with uh supermax policy centrics, all in the same workout in order to get the best uh kind of training frequency for everything.

But when we've talked about some of your programs in the past, often you drop out the stretch shortening cycle uh component of that uh four component uh framework because it's just simply either unnecessary or you don't want to do it all year round. So can you talk a little bit about when you do include some plymetrics in your programs and, you know, give us an idea of how much volume you're doing with those?

for myself and for any of the athletes that I coach. I'm always using honestly a pretty low volume of polymetric work. Um, you know, if I'm doing something like the the repeat calf hops with a straight leg and things like that. Maybe just, you know, a few sets of Five or so, honestly it's not a ton. And all I'm gonna do at that point is just monitor, you know, if someone is improving and that's it. And if the dose

is such that they're improving in a way I want them to. I'm just not ever gonna increase it.'Cause if people are playing a lot, you know, playing a lot of games, running, jumping, um, for me, skateboarding, all these things. You know, if I'm improving and I don't have pain, I don't have any sign of um any any tendon damage, tendon apathy, those things creeping up.

then I don't really see any reason to increase it and I'll just ride it out um as long as I can. I guess maybe in theory I could get a little more out of a little more, but, you know, I'm not really that worried about it. Like I said, as long as someone's improving, I'll just keep it at a very minimal dose. Frequency wise, um once it's in there I will do it usually every session, sometimes every other session, but just depends. But again, it's not a ton like in any one workout.

So really at that point I don't see any reason not to include it frequently. And then again, just monitoring, um, you know, the athletes, seeing how they're responding and just going from there. But yeah. Very very low volume compared to, you know, I've certainly seen some protocols where it's a lot of landing phases, a lot, a lot of rep.

Um we talked about one before the podcast that was, you know, like fifty to eighty in a week and things like that. And I I don't see any reason that would be beneficial and you'd have to be pretty special to be getting away with that on top of your your gameplay and your daily activities to not see some damage creep up.

If the opposite happens and the tenor stiffness overpowers as essentially is stiffer than the eccentric force of the muscle, then you won't get the tenor moving around in that particular context. So th this is really interesting because

The stretch shorting cycle uh that we're trying to improve doesn't really have a single adaptation. It's i there's no unique adaptation associated with it. It's literally just eccentric strength, which we're getting elsewhere anyway, and tendon stiffness, which we're getting elsewhere anyway. So the whole this is one of those really, really valuable moments where we can say, Look

This is why we don't think about outcomes um without also knowing what the underlying adaptions are. So when somebody says, Oh, we're trying to improve speed, my brain straight straight away goes, Okay, well there's a list of these adaptions that contribute to speed. Somebody says I'm trying to improve power, I'm like, Okay, hang on a minute. Now this isn't gonna work because speed actually and strength are the two things that underpin power. Power's a second order effect.

So now if you want to improve power, you've got to tell me how you're doing it, either by speed improvements or strength improvements or both. You can't do it directly. So straight away, again, this is exactly the same thing. Straight shortening cycle, like, oh I'm improving my straight shortening cycle. And like, okay, well, how are you doing it then?

Um are you are you making the eccentric strength of the of the muscle bigger relative to the tendon stiffness? And what are you doing to make that happen? And and it's really interesting because when you showed me that uh kind of uh sort of set of social media posts that you've been um collating to shock me with, um

It was basically lots and lots of s very, very submaximal um straight shorting cycle movements. Now technically Yeah, and we we kinda went around in circles a little bit to start with'cause we're like, does this fit the definition of plymetric? Because you need an impact phase but from a practical point of view, the impact phases were so kind of low in terms of uh the force generated and there were so the the level of effort was so low in terms of the subsequent movement.

that it kind of felt it was almost not really a plyometric, even though our standard definition is technically well, it's got an impact phase and it's a straight shortening cycle. So it kind of technically is a plyometric, but the level of effort was so low, I was like, what is actually going on here?

So I think not much. Not much. So this is the problem when people kinda go, Oh, I'm gonna do a stretch shorting cycle exercise and I'm gonna improve my stretch shorting cycle performance and this is apply metric. I'm like, Okay, yeah but How are you increasing your eccentric strength relative to tanninness, diffness? Because if if the thing that you're doing isn't doing that, then it's not gonna work.

And this is why I mean incidentally this is why we put them third and not second after speed stuff because uh ultimately they are an eccentric uh movement. The the thing that changes your straight shorting cycle is what happens in the eccentric phase. And this this then ties into the other important thing which is that

Um, you're already doing a bunch of speed stuff right at the beginning of the workout. A lot of people think that plyometrics yeah, exactly. A lot of people think that plyometrics are about improving speed and like, oh whoa, hang on, that's not what's going on here. It's not what's going on here. The polymetric is about improving the eccentric um strength of muscle relative to tendon stiffness so that you can get a better straight shortening cycle effect. Yes, that will enhance

your ability to move quickly because you're slowing down the muscle shortening velocity relative to the joint angular velocity. That's what the actual tendon movement is doing for you when you've got it. But it doesn't mean that your exercise is a speed exercise.

recognized or not, for example. Um but the problem is a lot of certifications, even if they are being recognised, even if they are being issued by, you know, high profile organisations, they aren't updating for the research of the last ten or even twenty years. So you're looking at information that was kind of current twenty, thirty, forty years ago and we've got some amazing physiological data from the last kind of decade.

especially on plymetrics, which completely reverses everything that most S and C coaches will say about what plymetrics are doing. They're like oh yeah, we're increasing tenders stiffness and I'm like, Well, not really. Got a whole bunch of polymetric studies showing that you don't increase tendon stiffness. Um and even if you do increase it slightly, strength training produces increases in stiffness that blow it out of the water. I mean, it's just mad.

So really not the special thing about polymetrics. Uh i the special thing about plymetrics is the ratio of eccentric strength gains to tendon stimulus. It's an eccentric strength training exercise um that doesn't really create some of the other force related adaptations like hypertrophy and um Yeah, whatever else is going on inside.

I'm not gonna kinda go down that route route root route right now, but ultimately you kind of what you're doing is a very uh short, sharp, um, eccentric stimulus that is gonna create some of the eccentric related ad or uniquely eccentric related adaptions and that's gonna then allow you to pull the tendon around without stiffening the tendon itself, which would come with the more kind of force strength related adaptions. So

This is really important. You know, you are programming speed stuff but you're tending to drop out the straight shorting cycle stuff and only including it i in the period of time when you think it's going to make the most difference because otherwise You're just gonna be exposing that to

It's going to want to adapt by increasing its stiffness as long as the stimulus was there to do that. And it's going to need to do any damage repair that you've produced. Now the issue is that isometrics probably don't produce very much damage at all'cause they're getting almost no strain in recall, whereas dynamics always will have a little bit of damage. So I think if you think about it in terms of budget constraints

Basically the the tendon can do two things and if it hasn't got to do very much damage repair you're gonna get more on the stimulus uh adaption side. So I think that's really what's going on. The isometrics are probably just not having to do the other sort of damage repair stuff that the dynamics are doing.

Now, I know that you've used isometrics a lot in uh various contexts. So just By way of uh kind of giving people a bit more information on that, can you just run us through some of the isometric conjections, even if that you're programming even if they're not explicitly for the purposes of increasing tenders, stiffness, but just so that we kind of see an insight into your programming of isometrics at the moment.

and they should be in a stretch position. So like a much more dorsiflex foot position. Uh I see people a lot of the time trying to do them on like a seated calf raise Um, you know, holding the squeeze, holding the top where they get a lot of feeling and the contraction. And the the loading there compared to a more bottom range, straight leg calf raise, is just gonna be nowhere near what you need.

um to really cause like those beneficial adaptations in the tendon. So for the Achilles, I really like very heavy, you know, like three, four, five second um isometric contractions just in that bottom range where I can go very, very heavy and know that I'm actually getting um, you know, a load, like a significant load.

through the tendon to cause that adaptation. Um, really like those. And for me personally and for people I've used them with, I've seen a lot of benefit. Um, when they've had issues with the Achilles tendon and stuff like that. And obviously you're gonna get some, you know Calf strength, calf growth, and things like that.

If you're trying to avoid hypertrophy, maybe not. But in the case of like improving tendon stiffness and using them to like help an Achilles tendon, those work really, really well.

Um, if I'm doing them it's gonna be either again every workout or every other workout. But those I've seen really, really good changes with. Um and again it's not like I'm, you know, monitoring the actual structural changes in the tent.

Just'cause you know, if people don't have um the hip flexor one, particularly if people don't have a great hip flexion machine or anything like that. Um, easy to just do those on a bench, knock'em out at the beginning of the session, and then they're good. And then uh you know, the other one I use a lot in terms of isometrics is gonna be just quads. Um we talked a bit about it on I think other the powerlifting podcast or a different one. We're using them for increasing recruitment.

um just like a single re uh leg knee extension ISO. And then for the, you know, patellar tendon and that, those are gonna be, you know, about your your best bet, like a just a seated knee extension, um, going very heavy. So

Um, just the population of people I work with and myself, it's not something I usually um see much of a need for, you know, maybe like a rehab setting when you can't go heavy yet, you know, you have pain and all kinds of things. then I might look to like more of a long duration ISO, especially with like um patellotendon and, you know, maybe Achilles and that. But for me, you know, most of what I'll talk about here, what I do is just kind of heavy, brief isometrics for the purposes of

recruitment and then tend and stiffness and all those things. And they're all going to be similar in terms of number of contractions, number of sets, things like that.

But when I start unfatigured and I'm like, okay, I'm not gonna pull as hard as I possibly can, it just feels totally different. And it's it's quite And it's not not in the sense of a powerlifting,'cause I've I've kind of done that. I know what that feels like. That doesn't feel like this. This feels to me different.

It's basically doing exactly the same thing. A lot of people get confused because they're oh it's isometric, it's not dynamic. It's like, well really biologically it's pretty much exactly the same thing. Uh tiny little differences here and there, but fundamentally it's uh you can treat it as more or less

Um cool. Okay. Um So in terms of coming back to the basic theme of what we've been trying to communicate today, um, tendon damage uh is probably at least in the model that we're working with, um, the i the responsible cause for tendinopathies and tendon ruptures. So we want to kinda try and manage that tendon damage. Two ways of doing that are to limit the amount of

uh plyometric activity if we're programming it. Obviously if it's part of the sport, that's not something we can control. We just have to be aware of it. And on the other hand on the other hand, we can obviously do a heavier strength training, um, keeping the loads heavy or using isometrics. um, you know, for the specific uh areas, the tendons that are likely to be negatively affected.

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So hopefully that has been useful today. We've uh carried on from talking about muscle strain injuries last time, uh talking about uh tendon injuries today. Um we will uh come back with another episode next time on a completely different topic.