SPEAKER_01 0:11

Hello and welcome to Running with Problems. My name is John Ison.

SPEAKER_03 0:15

And I'm Miranda Williamson.

SPEAKER_01 0:16

Running with Problems is a podcast about the exploration of problems encountered during a life in running. I'm trying out that new tagline. How do you like it?

SPEAKER_03 0:24

I like it a lot. I like the idea that we're looking at what we're doing and constantly evolving and changing our format and tagline and content to match.

SPEAKER_01 0:34

I like the fact that it focuses on in exploration, right? Yes. Because, you know, people ask us what our podcast is about, and it's about exploring what are people going through.

SPEAKER_03 0:46

Absolutely. We've evolved over the years and found our niche, and that's what we do.

SPEAKER_01 0:52

Specifically, what are runners going through?

SPEAKER_03 0:55

Ver ultra runners mostly. Almost exclusively, I would say.

SPEAKER_01 0:59

We do have a we have an audience. Miranda, today on the podcast, we have Michael Morrison, DPT, who we've had on twice before.

SPEAKER_03 1:10

Yes, that's correct.

SPEAKER_01 1:12

He continues in going over a single topic. Today's topic is tendinopathy.

SPEAKER_03 1:19

Oh my gosh. Michael is so knowledgeable. I have been talking about this episode ever since we recorded it. We've had it for a while without dropping it. So I have been telling everyone about it.

SPEAKER_01 1:34

You meet so many people out there who are going through tendinitis, tendinosis. This is another thing. Or, you know, the general term for all that is tendinopathy. It's this idea that there is some degradation to your tendons and your soft tissue. It's quite common. And so Michael goes through all of the phases of tendinopathy, everything you would call like tendinitis and inflammation, all the way to like where you've done serious irreparable harm to that tendon and how to manage it.

SPEAKER_03 2:04

How to prevent it.

SPEAKER_01 2:06

It was a really cool episode to record. Michael's incredible. I interrupt him quite a few bit.

SPEAKER_03 2:12

We go on little side rants regularly.

SPEAKER_01 2:15

If you listen to this podcast, then you enjoy those side rants.

SPEAKER_03 2:21

I think Michael kept bringing us back. He was really good at being like so good.

SPEAKER_01 2:25

He's so good.

SPEAKER_03 2:25

Now back to the topic in here.

SPEAKER_01 2:28

You know, I just want to take it where my mind goes, you know?

SPEAKER_03 2:33

He's a great repeat guest. Love having Michael on and loved um this conversation a lot.

SPEAKER_01 2:40

Well, we haven't released an episode in quite a while.

SPEAKER_03 2:43

Oh no, we need to check in.

SPEAKER_01 2:44

It has been what, somewhat like six weeks since our last episode dropped. And even that one was like a week late. So, first of all, I just want to apologize to our fans who are looking for that weekly or bi-weekly drop that we do. You know, uh we live lives. We we've been dealing with a lot of stuff in the early part of this year, and we needed a break.

SPEAKER_03 3:05

Yes, we were struggling to get the episodes out, and so we decided just to not keep that pressure of that every two weeks going. But we do have some guests in the future lined up.

SPEAKER_01 3:18

Yeah, we've reinvigorated ourselves. We have a ton of new content that we want to drop for y'all. Um, we're looking to interview a lot of people in the early part of the spring. I is it spring yet? I can't tell. It's like basically summer outside occasionally, except it was snowing and then we had alpine conditions yesterday. It was crazy. Speaking of, how are you doing, John? Oh my God. How am I doing? I if you are a close listener to the last episode we dropped, I was like, I sounded quite um unwell. Yeah, not normal. Uh I was I dealt with a lot of anxiety issues, uh, nervous breakdown is kind of how I call it uh through the early part of this year. And then I guess we're still in the early part of the year, but now I am I've that has evolved somewhat into I uh uh have decided to drop out of Cocodona, which that happened today, and the day we're recording this. That was motivated because I have to finally admit that I am dealing with long COVID. Um I spent many, many months hoping that if I just trained enough, I would get all of my lost fitness back. Um, I had COVID around January of last year. That's 14 months ago that I had COVID, and I lost a lot of fitness in that um viral infection. I actually don't even know if it was COVID, it's probably COVID, but who knows? And you know, I just thought like if I could get to training, I would be fine. And I've been training for four and a half months now, and I'm not fine. I'm not. And admitting that is really, really hard for me. Uh I I project a lot of uh, you know, toughness and uh and the ability to endure. And I still believe I could have I could have accomplished Coca-Dona. I mean, I I really can push through quite a bit of pain and suffering for quite a long time. But just because I can do that doesn't mean I should. And dealing with these health problems now seems like the right call. You know, going and seeing a professional and trying to figure out what's going on with me and how I can mitigate it best and try to really feel like myself again, which I haven't felt in a long time. So that's that's the recent news as of today, and how I'm feeling about it. I I think we're gonna have an episode on long COVID coming up with a guest.

SPEAKER_03 5:58

And John will talk a lot about his experience in there. I'm sure we'll go on some side chats.

SPEAKER_01 6:02

Yeah. And and I have to emphasize, I'm at the beginning of this journey. Right. Right? Admission is the first step. I mean, I suppose COVID is the first step, but admission's at least the second step, right? Uh, and I'm going to, you know, go down it and try and figure out what's going on with me and my body. Um, and until then, you know, we'll we'll save the deep dive episode for then. But yeah, I'm I'm stepping back from running to try and focus on what's going on with my body. Miranda, how are you?

SPEAKER_03 6:36

Oh my gosh, listeners, I wish I could say I'm wonderful like I usually do, but I've been struggling as well. Mostly it's been work stress. Um, but I put in my notice and we'll be exiting that.

SPEAKER_02 6:55

Good.

SPEAKER_03 6:55

Um and just for our listeners, don't ever put up with people treating you poorly. It's not worth it.

SPEAKER_01 7:03

You don't deserve it.

SPEAKER_03 7:04

You don't deserve it. It's not worth it. Just exit that situation. And I know that's a very privileged thing to say. True.

SPEAKER_01 7:12

Um, but I have to say But a ton of privileged people don't take the advice, so yes.

SPEAKER_03 7:18

And I felt kind of a sense of I have to do this because I can, so that other people don't have to deal with this. I have to like stand up for myself. I have to stand up for what's right and exit this situation because I know not everyone is in a privileged position like I am to exit when they are being treated poorly.

SPEAKER_01 7:44

Yeah, I think you did the right thing, and I'm excited for what you're gonna do next.

SPEAKER_03 7:49

But it's hard because I loved my job a lot.

SPEAKER_01 7:52

Yeah, you did. And I And you love the feeling you get from doing your job.

SPEAKER_03 7:55

Yes, and I help a lot of people. Um, like a couple months ago, one of the entrepreneurs that I heavily advocated for got a 30K grant. And this entrepreneur, it's called Goodness Gracious Grocers, and she brings GGG. She she brings food to really impoverished food deserts. She sources it from local farmers and then drives it in a little van out to these locations and takes um snaps. So takes like um food assistance programs in order to sell her really healthy, um, sustainably sourced food. And she got a 30K grant because of work that I did to support her. And that just goes so far. That ripple effect of that grant goes so far to support so many communities. And no one will ever know the role I played in that.

SPEAKER_01 8:54

I believe every one of these listeners will now know the role you played in that.

SPEAKER_03 8:59

But none of the people who get that food, who benefit from that resource will know that. But that doesn't matter. It's just like so meaningful that I was able to do that work. Um, and I'm leaving knowing that I was able to have a positive impact on so many lives through this work and through this job.

SPEAKER_01 9:18

That's absolutely wonderful.

SPEAKER_03 9:20

Yeah, but it's a sad time for me. I'm grieving as well.

SPEAKER_01 9:23

Yeah, because you because you're losing that in some way.

SPEAKER_03 9:27

Yes. But it was very stressful for the last two months before making that decision, hence our lack of podcast drops.

Winter Skyline Run And Lessons

SPEAKER_01 9:35

And real quick before we drop into the episode, we referenced earlier this run yesterday.

SPEAKER_03 9:41

Oh, yes.

SPEAKER_01 9:44

We ran Christy's birthday skyline.

SPEAKER_03 9:46

Shout out, Christy, friend of the pod. She's been on an episode.

SPEAKER_01 9:49

Yeah, she was on our How to Run 100 Miles episode with uh Rachel as well.

SPEAKER_03 9:56

Yes.

SPEAKER_01 9:56

So yeah, we ran Christy's skyline yesterday. It was down low, it was not bad. It was it was warm, the snow had just dropped. And there was maybe, I don't know, like six a little more than six inches down low, like where we live, like at five uh 5,500 feet. But once we got up to around 7,000 feet, uh where the 8,000 peaks are in like Bear Peak and South Boulder Peak, and there's uh there's big uh like burn scars on those mountains. So yeah, the wind was epic and the snow was so deep. I was wearing half tights, which are basically like shorts. And I I was not I was in snow up to my thighs so much. I there was like an hour and a half where I could not feel my thighs, or like not my thighs, sorry, or my calves. I couldn't feel any of my shins at all. And so going cold.

SPEAKER_03 10:55

Going up South Boulder Peak, just because like there's this window. It was like sustained 30 degrees. Anyone who like dug some tracks, it's blowing like the snow back over the tracks. So I got off trail real bad. I don't know if you did.

SPEAKER_01 11:16

No, I kind of know where the trail is.

SPEAKER_03 11:18

That's right.

SPEAKER_01 11:20

I've been up there enough times.

SPEAKER_03 11:22

Well, I got off trail real bad. It was in up to my waist a couple of times because I and I'm like, I gotta swim out of the snow.

SPEAKER_01 11:29

I was up in my waist on trail. At one point, I fell down on the backside of bear, and I just I was just laying in the snow and I couldn't feel it at all because I was numb through the front of my legs, completely numb. It was scary. It was a it was a if you stop, you die kind of moment, and it was so close to the house. This is like three miles away from where we live. And it's an if you stop, you die moment. So that was crazy.

SPEAKER_03 11:59

Chrissy and her friend, another friend of hers, Tyler, were up ahead of us. And then I was back with um a group of uh, there were four of us, and two turned immediately. They were like, Nope, not doing this. We're out of here. And so I was left with this one guy, and he's like, I'm turning around, I'm going. And I just shouted at him, you can't turn now. If you quit this hard thing, what else are you gonna quit? And he's like, Okay, I'm coming. So I summited with this new friend of mine.

SPEAKER_01 12:33

Yeah, good work, Matt. Nice job. I ended up completing the skyline, doing another 10 miles after that. Uh, it got hot on Cenitas. Like there it was just hot. Like it was like 50 degrees, direct sun. You know, after you experience those blistery winter conditions, and then you drop down into the heat, it can really uh wreck the system. But it's also what I love about the skyline. It's my favorite thing, is that you can have an alpine winter experience and a high desert experience in the same run. It's the coolest fucking run in the world. All right, let's get to the episode. Uh, thank y'all for your patience in waiting for this uh episode. And we will get back on the horse recording more episodes for y'all. Um, we're really excited to do it.

SPEAKER_03 13:22

Like I said, got some cool about three guests in the works that are really awesome, excited about.

SPEAKER_01 13:28

And I don't have a race to train for, so let's just focus on the podcast. Let's go.

SPEAKER_03 13:32

Let's go.

Guest Intro: PT Michael Morrison Returns

SPEAKER_01 13:34

Without further ado. Michael, welcome back to the podcast. So good to be here again. It's so much fun. Good to have you back. I love talking, all things uh physical therapy. You've really, I know I began everything talking about how good you are, but you've really helped me learn more about my own body through over the years of like seeing you and experiencing different injuries and different pain points, and be like, why does this hurt? And you'd be like, oh, well, it's connected to all these other things in your body. And I don't know, when I started this running journey, I probably didn't really understand how the body worked at all, how tendons connected to muscles and how a problem in one area could pop up in another, or how inflammation healing worked, or any of the things millions of things I've learned from uh from you. So appreciate that. And I hope that we can give the listeners some more of that knowledge through, you know, every six months or so, dropping one of these episodes.

SPEAKER_00 14:40

Yeah. I'm glad to hear you feel so empowered. I think that's the word. Like I love for my patients to walk out empowered, you know, with this the knowledge to like, okay, the next time this comes up, I might be able to handle, you know, unless it gets to a certain severity, but now I've got tools and I'm empowered. That's that's so I'm glad you're feeling that because that's often my goal. So it sounds like it's working at least sometimes. Definitely.

SPEAKER_03 15:00

Michael, I have to tell you something that happened to me.

SPEAKER_00 15:03

Yeah.

SPEAKER_03 15:03

So I've saw, I've seen a lot of people who've said that they've found you through the podcast and gone to see you. But I had the opposite happen the other day. Oh. I was running with a girl and she's like, wait, you have a podcast, don't you? And I was like, Yes. And she's she said, I started listening because my PT was on it. So I had the opposite happen on the trailer.

SPEAKER_01 15:33

Synergies. Yeah.

SPEAKER_03 15:34

She recognized my voice.

SPEAKER_00 15:36

That's awesome.

SPEAKER_03 15:37

From your episode.

SPEAKER_00 15:40

That's great. For HIPAA reasons, we don't necessarily well, she introduced herself to you. You could tell me your name, but Morgan. Yeah, okay. I know exactly what we're talking about.

SPEAKER_03 15:48

Uh-huh.

SPEAKER_00 15:49

Thank you, Morgan, if you're listening to today's episode.

What Tendinopathy Actually Is

SPEAKER_01 15:52

And thanks to all the listeners. Appreciate y'all. So, what do we want to get started with? Uh I know we wanted to talk a lot about tendinopathy. And this is a word that I didn't really know and when you mentioned it to me. So what I guess, what is tendinopathy and why should I care?

SPEAKER_00 16:13

Yeah, great. Um so top six running injuries uh for like your non-masters runner, kind of your 50 and younger. Um, Achilles tendinopathy is gonna be in that top six very common things. So we got things around the kneecap, we have the IT banner, kind of your top two. But then we quickly come down and Achilles tendinopathy, shin splints, plantar fascia pain, and bone stress injuries are the other four that are all kind of neck and neck in some ways. So odds are if you're a runner, your Achilles tendon is gonna bother you at some time. Um, and then, you know, with just such a boom in the last couple of years, well, in the last decade or so of the trail running, and just like the vertical stuff, like whether you want to call it trail, mountain, whatever you're doing, um the quads do a lot of work. So patella tendons, quad tendons are often getting a lot of float. And so, yeah, starting off just the basic anatomy, in case you don't know, like your muscle turns into a tendon so that it can attach to a bone. And then when that muscle contracts, it pulls on that springy, stiff tendon to create movement at that attachment point. Um, there's actually some theories, uh, like uh an aggressive sprint, your muscles holding isometrically and it's the tendon that's getting a little bit of a stretch and then snapping back to create the speed. Um so that's where and we'll talk about isometrics quite a lot in just a minute here. Excuse me. But um tendonopathy, uh, we have shifted to using that kind of terminology, and maybe even now we're gonna move more into calling it tendon pain. Um it was called tendinitis for the longest time. Um and the itis involves the concept of inflammation and that inflammatory response. And there's uh not always great agreement on like how long are we in an acute phase? Is it hours? Is it days? Is a week already getting chronic? Um, and this is on more like a cellular level in many ways. Um and then it started some more with the plantar fascia research circa 2003, uh guy, Dr. Lamotte, he started doing biopsies of the plantar fascia of patients who had plantar fasciitis. And looking under the microscope, he saw very, very few actual inflammatory markers. Right. So if it's not showing all that inflammation, do we really call it an anitis? Um, and in fact, what it did look a lot like was very like moth-eaten, almost like little micro holes in the tissue, like really poor nutrition, degeneration of that tissue. Um, and so we kind of started to see and consider like as tendon injury is prolonging, we're probably moving into some of that. Um, so there's great research uh all around the board, but one of the one of kind of the best four mothers of the tendon research is Jill Cook. She's got a great article talking about this continuum, right? Like I use a lot of analogies about things that are so nuanced. There's no like straight black and white.

SPEAKER_02 19:10

Right.

SPEAKER_00 19:10

Um, there's this continuum of you have like a reactive tendon. So maybe you just increased myelogen intensity last week and like your whole tendon is a little tender and sore. Like that's probably more of a reactive tendon. It's probably still got good nutrition and those kind of things, but it's kind of thickening and widening a little to disperse those forces so that those uh fibers aren't taking quite so much load, they can spread that load just a little bit. Uh, then we have tendon dysrepair. So when tendons are healthy, all the little fibers are very much parallel and in sync and run in the same direction. But if that thickening isn't enough, you kind of keep pushing the envelope and pushing through the overloading principles, you're not giving your tendon enough recovery. We start to see disorganization of those fibers.

SPEAKER_01 19:57

Wouldn't that exacerbate the problem?

SPEAKER_00 20:00

Well, with it's trying to like when things are parallel, like it can stretch a little easier.

SPEAKER_02 20:05

Yeah.

Symptoms, Sites, And Stages For Runners

SPEAKER_00 20:06

So like as you get cross-section and things are going different directions, like they since they're not all going the same direction. So it's trying to it's trying to stiffen itself because in general, we actually want stiff tendons. Because when they're stiff, they're very responsive. As soon as you stretch them, they spring back. Right. So think about like uh if you wanted to do a slingshot or a catapult, like you want something that as soon as you let go of it, like it's going to aggressively come back. And that's what you want. Your tendons. So if it kind of does that change of direction where things are starting to crisscross a little bit, like now it's not as easy to to just stretch that, you know, and think about like fabric that everything's running the same direction. You can kind of pull out a little easier when it's crisscrossed. It's it's not as easy to stretch everything out. I see. And then if you go long enough still, then you get to that degeneration that uh they call it tendon degeneration in this bottom end of the um.

SPEAKER_01 20:54

So these are the sort of levels of tendinopathy? Yeah, or tendon uh injury. Or tendon pain, tendon injury.

SPEAKER_00 21:01

Tendinopathy would be trending towards like that degeneration side of things and even that disrepair side.

SPEAKER_01 21:06

I see. And how does this present for the for the runner?

SPEAKER_00 21:11

Yeah. Typically, um very early onset, it's gonna be nothing during your run and a few hours after your run when you've been still, like say you rain in the morning and have a job where you sit. Um then you know, you get up for that lunch break and you're kind of like, uh, that's a little stiff, a little tender there with my first few steps. And like within five steps to the water cooler, it's already stretched out and feels fine. But if you keep going, then it'll start to be uh soar a little closer to when you finished your run and last a little longer, um, come on a little more frequently throughout your day. Um, and then when it's getting more severe, you start to feel it to begin your run. But a good distinction, if you're not sure if something is like a tendon muscle versus a bone thing, is your So it'll be stiff. You know, you classic late from work, joining the crew for the afternoon trail run, pull up to the trailhead, everyone's waiting. So you just throw in your stuff and you get going in your first steps. And it's, you know, it's at the bottom of the hill to start the run. So your first steps are a lot of calf use, and it's just like, oh, oh, oh, you know, a lot of tenderness and gimpiness to get going. But within half a mile to a mile, like you're already like, oh, attendance not a thing anymore.

SPEAKER_01 22:26

And then you can that's kind of how I felt with my ankle back when my ankle was weaker for years. It would just be the beginning of every run.

SPEAKER_00 22:35

It was just like, oh, oh, just get that get that thing warmed up, get it warmed up. Yep. Uh and then it'll warm up. And then depending on how long the run is, it may start to kind of tell you near the end, like, hey, this is all I got today. Or if the run is short enough, you won't notice anything. Um and and then again, like now it's getting more severe. So it used to be drive home and go to work and sit for hours and then it gets stiff. Now just to drive home and you get out and you're like, man, it's stiff again, just like it was at the beginning of the run. I thought I had warmed it up, but that was gonna be okay. Um and then if left's ignored longer and longer, it starts to just kind of be sore uh with like all your walking throughout the day.

SPEAKER_03 23:11

Would it be sore to the touch as well?

SPEAKER_00 23:14

Yeah, so most of the time it will be to squeeze it um along the cord of that Achilles tendon. Um maybe a good time to pause. Like there's kind of two places that as a PT, I'm considering where is that tendon irritated. As we said, tendons attached to bone. If it's right on that heel bone, if we're talking specifically about the Achilles, uh, if it's your patella, like you know, the very top of your shin, that little point, it feels like an apex of a mountain sticking out in front of you, like that's where your patella tendon attaches.

SPEAKER_01 23:42

Just for the listeners, everyone simultaneously attached all knees.

SPEAKER_00 23:46

I'm doing it under the table, yeah. Um like so at those bony attachments, if if it's definitely tender there, and especially for the Achilles, um, that's called insertional tendinopathy. And then if it's on the cord, if you squeeze like that cord of your Achilles tendon, like that can definitely be tender. It might be kind of slightly thick all along the one that's irritated and not on the other one in the earlier phases. And actually, the longer you go, if it's something you've kind of dealt with off and on for years, you might have like a really thick, more specific nodule when it's in that more degenerative, again, that broken down tissue phase, it actually turns into more of like a more specific nodule almost sometimes. And sometimes that is not always as sensitive to touch, but yeah. Um and then sometimes people will have some calf soreness and stuff with it, but it's typically right on that tendon. Um, yeah.

SPEAKER_01 24:39

So does this uh tendon injury apply to more than just the Achilles, or is the the Achilles just the the most common place to see it in runners?

SPEAKER_00 24:50

Yeah, in runners, the Achilles is definitely the most common place, but like I said, if you're doing a lot of downhill and you haven't been uh keeping your quad strength up to snuff, or again, it's just a change. Like last summer I did it great. I didn't do much downhill over the winter. Next summer I start like, you know, the weather's nice, I can get up high and I want to bomb down these hills. And then you might get some of that quad patella stuff is another commonplace. Um and actually another really common one is uh if at the top of your thigh on the outside, that bony knob out there, um, and we're all touching that same spot to the listener. We're all reaching there and touching. So that is where um your gluteus, medius, and minimus in particular attach. And your glute max has a role there. Your IT band goes over there. So that's actually a really common place when people think they have like a bursitis in their hip or something like that. It's often the bursa could be inflamed. That's just a sac that holds lubricating fluids, by the way. Like that could definitely be inflamed. But usually the root cause is glute tendon uh stuff, either glute weakness and or the tendon is getting irritated and inflamed. So the glutes are actually another common place, especially if it's sore closer to that uh bony knob on the outside of your thigh. It's called your trochanter, your greater trochanter.

SPEAKER_01 26:02

I had some pain in that area just two days ago.

SPEAKER_00 26:05

So Yeah, so you could be on the verge and take good notes.

SPEAKER_03 26:09

Oh no. Maybe we'll get into how to take care of it.

Treat The System: Stress, Sleep, Diet, Load

SPEAKER_01 26:14

All right. So what is the main like takeaway from a recovery and treatment perspective? Uh, you know, I guess a lot of people are very familiar with the word tendonitis. And you know, is this shifting of how we talk about these injuries indicative of our a different understanding and how to treat them as well? Yeah.

SPEAKER_00 26:41

So was it the July podcast where we went in depth on peace and love? Yes. Yeah. So go back to the July podcast that I was on to get the nitty-gritty on all that. But yeah, like this shift is really important because if we thought it was just inflammatory, right, then it's all about calming down inflammation. Go back to the peace and love. Like, wait, are we sure we want to calm down all of that inflammation? Like it has a role. But now, even more so, if we're seeing we think we're in those phases where it's less about anti-inflammatory stuff and more about dysregulation of the organization of those fibers and or degeneration of the health of those fibers, then we need to do something more proactive. We need to restore that capacity. Well, restoring capacity is basically training, right? And like you're not gonna get more fit, faster, whatever by resting. So we definitely need to be more proactive. Um, real quick, I've talked about that idea of that degenerated tissue having like little pockmark holes almost in it and stuff. We want to be clear that your tendons and your muscles and everything, like, there's so many thousands of fibers. You not the entire tendon is like about to rupture. Um there are like pockets of this, but there's also plenty of healthy tissue fibers around it. But it's gonna work optimally if we can get as healthy as possible. Um, and so as you dive down that continuum from that just reactive to dysregulated to degenerative, it does get harder to get back to full healing. So the sooner you catch it, the better. Um and so the ways we go about that are definitely very different. Um the first thing I usually start counseling patients on is the use of the zero to ten pain scale. Um and there's research from another one of the four mothers. It's these three women in particular had some really great stuff that we use in our tendon research. So I think that's just great to um see like what they've thrown out there. Um but Silber Nagel put out this um article, I think circa 2015. I could be wrong on the date, but um, where they kind of give like this green, yellow, red light approach to what you should do while you're working through this tendon uh uh injury. And so I usually describe it as zero is no pain at all, like totally healthy, normal tissue. 10 is whatever it would take you to the hospital to get it checked out. I'm not trying to be hyperbolic, life or death, but it's a really intense sensation and you're really concerned. And so you're thinking like that's a good choice is to learn pretty fast, like what's going on here. So one or two I would usually describe as it feels a little funny, a little tight, maybe a little puffy, maybe a little tingly. I wouldn't even call it uncomfortable, but there's just some sensation in that tendon that I don't have on the other side. Right? Yeah, I think sensation's the key word there. It's like I wouldn't call it pain yet, but I feel it. I wouldn't even call it discomfort. Right. It's just the awareness of something there. Right. And so that's a full green light go. Um, so whether that's uh a PT exercise you were given um or um your training or strength training or whatever, if you're feeling ones or twos, like of course I want it to be a zero, but please keep doing everything full bore. Um three, four. I'm starting to think it might call this more discomfort to four, like this is definitely discomfort and not just a funny sensation. I wouldn't officially call it pain though, right? Like there's a little bit of a difference between discomfort and pain.

SPEAKER_03 30:01

Yeah.

SPEAKER_00 30:02

Now that line can be hard to distinguish. So a more objective thing too, and this is bored to the person who's trying to tell themselves it's not bad enough to stop, but it can work the other way too, is if you have to alter your stride because of what you're feeling, right? It's one thing if you are altering it because like you've been doing it for a while. But if you think like actually I'm not feeling it there, it's just my bold habit I need to get out of. That's one thing. But if this is getting intense enough sensation that you're altering your stride or how you're doing a lift, or again, a tendon is a tendon is a tendon. So whether it's in your elbow, um, whatever, like this all applies. Like so, if you can't grip something the same way, it's not just a three, four, it's moving into the next zone. So three, four is it's definitely kind of strong, but I could still do everything with normal motions. That's our yellow light proceed with caution. I'd like to see if you can finish the activity without it going beyond that four. Assuming that happens, then we go into a 24-hour monitoring where um we want to make sure that four or six, 10 hours later, it's not a six or seven out of ten. Just took some time, but now that was too much. And we kind of just needed some time to figure that out. And then 24 hours later, we want it to feel pretty well recovered. So, like if it took five minutes to warm up on the trail and then it was good, then you get that three, four, then twenty-four hours later, I want to take five minutes to warm up on your run. Right. And I don't want to take 10 or 15 minutes. That means it did it's getting a little bit worse. That means it didn't recover.

SPEAKER_01 31:30

So it's important the trajectory of the injury. Yeah. Uh whether you know it's taking longer to warm up or shorter to warm up, you can use that as a point of evidence in how the injury is progressing.

SPEAKER_00 31:43

For sure. Yep. And then if you're feeling five, six, where you're like, maybe I'm gonna call this not just discomfort but pain, or I'm definitely calling this pain, or you're trying to tell yourself it's a four, but you can tell you're altering your movement because of those sensations, that's our red light stop. Um, so if you're experiencing that in any activity, don't do that. And that's all important because the way we rehab this, we actually want to get into that three zone a little bit, three, four, um, because we want to give it a good stimulus for healing.

SPEAKER_03 32:12

Now, does nutrition play a role in helping heal this? I mean, I'm imagining these little holes needing more nutrients to like recover. And I know you're not a nutritionist, but would someone consulting with a nutritionist help?

SPEAKER_00 32:29

Uh certainly. I mean, there's a couple things that we can look at that I can speak to. Okay. And then definitely like if we think there's something literally with your diet, like a registered dietitian or a sports nutritionist would be a great person to consult with to really dial that stuff in. Um so there's we talked about the meds concept, I think, in the one year's yeah, the the acronym MEDS for your tissue ecosystem. I think that's the one from last January.

SPEAKER_03 33:00

Oh my goodness. Okay. Good memory.

Pain Scale And Green–Yellow–Red Framework

SPEAKER_00 33:03

Basically, like we live here in Colorado, right? If it's dry enough and windy enough, long enough, like the ecosystem is ripe for something like a wildfire to blow up. Yes. Right. Whereas if there's a lot of snow on the ground and things like that, like it's not as ripe. Within your body is an ecosystem. And it can be more or less ripe to inflammatory responses and injury based on that acronym. MEDS are the four broad pillars that can keep that in balance. So your mental status, your stress, your exercise, your diet, and your sleep. So just in general, like usually it's stuff like just not sleeping enough and just not eating enough. Not too often is it like specific foods and stuff that we need to do. There are times where that isn't in play for uh a specific patient or runner. But a lot of times, like just a cursory, like you're just not eating enough and you're just not sleeping enough to recharge, therefore, refuel those fibers that have been working hard for you. Or it's on the exercise side where your programming or your choice of how to understand with your coach wrote for you, because I think a lot of times the coaches have good programming, but the athletes kind of their compliance to this programming can sometimes waver. Um if you decided to do a lot more, that was a sudden change in that load. That's the most common reason for attendance stuff for any injury, really, is a sudden change in the load that you're putting on it in a certain period of time. So specific to the tendons, the one nutrient that is out there is collagen with vitamin C. Um around 10 to 15 milligrams of gelatin with around 45 to 50 milligrams of vitamin C has some evidence behind it to being useful. And in particular, you want to be thinking about taking that before your activity. So you're almost like priming your system.

SPEAKER_01 34:53

Good job. Your hand has been trying to feed me collagen for years.

SPEAKER_03 34:57

I do. I try to put it as coffee in the morning before I run. This is a good way to ruin a coffee. Yeah, it's made me stop.

SPEAKER_00 35:06

So that there are some that think that priming those tendons with uh a cocktail that has around those doses um does show some help for tendon priming. Whereas like you might take your protein stuff like afterwards as a replenisher. You do want to think about this as like a primer.

SPEAKER_01 35:21

Um I love this. I'd love to touch a bit on this like idea of like stress and sleep having uh a large impact in healing. And so I mean, it's always important to be low stress and and get good sleep, uh, but I mean, life gets in the way. Life is real, yeah. And how could you figure out that? Like, how would like let's say I'm uh you know having trouble healing? Like, how do I know it's like ah I I need to change my life? You know, I don't know. Like, like how do I how do I tell somebody, I mean, I you know, I can be obtuse and just be like, yeah, you just need to sleep more, dude. But what like how do I figure that out? Like what like how do I help you figure that, right?

SPEAKER_00 36:11

Like when you're in your social media. Can you help me figure it out? I love it when I can help the patient realize it for themselves, right? Versus me telling. So I'm usually gonna try to do a lot of asking questions and let you kind of come to your own. Like, as I'm talking this out, I think I'm seeing some of these root things. So, yeah, not to hijack the attendant thing too much, but real quick into that. I'm gonna ask uh not like is your life stressful? Like everyone's life has stresses. And let's be clear stress is just another word for loader demand. So it can be positive things. Like I worked with a guy today whose one daughter's off to college and the next one goes off to college next year. And he's raised two daughters. I've worked with both of them independently in the clinic that can articulate for themselves, carry a great conversation with an adult, can advocate for them. Like they've done a phenomenal job and they should be proud of the humans that they've raised. And they're probably excited for that next step of their journey. And it's all very positive things, but it's still a load and a demand. And so whenever we have increased stress, we have more cortisol in our body. And that's an inflammatory hormone. So what I'm gonna ask is like, is there anything in the months preceding this that is different for your in terms of your stressors in your life?

SPEAKER_01 37:17

Okay.

Collagen, Hydration, Protein, And Sleep Hygiene

SPEAKER_00 37:18

Than what is normal for you, assuming prior to this injury you haven't had problems. Right now, if this has been a cycle that's been off and on for you, I might not bring this up first session, but as I get to know you, I'm gonna learn things about you. And like I've got another guy, totally different family, but also have seen his whole family and his girls who are also amazing at advocating for themselves and going off to school at the end of this year. Like he's flat out told me, like, his job and the company he works for, like, he wrestles because he really does not like their mission, but it provides really well for his family. And he's constantly in this stressful balance of like, how much longer do I have to pay the devil to get free? Kind of vitality. Yeah. Now that's somebody that I'm having very real conversations with the reality, like, look, there's a lot of privilege to consider that like you could just leave and go and do something else. Like, I don't ever say it that way. But I do just say, like, I'm not here to tell you that this is the case. I'm just making sure you're asking yourself, is this worth it? Is the toll it's taking on you physically worth it? I I can't answer that. You can. But that's how I would bring that up to have the patient be thinking about those kind of things. And then we have some life stresses are modifiable and some are not, right? Like uh someone just died in their family. Sure. You can't change that, you know, and that's hard and you got to work through that. So then what we say is do we want to consider modifying your training? Because we know that right now the battery. So the analogy I often use is the the phone, right? How many times we're walking through the day, like plugging in for five minutes at a time, trying to get from 13% to the end of the day starting at 8 a.m. Sure. If we can just make it to the end of the day and we can plug in overnight, right? But then you forgot to plug it in overnight. So tomorrow you're doing it again and eventually you kind of like, shoot, I ran out of a place to plug in and you run out of battery and your phone dies. Like, how many athletes I'm doing, like they've been living their life that way versus like, well, let's reduce how much we're using the phone. Stop checking whatever at that time so that you don't use the battery for that. Turn it off for three hours in the middle of the day if you have to like let's reduce your training intensity and volume for a little bit while you manage this other demand on your system or lack of recharge for your system.

SPEAKER_01 39:32

Thinking about doing that makes me physically uncomfortable. Like I don't want to, I don't want my inability to handle my life affect how much I'm running. Like I like, like I wanna, I want to meet my running goals, you know, and like if the rest of the life has to like fit around that. And for those times where my life is just too stressful, uh like I hate the idea that I would have to give up something and running to make it better. You're probably right. It's just this is my reaction. My last injury when I tore my calf, calf strain, uh on like a shakeout run. It was on, I was super stressed that day. I'd come off work like so stressed about some task, and I went for uh a short, easy run and had to limp home because I my calf was strained and like I felt so tight. Uh, you know, I woke up tight and I was like, oh, it'll loosen up when I run. But that day it didn't, it snapped. And yeah, I mean, I believe you that the stress affects it, but you know, maybe I need to approach it in a different way.

SPEAKER_00 40:42

And we're always balancing, like, we'd like to think that one stressful day doesn't suddenly put our bodies so fragile. But my curiosity would be like, were there precursors to that stressful day?

SPEAKER_01 40:51

I mean, there was a buildup of stress, of course.

SPEAKER_00 40:53

So I want to be really cautious to be like one stressful hour, you know, or whatever doesn't put us at that risk. But yeah, if you're living it that way over and over.

SPEAKER_01 41:01

Aaron Powell No, it was a buildup. Yeah. But I didn't think that an easy run could create an injury because the conditions were ripe in my body. And and it turns out that's not true, but I just didn't think it was possible. Right. Well, and then we also have the the physical stress, right?

SPEAKER_00 41:18

You were at the end of a training block. It was a shakeout run. And I had a I had a race coming up. Right. So like combining all of those stressors, yeah. And then just real quick, like I would ask things like hydration, nutrition. I'm going to ask about hydration. Yeah. Like and you just kind of fill me in on how you drink throughout the day. Uh my dietitian friends have suggested around 50% of your body weight in pounds, take that to ounces. So if I weigh 150, I want to go for around 75 ounces of water a day, with at least one serving of those being electrolytes. Um, regardless of whether it's a hard training day or not. I think we're more than water inside, so electrolytes are pretty good. Um, and then a food thing, like I would start off more general of like, do you feel like you're eating enough to fuel? Like, do you feel hungry all the time? Things like that. If you're saying you feel pretty good, I'll leave it at that there. I do often come back to the protein discussion um a little bit later if like we're seeing some progress, but then things are kind of plateauing. Um a lot of people, there's mixed opinions out there um on how much protein, depending on like are you trying to bodybuild or whatever. But just remembering things like the USRDA is enough to prevent a deficiency. So for you to survive, but not really designed to tell you how much to thrive.

SPEAKER_01 42:29

USRDA is recommended daily allotment or something.

SPEAKER_00 42:32

Allowance, yeah, I think the International Society for Sports Nutrition will recommend as much as a gram for every pound you weigh, and even more if you're trying to do weight loss, because it does a lot for making you feel satiated. Um so most of my clients, um, as a runner who's going to do some strength training because they listen to the podcast we talked about in July when we went in depth on strength training and actually last year too. Um then I'm looking for maybe around three-quarters of your body weight in grams of protein a day if that's relatively close to achievable. And then sleep, you never ask somebody to sleep more. Like uh just carve out more hours of the day, make the sun stand still over in Japan and keep sleeping, right? Like that's not gonna work. We could ask, like there are some things that like, are you just putting on video games an extra hour that you shouldn't? Then maybe we can find it. But usually it's are you getting quality sleep and how can we improve that? Is it quiet? Is it cold? Is it dark? Are you trying your best to turn off stimulating things like screens at least 15 minutes to an half hour, and then ideally about an hour before getting your shut eye, like trying to get off of technology and stuff if you can? Um careful about alcohol consumption later in the day and coffee, it depends on like most people shouldn't be having coffee uh after around like 12 or so, just because of the half life of caffeine and how long it might still be in your system when you're trying to go to bed. There are some who can genetically process caffeine a little bit faster.

SPEAKER_03 44:00

I don't understand those people.

SPEAKER_00 44:01

Yeah, I don't the dinner coffee people that aren't getting decaf or blow my mind.

SPEAKER_03 44:06

I am not one of them. Yeah.

SPEAKER_00 44:07

So those would be the factors that I'm thinking about the nutrition, all those resources for this human who's not coming in with this tendon situation.

SPEAKER_01 44:17

And all of this is to provide a healthy environment for healing. Yeah.

SPEAKER_00 44:21

Or for a healthy ecosystem for training body.

SPEAKER_01 44:24

Yeah. Exactly.

SPEAKER_00 44:25

And or assessing like, is your ecosystem within part of the contributing factor besides just the training program that led to this tendon getting irritated?

SPEAKER_01 44:34

Yeah. And I think my reaction under lies you know a common phenomenon in runners at least, where you just you just want to separate it, right? You want to consider the training as its own thing and the rest of your life as its own thing. But it really all takes place in the same ecosystem, the same body. Unfortunately. So you have to consider how one affects the other. Yep. Interesting. Well, I'll do some thinking about that personally. So I guess we'll come back to the tendons.

SPEAKER_00 45:06

Yeah. So let's say you come into my clinic with this tendon that's flared up, right? And we're saying, well, we don't want to be passive. We're not throwing ice on here and telling you to elevate it and stuff. And you know, the the primary care physicians, uh I get that they're not trained in all the musculoskeletal stuff. I'd love it if there was a little bit more awareness of like we need to be more proactive and movement is medicine kind of approach. Um, there are some that definitely do a good job of that, but there's plenty that I'm like, uh I understand they told you to do it that way. Let's talk about it. Um so I think one of the big reasons I've been talking about tendonopathy so much this year and why I thought it could be a good uh topic is a lot of people listening to this probably have heard of ways to deal with their tendon. And in particular, they're gonna go to eccentric exercises. And an eccentric exercise is when we are in control and we slowly lengthen a tissue. So for the calf Achilles, think from the top of a calf raise, slowly lowering that heel down, down, down. If your foot is on like a step, you're gonna take that heel even down beyond that step, right? So that's the eccentric phase, the lengthening phase of that muscle. Um and there's nothing inherently wrong with eccentrics in and of themselves, but depending on your phase of irritation, we may choose um a different exercise that has shown some really positive effects for pain relief and um for helping address a concept called the shielding effect, where I mentioned not all of your tissue is broken, right? That not all that tendon is broken. So the healthy fibers will often try to shield and protect the damaged ones and take on the load.

SPEAKER_02 46:41

Yeah.

Isometrics vs Eccentrics: What Works When

SPEAKER_00 46:41

Um, and very thoughtful of them, however, that it also enables those damaged ones to never get stimulus to try to respond to and adapt to and to grow and to get better, right? Again, how do we grow? By being challenged. We need those tissues to grow. They're undernourished, we need to nourish them with growth and challenge. Um, so we do a lot with isometrics now. Um, and so an isometric contraction is when you engage a muscle, but it does not change length at all. So therefore, there's no movement. Oh. So for the calf raised picture going up onto the ball of your foot, holding that heel up nice and high, and then just staying there. That's an isometric contraction. And you can stop at any point in the range and hold. If you're holding, then you're doing isometric contraction. Um, and so uh study circa 2019 looked at the patella tendon and volleyball players, and they had them do um like five rounds of 45 seconds with a pretty heavy load of a wall sit. And these are for patella tendon, jumpers knee. And they showed a very drastic reduction in their pain, um, like five points on the zero to 10 pain scale from just five rounds of 45 seconds of holding. Like there's not much medication that does that that fast. No. And so a significant reduction in their pain. And then also because you're not in pain, now your body's feeling more confident to try to engage those fibers. So then a significant increase in their uh force output of those quadricep muscles using some machines that measure that. And so um, yeah, so we go into a lot of isometrics when you're in a high irritation dose. So high irritation is when you're really feeling it during your runs, you're feeling it kind of all day long. It takes just that drive home and it's like super painful to get out of the car and limp in, things like that. Um so isometrics, that's there's a lot of cool stuff about them uh that we're learning.

SPEAKER_01 48:34

And uh so is it just at the contracted point in the muscle, or do you also would you also do isometrics at like sort of an eccentric position where you're elongated with the muscle?

SPEAKER_02 48:46

Mm-hmm.

SPEAKER_00 48:47

So remember I talked about the two different places of the Achilles that I would be thinking about as a PT.

SPEAKER_01 48:53

So you you'd be talking about where it attaches to the calf uh muscle and where it attaches to the to your bone on your heel. Yep.

SPEAKER_00 49:00

So before we answer that, we want to appreciate that tendons like tension, but they don't like compression.

SPEAKER_02 49:06

Okay.

SPEAKER_00 49:07

So if I have you do this isometric hold with your heel off of the step and lower, can you appreciate how that heel bone would almost be pushing from within against that tendon? It's gonna be a lot that tendon's stretched and it's stretched out right around the bone. Whereas if we come up higher, it's gonna be a little shorter and it's not, it's gonna have some slack and it's not gonna have all that compression from within, right? So usually if you're really highly irritated, I'm gonna have you go into the higher position. Or if your symptoms are on that bone, I'm gonna have you in that highest position. As you're improving, I might say, okay, so now like if you're gonna do four holds, I usually suggest around three to four holds of 30 to 45 seconds. Our goal is to have a load that's around three-quarters of our max strength. It should be a decent amount of work. Uh, otherwise, we don't get that shielding effect concept for sure. Um and so as you're improving, I might say, like for each hold, be in a slightly different length of muscle, or as you're saying, like a different position, you know, from the shortest to halfway to level. So yeah. So I like to play around with different angles for sure.

SPEAKER_01 50:17

So they're all effective given that they aren't uh exacerbating your pain. Yeah. That's what you can always say if they if your pain is right at the heel and you go to that elongated position, you're gonna be pressing against that painful spot right on those damaged fibers and possibly irritated. Improving things. Right.

SPEAKER_00 50:35

And so that's why the first thing I talk about is the zero to ten pain scale that we talked about at the beginning here. Hey, if you're in those fives and sixes, that's too much, we need to change it. If you're three, four, that might be exactly what I want. And then we'll just make sure that the rest of the day it didn't feel worse. It felt okay. Um, and then and that's how we kind of guide that. Once you're out of that high irritation phase, we're gonna come back to strength training again. It's all about load. Yeah, you gotta, you gotta stress it and uh and build the strength of the muscle. And so um it's time under tension, and so slow and heavy has got a ton of publicity in the literature right now. And so first let's kind of define like that lower irritability. You might have that five minutes of something when you first start, but otherwise the rest of your run goes great. Maybe it's a little sore after three hours of sitting at the computer for your first few steps, but in general, it's not much of an issue in your day. And when it is, it's low intensity, right? So we're in that low irritation phase. So the isometrics, we're doing those every day from that high irritation phase. We're doing every day three to four rounds holding for 30 to 45 seconds. Slow heavy strengthening, the principles of strength training apply. Like if we're doing a heavy enough load to stimulate it, we need to give it recovery. So we're only doing two at most three days in a week. Three sets of five. Each repetition, I'm taking an honest three seconds to come to the top of that heel raise, and an honest three seconds to come all the way down smooth and control the whole time. So it should take me about 30 seconds to do just five of those really well. And again, we want pretty heavy, so when we get to five, we're thinking I could have done two more of those all the way through the full range with good form, but I d really don't think I could have done an eighth one. Like so, leaving about two reps in reserve is how I would phrase that. Um The really key thing too, we have to appreciate which muscles make your Achilles.

SPEAKER_01 52:31

What do you mean by that?

Soleus vs Gastroc: Train Both

SPEAKER_00 52:32

Yeah, so there's two muscles that make your Achilles, not one. Okay. And so you have one that starts above your knee, comes down about halfway down your calf, it almost looks like a butt. It's like two heads that kind of curve up. If you look that if it's like an upside down heart, the top of a heart upside down is another way to think of it. And then it's tendon all the way down. That is your gastrocnemius. Um, and so when you do calf raises, isometric holds with your knee straight, you're biasing that muscle more. Below your knee, at the back of your tibia, your shin bone, uh, is the beginning. And then if you go down kind of just above the skinny cord of your Achilles and you come up a little bit, and you can feel like the thickness of some muscle there.

SPEAKER_01 53:18

Yeah.

SPEAKER_00 53:18

But we're well below that two-headed meaty monster of the gastroc.

SPEAKER_01 53:22

Okay.

SPEAKER_00 53:22

That's your soleus. Oh, soleus. Oh, your solar plexus. No, no, your soleus. And so the the soleus, when we bend the knee to around 90 degrees, we bias that. The soleus is likely your more like the one that produces more power with every toe-off. Your soleus, uh cat cataveric studies have shown that it's 50%, and some have seen as high as 75% of your Achilles tendon is made up more of soleus fibers than gastroc fibers. So when I'm doing those isometrics, I'm telling my patient uh on that high irritability phase, I'm going on your odd number days of the of the calendar, you're doing knee straight, and on your even days, knee bend.

SPEAKER_01 54:06

Okay. So there's a there's a functional difference between knee straight and knee bend for those. For biasing those muscles. You're basically exercising two different muscles or primarily.

SPEAKER_00 54:17

Yeah. No, exactly. Interesting. And yeah, you're never putting one on zero and the other on 100%, but you're biasing load a lot more towards one or the other. And so then on those uh when we're in the slow heavy stuff, we're doing the same thing. Um and that's where like there are ways to do it at home. Um most of my patients get a pretty big laugh at this, but I'm actually serious when I tell them I'm like, uh so like Miranda, if it was your soleus and we were ready for that phase, I'm like, what I want you to do is like, what do you have at home? Let's say you don't have the gym that you all have here. I'll say what I want you to do is I want you to try to have John sit on your knee and do your calf raises. Or in your isometric phase, I want you to see if you can raise your heel up off the floor with John sitting on your knee. And like a lot of people are laughing at me, but that soleus is a very strong and powerful muscle. And we usually need quite a lot of load to really challenge it.

SPEAKER_01 55:05

All right, I'll sit on you.

SPEAKER_03 55:06

All right. Let's give it a try.

SPEAKER_00 55:08

Um, but if you're if you have access to a gym, that seated caffeine's machine, like I'm not the biggest fan of like seeking out the machines that isolate things, but when we do need something isolated, they do shine, and that seated caffease machine is magic when you when you need to isolate that soleus for your Achilles rehab.

SPEAKER_01 55:26

I have a question about something you mentioned some minutes ago as as it relates to my current injury, and something I'm thinking about a lot, is you mentioned this idea that your body is used it your body is basically trying to avoid uh an injury by by biasing away from the injured area and you know, and and using good muscles, fibers, or or a path to create the force that you need. But it's it's basically saying, Oh, you have an injury, so I'm gonna use these different muscles to engage. So subconsciously, your body is basically avoiding a pain point. And what this can do in the long term is create even more injury as you're basically favoring or altering your gait in some way.

SPEAKER_03 56:20

Uh and what I guess what I'm wondering is, because I'm at this point personally, is like maybe you should share it with the listeners, like where you're at personally a little bit so that it makes sense.

Brain Mapping, Gait Compensation, Needling

SPEAKER_01 56:33

Yeah, yeah, yeah. Okay, that's a good point. Uh so I have a left leg, my left leg, the way I told Michael a few weeks ago was my left leg just doesn't feel right. It just doesn't feel like my right leg. When I do single leg squats, I can lift the same weight on both legs. So when I isolate it, when we if let's say we were using a machine, like a one-legged leg press machine, I you know, I both my legs are equally strong. But in practice, in running, my right leg feels like I could just take a step in any direction, lift up, I could land on it in any way, and it would hold. And my left leg feels like I have to be very straight, I have to be very rigid. And so it just, I don't feel like it is strong enough to take a load that might be off center or or crossing my body. I always have to align. And one thing that we did too, we talked about in as like what I might be experiencing was perhaps that my body has like essentially compensated for an injury that I didn't realize was there. And I'm sitting here thinking, okay, how can I undo that unconscious or subconscious uh biasing away from the injured location? And I guess is there a general theory here about like how to retrain these subconscious like biases that you like your brain just does while you have an injury? I don't know. I've kind of rambled a bit.

SPEAKER_00 58:12

Did I confuse the question? No, I think I understand it. Okay. So, you know, we would come back to so many times like when someone has an injury or like what's the thing that hurts? Like, that's usually the thing I want to do. So I'd say, like, it sounds like when you have pre-programmed things, like you have all the confidence and like you said, things that feel like they aligned up. So how often did you train? Remember last year you were going to train for the run in the sand? Yes. And we talked about getting the sandbox.

unknown 58:39

Yes.

SPEAKER_00 58:40

Like, so how often are you having fun with like a single leg and like literally jumping up and down, but trying to get your left leg to go just a little bit outside, a little bit inside, right? A little bit forward, a little bit back, like having like a thin line even, right? So, how much are you even training that concept that feels like it's lacking? So the first thing I would do is say, like, can I get to a way to um strength train it? And or this sounds like a little bit more of like plyometrics, like load acceptance and response. Um, but like, what are ways that we can like, okay, now I want you to do it with it in a toe out position for those squats for just a couple repetitions, a toe in for a couple repetitions, uh, you know, something like that. Um go a little lighter, get a hand on a wall, and just slightly lean so it's not directly underneath of you, you know, and and do a couple repetitions. Right.

SPEAKER_01 59:30

So make it uh emulate a little bit more the trail running experience where it is not, it is not a stairmaster out there.

SPEAKER_00 59:38

Yeah, exactly. It's not a track, it's not a road, you know, although roads can have their own things, but yeah. So that's like the first thing I would go to. But the other thing that's a little harder is appreciating the power of the nerves in the brain. So your brain has this uh like the outer part of the brain, we kind of call it the homunculus, and it's a mapping system of your body. All right. So like one part of your brain is responsible for like your elbow very specifically. If you're listening, sorry, but like I'm pointing to a very specific spot on my elbow. And then right next to it, it's responsible for the next part and the next part, right? So your brain, like certain parts of your brain are responsible for certain parts of your body and like processing what's going on there. When we have injury, there is smudging of these lines that have demarcated like these exact points in the brain along the homunculus, and there's smudging. So the brain is not quite as clear that I feel that right there or half a centimeter further, or a whole centimeter further, like and so um we need to consider that possible contributor. Again, I always do that soup analogy. It's one of the ingredients to what's going on, right? I think we can retrain some muscle patterns that are more variable in your training specifically, but I think there can be, is there a problem there? And so like in the dry needling space, there are very specific. Um, so it's one of the biggest reasons to go ahead and use electric stimulation current uh with your dry needling. Uh, almost every patient I'm going to try to get the current going because we've seen um these current models that show that something comes in, what's called an aperent, so coming into uh a certain part of the spinal cord, and then it gets into this little tract that goes all the way up to your brain, and it's kind of like cleaning up and redrawing those lines so they're more clear again. And then it comes out the efferent, so that's going back out to the region that the needle is in, usually a muscle, and helping to kind of redraw, clarify, and improve that neuromuscular communication. Um, and so using like so there's all kinds of tools in the tool bag, and depending on where we think this is going, do we think that that could be part of the cocktail that helps your body to kind of have um a little better picture of it? So the dry needling course that I took, like the guy who teaches it and the gal who teaches it, like they both kind of talk about this concept of it's true in the literature, like your best predictor of an injury is a previous injury to that same spot, right? So, hey, you strained your hamstring, like the odds are you may strain that again compared to the other one. And we do think a lot of that might be to that neural mapping and the way that this dry needling stuff can improve the mapping and then therefore the communication and the access to all the little things in there.

SPEAKER_03 1:02:36

That is very interesting.

SPEAKER_00 1:02:38

Oh, it's so fascinating.

SPEAKER_01 1:02:39

It's not just like, oh, you have a weaker tendon muscle connection, but the way your brain is trained to use those tendon and muscles.

SPEAKER_00 1:02:49

Yeah, recruit is the word I would use. Yeah, the recruitment of the of those muscles and fibers and and the coordination of exactly how much force each one wants to create to put it in that exact position and stabilize or create motion, like that whole patterning. You know, just think about like how freaking complex like one walking step is, let alone running 100 miles, you know? It's just so incredible.

Coaching Cues And Form Change That Stick

SPEAKER_01 1:03:14

How much effect can you have just thinking about your form? Right? Like this is something I'm I'm dealing with right now is like I know I've been underutilizing my big muscles, and that has caused me weird pains, and I need to restart, you know, engaging those glutes, right? People talk about engaging those glutes all the time. And I'm wondering how much like can if I think about engaging my glutes on every step, can I actually make a difference in my form? And how long does that take? And like, like, you know, yes, there's something to like running electric currents through, but what is just what is the power of our brain, just pure like frontal lobe thought to to untrain these behaviors that we've subconsciously learned.

SPEAKER_00 1:04:01

Nice. Just a quick note. We will get back to the last phase of the tendon stuff. That's my favorite part of these podcasts, is where they go. Um, John's injuries. I'll try to be quick on that. Um so there's a great study, uh, Rich Wille in uh based out of Montana now. Um he looked at these runners that we did strengthening exercises to see if it would help with their running gait. Um so we got their muscles stronger, we could do testing and show like they could produce more force. But if they ran with like an overstride, they still ran with an overstride, even though we strengthened their posterior chain muscles to pull that foot back underneath, right? Their hamstrings and glutes to pull that foot back underneath faster. Like so they have the ability to and the force to, but having the strength and knowing how to utilize it are two different things. And so you have to So the first question is are you sure you have the strength, right? In those muscles, to to execute the way you want them to execute. Yeah. Right. And then yeah, like there are uh a million tricks out there. Some have been studied and shown to prove to work really, really well, others not so much. What I will say is typically in the coaching, like lifting coaching as a PT, like coaching you through a movement in that space, the psychology research shows that if we give you an external cue, something outside of your body to think about, you're usually going to be more effective than an internal cue. So thinking squeeze my glutes is might be good enough. But what I might say to get the same reaction of engaging your glute max would be I'm giving you a winning lotto ticket for hundreds of millions of dollars, and I want you to hold it between your cheeks and don't let me take it from you. You will probably also engage your glutes just as much, if not more, because of that external cue of what to do. Um, so external cue is Usually thinking about uh direction um and and speed um and and those kind of concepts. So something outside of your body. Um when I'm coaching the deadlift, right? I'm coaching like belt buckle to bar, you drive your belt to your to the bar, um things like that. So you want to do your best when you're finding your running cues to think about an external cue. Um so another one that I find for getting like the glutes to work really well is focus on the part of your stride from your foot on the ground to pushing back behind you. Because the more you're thinking about that, then you're gonna engage the muscles that push back. Don't worry so much about the knee drive forward, because then you'll start thinking about your hip flexors in the front of your hip and your glutes on that other side. So those are like some examples. Okay. Um, if it's the side to side glutes that you're trying to work on, like it might be like imagine you're running in a very narrow um hallway. We've talked about Star Wars before. You're in the trash compactor and it's narrowing and narrowing and you're going three PO, three PO.

SPEAKER_01 1:07:00

Oh my gosh. It reminds me of running in these rutted trails on Dark Divide, where like you basically have to like put your feet directly in front of the other. Yeah. We're gonna be talking to somebody who ran that race next week. Nice and and he uh I got done with this particularly bad rutted section, and I was like, oh, that was so difficult because it's like it was all it was like you know, 10% downhill grade. Oh gosh. And and the the walls of the trail were like two and a half, three feet high with bushes on top. So when you got off balance, you just fell into a bush and you just you couldn't you couldn't put poles anywhere to sort of balance you.

SPEAKER_00 1:07:37

That sounds like you should book your IT band treatment appointment for me. Like with a crossover gate plus downhill. That's an IT band recipe, right there.

The Long Game: Heavy Slow + Plyometrics

SPEAKER_01 1:07:44

Exactly. We got done talking to Dave, and he was like, Oh, I didn't feel like that was that bad. And I was like, Oh, you must, you must have great balance, Dave, because I was falling over the whole time. That's awesome. Anyway, yes, strengthen the side muscles. So yeah, I guess we can get back to tendonopathy treatment.

SPEAKER_00 1:08:03

Sure. Well, just the last phase. So if I didn't say it already, the other thing about tendons is um it's a nine to twelve month process to like fully recovering and restoring and restoring that tendon. Right. So you're usually only in pain for uh two to six weeks, depending on how long you've been putting up with it, with that isometric dose of exercise that we talked about at the early end here, you tend to get that pain relief really fast. And that's actually part of the problem, is you think, well, I'm pain-free now. I'm better. I don't have to keep doing that specific muscle tendon.

SPEAKER_03 1:08:34

That's an important point to make.

SPEAKER_00 1:08:36

Yeah. And so I use the analogy of like a demolition for a remodel in a house. Like you got to get all that debris away from the demolition. Well, that's what all the pain relief is, but you haven't even begun to remodel it. So it's not really livable yet. And so then we do that heavy, slow strengthening and that low irritation phase that I was talking about is a lot like putting up all the framing and and whatnot. But then we have to do all the finishing work, right? We got to get the wires in the wall, the drywall, the molding, like all those little things. So um and that process is the part that takes the longest. And so you can get yourself pain-free in a month, usually for a lot of these things. If you've been doing it for a really long time, six six months, a year, like it might take longer than a month to get out of it. But that recurring cycle of three months later, training is building and that tendon is coming back, it's because you probably didn't finish the job of restoring its capacity and trying to improve whatever level in that continuum you're at to try to move back up towards healthy tendon. And so the heavy slow strengthening is like the bulk of it, but we have to do some energy storage and release. Um, and that's just a fancy way of saying we have to do like jumping. Oh. And so I usually prescribe about two months, twice a week, three sets of five, slow and heavy, honest sense of maybe two reps left in the tank. And then one month where we'll go kind of fast. Again, if it's the the calf Achilles, maybe you don't even have to do jumping, but like pogo jump roping would be fine. Or just not even leaving the ground but up and down kind of fast uh on one day. Maybe another day we go up slow and we drop and catch right before the heel hits the ground. You know, those are my favorite. You know, some of that kind of stuff. So um and then of course, like throwing in even just legitimate jumping, um, whether it's um side to side on a ground, you know, maybe to help your situation there, John. Sure. Whether it's some box jumps, um, jumping from high down to low and absorbing. Um and so I usually do like about a month where we don't worry too much about the slow heavy, um, but we just focus on that. And then I'll do that three-month cycle, right? It was two months slow heavy, one month like plyo, and I'll do that two months, that same three-month cycle one more time. So between about one month of isometrics and those two, three-month blocks, we've at least brought you about seven months along of that nine to twelve month process to like fully recovering your tendon. So tendon is a long game. You gotta have patience, you gotta trust the process. It is safe and encouraged to keep training during that tendon irritation as long as you're following that zero to 10 pain scale concept. Um, but don't stop just because the pain went down, or else you might see yourself more likely to be in that cycle. There are some people who are doing everything right and there's just other factors, and it's it is just off and on. I get it. Um, I would encourage like, are we sure those meds are on board, right? Where's the stress, nutrition, and sleep? Um, what is the programming looking like? Is there something in the programming that like every time it's there, like, do we need to change how we get to there in your programming? I don't know, right? That so there can be all those kinds of individual factors, but typically if we go through that nine months of like really working on everything dedicated, like we see really good results in the tendon space.

SPEAKER_01 1:11:46

Interesting. This is great. I mean, I I don't think as a runner I jump enough.

SPEAKER_03 1:11:52

I jump every week.

SPEAKER_01 1:11:53

You jump every week.

SPEAKER_03 1:11:54

My um class, my weight lifting class has uh cardio intervals that has jumping in it.

Maintenance PT And Protecting Life Margin

SPEAKER_01 1:12:01

Beautiful. Nice. As a kid, I jumped all the time. That's basically all I did. Jump and play video games. Uh yeah, that was interesting. Do you have any final thoughts? Or do you have any?

SPEAKER_03 1:12:13

Yeah, I do have a final thought, and it's unrelated, but it's related to Michael and PT. And I wanted to say, like, and encourage our listeners to not just go in when they have problems because thank you. What I what I did is I ran I ran high lonesome and then I had a quick turnaround to go run TMB, and I didn't have any issues really. I came out of High Lonesome being like, I don't really have any problems, but oh my gosh, I don't want to get to Europe and realize I have a problem. So I'm gonna go check see Michael and have him like give me a tune-up or like check in on my body to let me know if he sees anything or notices anything off.

SPEAKER_00 1:13:04

I remember that session. I'm looking forward when we're done here to hear about how DMB went.

SPEAKER_03 1:13:08

It went amazing. And part of it was that I think my body was like ready.

unknown 1:13:14

Yeah.

SPEAKER_03 1:13:14

And that was a really helpful component in getting it ready for that adventure. So I want to encourage people. I want to encourage people to like not just wait till you have problems. If you need a tune up, yeah.

SPEAKER_00 1:13:27

Seeing us for maintenance is like a great thing. Or like there's the smallest sign of something, like go ahead and get on top of it. Like and not everybody is in a place where the resources, time and money are there to do it that fast. But if you can, you can often save yourself, you know, in one visit, we get it covered instead of needing three to six to seven months of, you know, you're not seeing me every week, but a long process. So yeah, thanks for that plug. Exactly I couldn't have paid you more to say it just like that. That was perfect.

SPEAKER_03 1:13:55

Um and we like to end our podcast by having our guests share a piece of advice. Michael, you've you've shared multiple pieces of advice, but I'm sure there's more you can share.

SPEAKER_00 1:14:08

Yeah. Usually I'm thinking ahead of time because I know that's coming. Uh-huh. But uh Do you need me to stay over time? No, no. But I mean, other than don't play leapfrog with a unicorn, that doesn't go well. It's funny. I like that. Um I think in this time and space, like thinking about self-care and thinking about margin in your life. Uh to not belabor that meds concept too much, but I do believe a high percentage of what I treat in the clinic, a high percentage of just what I see for people, my friends that are struggling with things in life. If you have the space in your life, like you have the bandwidth and the resources to support things by making some modifications to give yourself just a little bit more downtime. Um, and maybe right now you can't because these are non-modifiable factors that are happening in your life. Have a game plan for when those are different. What can you change? Um, and if you're in a space now where you do feel really good, it's probably because there is some margin. Notice that and and pay attention to what you say yes to and how it's going to impact that. So again, like thinking about the power of the word, not necessarily no, but not right now, um, for taking on opportunities and responsibilities. Um, just having a little pause and and and prudence and thinking before just saying, yeah, I'll do that challenge, I'll take on that extra role at work, um, whatever it is. Um, and just appreciate that margin and that parasympathetic decompression time. It's so valuable for mind, body, and soul.

SPEAKER_03 1:15:55

I love that.

SPEAKER_01 1:15:56

Yeah. I mean, towards the I often think of running as cyclical. And so there's some periods where you need to step back in one area and push forward in another. Well, thank you, Michael, for round three. Appreciate everything. I hope everyone learned a lot about tendinopathy. And uh, we'll see you next time.