#797: Dr. Keith Baar, UC Davis — Simple Exercises That Can Repair Tendons (Tennis Elbow, etc.), Collagen Fact vs. Fiction, Isometrics vs. Eccentrics, JAK Inhibitors, Growth Hormone vs. IGF-1, The Anti-RICE Protocol, and How to Use Load as an Anti-Inflammatory

Transcript from https://podmenti.com/t/35a299190bcd35b6

Hello, boys and girls, ladies and germs. This is Tim Ferris. Welcome to another and very detailed, very practical episode of the Tim Ferris Show. My guest today is Dr. Keith Barr. He is a professor at the University of California, Davis, in the Department of Physiology.
in membrane biology. We get into
So many facets.
of exercise what you can use today
that is counterintuitive.
I
Had my mind blown. I took so many notes.
We talked about isometric exercise for tendon health.
Optimizing different protocols.
Debunking on some level eccentric training, specifically for connective tissue.
How to load post injury or surgery collagen supplementation.
Things like BPC one fifty seven.
Pharmaceutical impacts on tendons, estrogen's role.
in tendon health and strength, mitochondria, ketogenic diet, longevity, inflammation.
And taking a balanced perspective on all these things. How do you use them? We get into exact
Training protocols that rock climbers use.
It is an amazing episode, and that's not because of me, it's because of Keith. So let me give you a quick bio and then we'll hop right into it. During his PhD studies, his research revealed that the mechanical strain on muscle fibers activates the mammalian target of rapamycin. Some of you may know that as mTOR.
signaling pathway, a crucial regulator of muscular hypertrophy or muscle growth. So he knows a lot about muscle growth. He's been a strength training coach as well. Subsequently he studied the molecular dynamics of skeletal muscle adaptation to endurance training under the guidance of Dr. John Halazi, a legend in the field of exercise physiology.
considered the father of modern exercise biochemistry.
Building on all of this, he conducted research into tendon health and the potential for engineering ligaments.
That is creating ligaments in the lab.
Upon which he can test all sorts of things, which could also have implications for treatment and recovery from injuries. Dr. Barr now runs the functional molecular biology lab at UC Davis. His lab's work
Ranges from studying molecular changes in our cells to conducting studies
to affect real world improvements and people's health, longevity, and quality of life. You can find him on Blue Sky.
As muscle science, you can find him on the UC Davis website. We'll link to that in the show notes at Tim Dotbloc slash podcast, and his new company, which you can check out.
Which is designed to improve tendon loading with various technologies and tools is sinew
Us sinuus. So S I N E W U S dot com. And now let's get to the show.
But first a few quick words from our lovely podcast sponsors who make products.
And services that I use.
Every day.
Or every week. I personally vet.
Everything.
And that means that probably less than twenty percent of the podcast sponsors who wish to sponsor the show
end up sponsoring. But I'm fine with that and here are the few that made the cut.
Listeners have heard me talk about making before you manage for years. All that means to me is that when I wake up, I block out three to four hours to do the most important things that are generative, creative, podcasting, writing, et cetera.
before I get to the email and the admin stuff and the reactive stuff and everyone else's agenda for my time for me.
Let's just say I'm a writer and entrepreneur.
I need to focus on the making to be happy. If I get sucked into all the little bits and pieces that are constantly churning, I end up feeling stressed out and
That is why.
Today's sponsor is so interesting. It's been one of the greatest energetic unlocks in the last few years.
So here we go.
I need to find people who are great at managing.
And that is where Crescent Family Office comes in. You spell it C-R-E-S-S-E-T. Creset Family Office. I was introduced to them by one of the top CPG investors in the world. Crescent is a prestigious family office for CEOs.
Founders and entrepreneurs. They handle the complex financial planning, uncertain tax strategies.
Timely exit planning, bill pay, wires, all the dozens of other parts.
of wealth management and just financial management that would otherwise pull me away from doing what I love most, making things.
Mastering skills, spending time with the people I care about. And over many years, I was getting pulled away from that stuff at least a few days a week, and I've completely
Eliminate that.
So
Experience the freedom of focusing on what matters to you with the support of a top wealth management team. You can schedule a call today at crescentcapital.com slash Tim. That's spelled C R E S E T. Crescentcapital.com slash Tim to see how Cresit can help streamline your financial plans.
And grow your wealth. That's crescent capital.
dot com slash
Tim. And disclosure, I am a client of Crescent. There are no material conflicts other than this paid testimonial. And of course, all investing involves risk, including loss of principle. So do your due diligence.
This episode is brought to you by Shopify, one of my absolute favorite companies, and they make some of my favorite products. Shopify is the commerce platform revolutionizing millions of businesses worldwide, and I've known the team since 2008 or 2009.
But prior to that, I wish I had personally had Shopify in the early 2000s when I was running my own e-commerce business. I tell that story in the four hour work week, but the tools then were absolutely atrocious, and I could only dream of a platform like Shopify. In fact, it was you guys, my dear readers, who introduced me to Shopify when I polled.
all of you about best e commerce platforms around two thousand nine, and they've only become better and better since.
Whether you're a garage entrepreneur or
Getting ready for your IPO, Shopify is the only tool you need to start, run, and grow your business without the struggle. Shopify puts you in control of every sales channel. Doesn't matter if you're selling satin sheets from Shopify's in-person POS system or offering organic olive oil on Shopify's all in one e-commerce platform.
However you interact with your customers, you're covered. And once you've reached your audience, Shopify has the internet's best converting checkout to help you turn browsers into buyers.
Shopify powers 10% of all e-commerce in the United States. And Shopify is truly a global force as the e-commerce solution behind all birds.
Roth's, Brooklyn, and millions of other entrepreneurs of every size across more than one hundred and seventy countries. Plus Shopify's award winning help is there to support your success every step of the way if you have questions.
This is possibility powered by Shopify.
Established in twenty twenty five.
Has a nice ring to it, doesn't it?
So sign up for your one dollar per month trial period at Shopify.com.
Slash Tim.
All lowercase.
Go to Shopify.com slash Tim.
To start selling today.
with Shopify. One more time, Shopify dot com.
Slash.
Tim.
Optimal minimal.
At this altitude, I can run flat out for a half mile before my hands start shaking. And I also do those questions.
Now we're just seeing.
Cybernetic organism, living tissue over metal and doscality.

All right, let's start off, Keith, just by saying thank you for the time.
Hey, thank you. This is gonna be great. This should be really fun.
Should be a good time. I have a lot of questions and the start time for this was delayed because I was getting
Focus shockwave treatments.
With a doctor I think is very credible.
And
That is why we're starting late, which segues very nicely into our conversation. And I wanted to
give the Genesis story because I came across your work for the first time
Shockingly, it's astonishing to me I didn't come across you earlier.
Because I put a
Tweet online, not sure what the noun is for something like that on X at this point.
Asking about remedies related to
Tennis Elbow specifically. And it was within the context of rock climbing.
And someone put up a video
From YouTube by Emil Abraham. I'm probably pronouncing that incorrectly.
who is a high level climber, great YouTube creator and teacher.
Who put up a video?
Called something like
Doing hangboard training.
twice a day for thirty days.
And
That is where he referenced study of yours.
Or it may have been a review, I'm not sure exactly, but minimizing injury and maximizing return to play.
Lessons from engineered ligaments. And I just want to give people the punchline to this because and then I'll shut up and let the expert talk.
He is a high level climber. He climbs V fifteen's bouldering. He is
Incredibly good.
And after thirty days of doing ten minutes a day.
roughly of hangboard
not even full hangs, let's just say 70% body weight. So his feet are on the floor, kind of like a nice stretch for
Ten seconds on, fifty seconds off.
So a hundred seconds of tension.
Yeah.
He I think added sixty percent weight to his maximum.
Hangs. So this is weight attached around the waist.
He went from something like a point five second
one handed hang on a tiny little ledge. I'm not using technical climbing language here.
to thirteen seconds.
And so on and so forth. And it just blew his mind completely.
So let's just start with asking.
What is happening here?
What are the adaptations?
That are allowing something like that to happen.
And then we'll kick off from there.
It's a great place to start because
We think it actually shows something fundamental about
Strength.
Because
What we do is I'm in our strength physiology facility here and and we normally think of strength as yeah, we're gonna lift weights. We're gonna do something really, really heavy.
And because that's gonna make us stronger. We know that when we lift heavy weights we get stronger.
And the reality is that
There are certain especially certain athletes like climbers where
They're doing all kinds of heavy lifts. They're doing all kinds of heavy work.
They're doing all kinds of really dynamic moves.
What breaks down is they break down in their finger tendons and they break down some little pulleys within the tendons.
And
We had come to this because for years
I had been working on how to make muscles bigger.
And stronger.
And I always said, Okay, bigger and stronger because the definition in my old textbooks would say that the
Strength of a muscle is
related to the cross sectional area is proportional to the cross sectional area of the muscle.
And so I was like, Okay, to get stronger you need to be bigger. So
I actually was really fortunate to be
Part of the team where we discovered
the the small molecule in our cells that actually allows our cells to get bigger when we do resistance exercise.
What is the name of that?
Just in brief.
Yeah, so it's MTOR. So it's M Tor Republics One. It's the mechanistic target of Rapamice and
So I had been doing this I had a laboratory
I was my first
Laboratory was in Scotland and
I was invited down by the English Institute of Sport to come to their cycling center and they were like, Okay, this is great. We have these incredible athletes who are winning all kinds of gold medals and we want them to get stronger.
And so I go in there with my
Spiel about bigger muscles and all of this. And they're like, Yeah, but we gotta carry that muscle mass. And I've got
Five years of data that shows me I'm getting these athletes stronger without making them any bigger.
And in many cases making them smaller.
And I'm like, Oh, well
So much for all the science that I've been doing for a long time.
But then I had to figure out, okay, so how is this working? How are they getting people who are stronger?
Without them getting bigger. And so what it came down to is it
If we have the little motors in our muscles that are going to produce the force
What we then have to do is we have to transmit that force.
And that force has to be transmitted from our muscle where we're producing it to our bone where the movement is gonna occur.
And that's gonna go through tendons, it's gonna go through connective tissue, it's gonna go through all of these proteins that we call colloquially force transfer proteins.
And so that was the first thing that we were thinking of. And then what we what we were doing is we would make these little engineered ligaments. And so
The goal.
at the beginning is hey, I'm gonna make ligaments. You're gonna rupture your ACL. You're gonna send me like a a sample that they'll take it in the doctor's office. I'm gonna isolate the cells I'm gonna make you an A Cl in the dish in my laboratory. I'm gonna send it back to you.
So you don't have to take your hamstring or the middle third of your patella.
And we can replace
That ruptured ACL.
That's the idea. But we have to get them stronger. So we started looking at okay, we know exercise makes these tenons stronger, but what about the exercise?
And what we found is it didn't matter whether we
Stretch them twenty percent or five percent or two percent.
The signals to get bigger and stronger were the same.
Oh.
Then we started doing for different timelines and it
The signal would go up and then it would go away really quickly.
And so the way that I explain it now is that
Your tendon ligament, your bone, all of your connective tissue cells are a lot like my 17 year old daughter. She's gonna listen to me for maybe five minutes, maybe 10 minutes, and then she's gonna just tune me out.
So I need to get all the information in in that five to ten minutes. So if you're gonna go and you're gonna climb, for example, like Emil would do all the time, he's gonna spend three, four, five hours
At the wall, doing different things.
The tendon stopped getting the signal to adapt.
At ten minutes.
Everything on top of that was just wear and tear that could
Yeah, slightly.
Cause problems.
And so
What that meant to us is that
There's this minimal effective dose. So if I give you ten minutes of loading that is optimized
For those connective tissues, whether it's tendon, ligament, cartilage, or bone.
I can get you to get all of the signal
From that whole exercise boat.
In ten minutes.
So
That was the first part. The second part was
How long does it take before I can get more signal to go through that system?
Think of it like your toilet.
I flush my toilet.
It's gonna flush, but it
You know, when my daughter was younger, she would Oh, that was fun, let me do that again. It wouldn't flush for a while. She needed to let the bowl refill
Let the tank refill so that I can flush it. So that's called the refractory period. How long do I have to wait?
Before that next year.
Session.
What we found is about eight hours, six to eight hours later.
Amazingly, that was almost exactly the same thing that it other researchers had found for both.
It.
As few as forty stimuli.
With eight hours of rest was maximal for bone. We found that
Ten minutes of activity. Whether you did
Like
walking or running or just holds.
Ten minutes worth. So ten seconds on, fifty seconds off, hundred seconds total.
Over that ten minutes.
That's all the signal your cells need.
You wait.
Eight hours you could do it again.
And so
Emile's brother had lots of injuries.
So he did it twice a day. And he got
His hands are healthy now, he can climb again.
Emile, because he's a huge strong boulder who does these dynamic loads.
He had a really big effect of doing those isometric holds.
Because
He was getting all of the stimulus to make the muscle stronger, the brain power to stimulate the right muscles, to have him to be able to contract that. What he was missing was he was getting too much wear and tear on the tendons on the
Force transfer stuff.
So when we just got him to do those ten minute sessions.
His force transfer capacity went way up. And now his grip strength went way up. And one of the best videos that he has is
He becomes a competitor in the world's strongest grip competition.
And so these guys are twice his size, and he's grabbing all these things about the same as the people who are twice his size.
And it's awesome because Emil's smaller than me, he's a great guy and
It's like, okay, so you're getting to the point where you have some of the strongest group in the world.
And all you're doing is these little things you're doing your dynamic climb and you're combining that
With these
Isometric holds.
And so what we're improving is that
ability to transmit the force between the muscle that's making it
And the bone that's trying to
Help us do the movement.
Okay, so let me dive into a few aspects of that with clarifying questions, just just so we can keep
folks who need Scooby snacks engaged with just some prescriptive stuff. But before I get to that, let me just ask you, and uh we can come back to this because I
Sure it's a large topic we could uncork, but
In two thousand
Sixteen, I interviewed David Sabatini.
on mTOR and then Navdeep Chandal on Metformin, and we did it in
Easter Island or on Easter Island, so Rappa Nui after which Rapamycin is named.
And we had a great conversation and you mentioned earlier
I suppose and I don't know if this is correct me if I'm getting this wrong, but the M Torque one pathway as being key for sort of resistance
exercise induced hypertrophy muscle growth, right? Does that mean
Now that
Taking something that has maybe more of a systemic effect, like rapamycin. A lot of people in Silicon Valley and elsewhere take rapamycin for
hoped for longevity purposes, since they've seen that demonstrated in some species. Are you s making sacrifices on the hypertrophy side?
Hypothetically, or is or do you expect not much of an interference there?
The short answer is that at the doses that they're taking for longevity, you have
A minimal effect?
On
the adaptation of skeletal muscle.
But you're still going to have a somewhat negative effect.
So
For most people, that's not enough of a negative effect to see a difference.
If you were trying to do
high level competition or build your muscles to the biggest possibility.
That would
prevent that to some degree. It's the same kind of thing that endurance exercise can do.
Because endurance exercise like Met Forming can
activate pathways that counteract
M Tor complex one.
And so you've got this balance.
And a lot of times what we're doing is
People will target MTOR.
The thing that they're trying to do is they're trying to decrease
Systemic inflammation.
Because just like our muscles.
Our inflammatory cells need MTOR activity in order to respond to
The stress.
Our muscles need MTOR activity to respond to the stress of lifting heavy weights.
And to allow us to incorporate
More of
What we
eat in our meals more of the protein that we eat in our meals.
into our muscles to store that or those amino acids as muscle proteins.
our immune cells, they are doing similar things. They need
MTOR activity in order to respond to immune
Challenge.
And so you do see the same thing with people who are taking Rapamycin is that they do have a little bit of an immunocompromised situation.
And it's the similar kind of
Muscle compromise situation is what we'd say.
Yeah, and I would say, folks, talk to your doctor, number one, and number two, watch your dosing and look up the original applications of Rapamycin before you start gobbling it like tic tac.
Alright, I wanna come back to
the meat and potatoes what you were just saying before.
And ask specifically
Because I've seen a a lot of pain relief from imitating the Abrahangs.
even though these are the seventy, eighty percent body weight, feet still on the floor hangs that Emil demonstrates in his videos.
It may not even be for my current problem, but just for people listening who may have, say, golfer's elbow, so people have pain on the medial epicondyle, the knob on the inside, or tennis elbow on the outside as I do.
In the video
Emil is doing
Ten seconds on, fifty seconds off for ten minutes.
digging around online there are other people who claim
You can't believe everything you read. They're like
As per Keith Barr.
I am doing thirty second hangs.
semi f like semi flexed.
With two minutes in between for four repetitions.
So one is a question on what you think the optimal
load duration and rest.
Intervals are.
Four
Take your pick. Let's just for fun.
could be golfers or tennis elbow. And then secondly
Is
Why isometrics? Because for instance, fifteen feet away from me, I have a
Flex bar. This is uh a device that looks kinda like a churro.
And you use it to apply eccentrics, right? And you hear a lot about eccentric loading for
Say tennis album.
So those are the two questions. Kind of the
how you would prescribe like the loading protocol in terms of duration, number of intervals, et cetera.
And then
Why isometrics versus
Say eccentrics.
Alright. This is the money question. So so this is like
What I love about what I'm doing right now.
So let's start with why the eccentrics, okay?
And can you explain to people just uh like if you're doing a bicep curl, folks, and you're lowering the weight after curling it up.
That is the eccentric
or negative portion of that movement. But you may be able to give more color for that.
No, it's perfect. So when I'm curling up
That's my concentric move. When I'm holding it still, that's the isometric component.
And when I'm doing
I'm lowering it. That's the eccentric component.
All right.
So when I'm completely healthy.
And when everything is working perfectly with my tendon.
It doesn't really matter.
what I'm doing as much.
The reason that that I say that is that your tendons
Like any other tissue in our body, it's not a homogeneous
Tissue.
But what it is is a mechanical tissue.
And what that means is I'm passing load through it.
And so if there's strong parts and there's weak parts, the load is gonna go more through the strong parts because they're stiffer.
And so when I load quickly
Load goes through the strong parts.
When I have an isometric hold.
The strong part gets tired.
And the load then is put onto the rest of the tent.
That's if the isometric is long enough, or just by virtue of being isometric.
By virtue of being isometric, but then
The longer the isometric, the more evenly
the signal is given to all of the cells.
Think of it like this.
The Rock and I are doing a tug of war together against somebody over there.
Okay. So at the start
It doesn't matter if I'm there or not.'Cause the rock is gonna be like
putting in nine hundred percent of what we're gonna put into that rope.
I'm just standing there.
For contrast, right?
But then what happens is the rock doesn't do much endurance work. That's how he gets so big, so he's gonna tire really quickly.
And as he tires, suddenly I'm
having to put more load on the rope in order for us to maintain that position. We all had a sadistic gym teacher who said, Okay, go to the wall there.
Put your back against the wall, go down and sit.
So that your legs are ninety degrees and ninety degrees the hip and the knee. And you did a wall sit.
And you're sitting there like I am not moving. Why the hell are my legs burning like
The world is on fire.
The reason is that as I hold that position
My tendons start to relax.
And as my tendon starts to relax, in order for me to stay there, my muscle has to contract more.
And so what I get is I get creep.
In my tent.
Now that's really important because if you take a paper, piece of paper and you just load it, and I don't know if you do you do the video, so I'll do this demonstration.
And just describe what you're doing as you're doing it. Yeah. I will. Yeah. So if I take a piece of paper, just like our tendons
Piece of paper is made up of fibers.
And in this case it's paper fibers or wood fibers. In my tenant, it's made up of collagen. So if I load that dynamically
I'm loading all of the fibers within the
Now fine.
Tear this. And I the people who are just listening just take a piece of paper, tear it.
And then
Just you have a little
Edge there.
Now if load goes through that, what's gonna happen is it's gonna tear across.
But if I just go back and I dynamically load.
Doesn't go through there. It doesn't tear.
Because there's no load going through this.
There's a beautiful set of papers done by this wonderful old
Japanese.
Professor named Hayashi.
And what he did is he took a metal wire and he put it from the patella into the tibul plateau of a rabbit.
He just tightened it so that there was no load going through the
The teller tended.
And within two weeks
He had all of the
Indications.
That the tendon was scarred.
Perfectly healthy tendon, but it had tons more cells.
It had smaller collagen molecules and they were not directionally oriented.
Those are the definitions of a scar. So if you have a scar, that's because you didn't get load through it.
And so all I have to do in order to get loads through this area.
Yeah, I just have to
Put a small amount of weight and just be patient.
'Cause if I wait here, what's gonna happen?
Right, and just just for people who aren't seeing it, you're pulling from top to bottom and the paper is talking.
Yeah.
And now
eventually the paper will tear right at the point where we put that original injury.
The reason for that is because
What happens is
Normally when our tendons are
Ready to go.
Or kind of.
Just sitting there. We've got the weak spots, we've got the strong spots.
The strong spots are shielding
The weak spots from the stress. It's what we call stress shielding.
And so all of the load is going through the strong bits.
This is why your favorite athlete doesn't rupture their Achilles tendon on the first or second thing.
They do it after warming up. They do a bunch of loading. Then they go and do that load where they put their foot in the ground and now it's gonna rupture.
What's happened is you've
Kind of fatigued out.
The strong part.
And it can't shield the weak part anymore. And then just like my piece of paper, it tears.
So quick interjection, if I may. So the isometric allows you to recruit you instead of just the rock, right? Using your
Exactly.
Metaphor from earlier.
But E centric movements do not
Allow you to do that?
The standard of care for tenant injuries has been for the last twenty five years ecentric loading.
It's a actually a really funny story because
The guy
Who developed the protocol?
This is Guy Henderson. It was this Scandinavian guy.
And he knew from his experience as a scientist that
It's easier to heal a tendon once it ruptures than when you have a tendon opposite.
It's shorter the time period. You get more complete healing.
So what he was trying to do is he had an Achilles tenon injury.
Yeah, he had Achilles tenanopathy.
And so what he was trying to do is he's trying to rupture it.
And he thought the best way that I can get the most load through this is if I put all the weight I can and I just
Trying to hold it there and slowly go down.
What he found out is that it actually fixed his
Achilles tenant.

Just like what they used to do with the racehorses. Yeah. So that was the genesis. But if he wanted to rip it.
All he had to do is take that big heavy weight and move super fast.
Because now you have the
What we call jerk.
And so for our tendons, again, jerk is not just that person that you hate in the world. It's actually a physical property.
So where I am, that's my location.
The rate of change in my location, that's my velocity.
The rate of change of my velocity, that's my acceleration. Everybody's good up till now.
The rate of change of my acceleration.
That's jerk.
So when I'm accelerating one way
So I'm gonna do a snatch and I'm gonna accelerate up.
The bar.
Gravity's accelerating down. So when I hit that bar and I get that catch.
That catch is jerk. That's why that's where we get the most injury.
The reason I get tennis elbow, I'm swinging a tennis racket in one direction, the ball is going the other direction. I get a small amount of jerk that goes through the tendon.
The reason I get golfers elbow on the inside is I'm swinging through.
I'm gonna hit and it's
doesn't usually happen on grass because there's not too much resistance. It happens much more on
The synthetic surfaces.
Now I get
That jerk in the opposite direction?
Now I get pain on the inside of the elbow.
But
It's the same thing with jumpers. Jumpers get jumpers because they're doing these dynamic moves.
Jerk is the thing that's going to induce injury.
Jerk is that rate of change of acceleration.
So now
The reason that Ecentrics were working is because it wasn't about eccentric. It had nothing to do with that because Michael Crish beautiful work. If you do really heavy strength training,
It has the exact same effect as these centric.
The reason is when I lift a weight that's heavy, I have to go slowly.
The core
Of the
eccentric training was to do a slow eccentric.
It had nothing to do with the East centric, it had nothing to do with the concentric. It had to do with
The velocity.
And so when we realized that the velocity was the key, then we said, Okay, what is it about velocity? So if we keep velocity at zero.
Now what we should see is we should see the biggest bang for our butt.
And so all we had to do is make the velocity of the movement zero, and suddenly
We got load through the whole tendon.
That's fascinating. So the whole eccentric
thing which has become kind of scripture.
in a lot of places, just like rice, which we might talk about, right? Rest, ice, compression, elevation, which we'll talk about at some point, hopefully, if we have time.
It was a false positive in a sense, right? Where they thought it worked because of the eccentric nature of the movement, but it wasn't that at all. It was the reduction of velocity.
And maximal reduction of velocity is isometric.
Yeah. And so if you're trying to hold the weight.
While you're doing that slow eccentric load.
Yeah, the weed is good.
But from our engineered ligaments it didn't matter whether we did a big movement or a little movement or a heavy movement or
What mattered was we got
Load through the cells.
So the cells could sense the load.
And
That we did it and we could stop at about ten minutes.
And those were the two things that made the difference.
Do you see any difference? I don't know if you were testing this in the lab, but
Back to the original question about
intervals or duration of stressor.
Ten seconds on, fifty seconds off for ten minutes straight, versus like thirty seconds on, two minutes off, thirty seconds on, two minutes off. Have you been able to draw any not necessarily conclusions but inferences?
Hypotheses worth testing as to what might be better.
We actually do have really good data there. So what we
No.
Is it when
The tenant is
Pretty much healthy.
We can do shorter.
Duration isometrics. So we can do one to ten second isometrics when we've got pretty good health. That'll get us our maximum signal without a problem.
If I'm recovering from an injury
And the more mature the entry, the more
Problematic it is.
Now
The system that
Shielded.
The injury
is much better at shielding.
So now I need longer for that to relax. So it's akin to the rock has done a little bit of aerobic exercise now. So he's gonna hold on a little bit tighter for a little bit longer. So I need to go for a longer period.
Yeah.
I've been training
My big
Partner.
to do those longer duration things.
So
If they have been having to shield
The injury for longer.
Now it takes me a longer isometric to get to the point where
I can get that load evenly across the tissue.
What would be the minimal effective duration for a longstanding injury? Let's just say tennis elbow.
What would uh
reasonable duration look like.
So the reason that we've gone with thirty seconds
We can do this, we can take out the tendons from animals, we can pull them in our machine and we can watch actually the stress or the force that we need to hold it in that distance apart.
go down and it goes down exponentially.
By about thirty seconds is about eighty five percent of the way
Two.
the bottom.
And if you wait out to two minutes, you only get about fifteen percent more. So we didn't figure that that was gonna be.
Exactly.
And so
At ten seconds you're still coming down at a fairly steep
Curve.
But you're still getting some stress relaxation.
But by thirty seconds you've turned the corner and you're basically getting diminishing returns from there. And so that's why for the
Injured.
tendons. We're going at that thirty second hole.
And then when you've got somebody
Like Emile, who's doing pretty well. Now we can go with a shorter hole.
The other thing when we're talking about the climbers is
The tendons aren't as big.
So I don't need as long on my flexor tenon in my finger as I do on my patella tenon or my Achilles tenon.
My Achilles is my biggest tenant in my body. It's gonna take longer for the strong parts to relax than if I am looking at my flexor tenant.
I
Just a quick thanks to one of our sponsors and we'll be right back to the show.
This episode is brought to you by AG1, the daily foundational nutritional supplement that supports whole body health. I do get asked a lot what I would take if I could only take one supplement. And the true answer is invariably AG1. It simply covers a ton of bases. I usually drink it in the mornings and frequently take their travel packs with me.
On the road. So what is AG1? AG1 is a science driven formulation of vitamins, probiotics, and whole food source nutrients. In a single scoop, AG1 gives you support for the brain, gut, and immune system.
So take advantage of this exclusive offer for you, my dear podcast listeners, a free one year supply of liquid vitamin D plus five travel packs with your subscription. Simply go to drinkag1.com slash Tim, that's the number one. Drink AG1.
dot com slash Tim for a free one year supply of liquid vitamin D plus five travel packs with your first subscription.
purchase learn more at drinkag one dot com slash Tim.
I
So let me tell you what I'm doing and then I want you to critique it if that's okay.
Absolutely.
This whole conversation is a pretext for me fixing my album.
So let me tell you what we can. That's only uh half said in jest.
But
Many, many, many years ago. This is like twenty plus years ago, did a lot of jujitsu and had my arm hypere extended a number of times. Yep. And like many men of younger vintages felt I was invincible, so I would
Ice it, wrap it, and just go straight back to the gym like an idiot. Now that has come back to haunt me and
I love climbing. I'm not particularly great at it, but what happens is I take a long break, usually a few years, then I come back, I start climbing, everything is great.
until I get to about five eleven A, where I start having these
Harder.
For me.
crims and at that point
my elbow goes absolutely berserk in that lateral epicondyl area. I think there's also some damage in the joint or joint capsule itself.
But let's put that aside for now. I also have quite a bit of pain kind of uh lower tricep near the elbow.
But then I take a long break, I go back and the process repeats itself. Then I got very excited about fixing this with isometrics.
And I thought to myself, okay, and we may not have time to dig into this, but I do have questions about collagen and vitamin C. So I've been taking
Hydrolyzed.
collagen peptide powder. We can talk about whether that checks the box or not.
With vitamin C about an hour prior to doing isometrics.
And then
I've been varying because the internet has
different things to credit you with and I don't know which are correct
One is I don't have
Proper
Tools here, but I'm using it.
Basically a cast iron pan.
For people listening, you can imagine I'm holding this in my right hand, the pan is pointing straight up, my elbow is by my side.
And then I'm
Rotating.
So that the top of my hand is up and holding it in that
There's probably a better technical term, but kind of internally rotated position, holding that for thirty seconds.
And then
Taking two minute rest, another thirty seconds.
and doing four total rounds of that.
I've done that. I've also
Experiment with having
my arm flat on a table and then pushing down on the top of the hand, so it's effectively like
Holding a reverse curl.
You might think of
And have played around with that.
What should I do to fine tune that? What are your thoughts?
So this is great question. This is one of the reasons that one of my
Postdocs and I are actually starting a a small company. We just spun out a company because
What we're always doing is we're trying to figure out
How can I do this with
A bunch of stuff that's not well suited for it.
And so what we're doing is we're designing devices and then we're instrumenting them so that you can see how much load you're putting through it.
And you can then
Understand.
Okay.
I'm gonna do this repetition, this here's my strength curve, okay, there's my thirty seconds, okay.
Until those things are out, basically what we would say is you're trying to do exactly what you're saying there. You're trying to keep first of all when you have
Injury.
What we're trying to do is we're trying to keep
The pain on the scale of one to ten.
We're gonna try and keep it at two or below.
Because what we want to get is we wanna get load through there but without getting too much load. We don't need a ton of load, remember. So that's what the Abraham's are good with. And they're you can start even with forty percent of body weight.
And
It's independent of the load.
And so as long as you can get load through the tissue, that's fine.
So if you have a really big
Damaged
You're basically your cast iron pan might be a little too much.
So you might be overdoing it a bit and getting a little bit more of the
Signal.
To the where
Which is what we're looking at.
So what's your ratio of signal to wear? And we're trying to maximize the signal with minimizing the wear and tear.
And so the other way to do it is to s take a tennis racket.
And find like a
door jam or something and just put it underneath.
And just do the opposite.
I see. And then you can do that in both directions. Or a golf club. I've seen demos with that as well. Exactly.
Yeah, under a kitchen island, like I have
In front of me here.
I got it. So you
Basically be
Pushing against it.
Yeah.
And so that's called an overcoming isometric.
You're trying to overcome something.
And the important thing there
The reason that I like
What's called an overcoming. Think of it like a leg extension.
When you're starting with your knees
Both
Bent.
You haven't touched the little pad down there to start extending your legs.
Now I put my feet against a pad and I'm gonna extend out.
I have to try and overcome the weight.
If I put the whole stack of weight down there, it's an overcoming isometric.
The reason that we like these overcoming isometrics versus what you're doing a little bit with the
pan which is called a yielding isometric. Yielding isometric. A yielding isometric is you
Basically the way of thinking of it is going back to the leg extension. I'm kicking out with two legs.
And then I'm taking the weight onto one leg.
Okay. And I'm holding it with a one leg.
So those yielding isometrics, we're gonna get a lot more load, but again, that's not necessarily the key component that we wanna start with. We'll wanna build to that.
But at the beginning, we need to make sure that we're controlling the load.
What I like about the overcoming isometrics is I can have you now instead of going
Like
hold the pan and you have to immediately hold it and you get jerk.
At that immediate part.
Now what I can do is I can minimize jerk.
And so what I'm gonna do with them overcoming isometric is I'm gonna say I want you to develop force over three seconds.
So I want you to start nice and light, just feel the pad on that
Leg extension. And I want you to slowly
Try and extend your leg until you get to your maximum force. And then I want you to hold it there for 30 seconds. And then I want you to slowly let it off.
And now what I've done is I've
Decreased that
Wear and tear component.
As low as I can, and I've maximizing my signal component because I'm gonna do that 30 seconds, I'm gonna do a two minute rest, and I'm gonna do
Four of those.
And now that's gonna give me eight minutes, so ten minutes of work.
Ten minutes of activity on that one tendon I'm looking for.
And that's going to give me
All of my signal.
And a very, very small amount of wear and tear.
Because I've minimized your
I've gotten the signal into the cells.
And basically that signal is just like, Oh, look.
There's load and the load's coming from that direction.
Because the reason you get a scar is it doesn't feel the load.
It doesn't know where the load is, so it puts collagen all out in all kinds of different directions.
When the load comes through, now it goes, Oh
We just have to make it this way. And it makes all the collagen in one direction. Now you can
fill in your scar because now you can synthesize collagen in a directionally way that's going to meld up with the the whole tissue from the beginning and now we can regenerate that tissue pre-complete.
Bunch of follow ups. So it sounds like if you had a clinic and you're just private practice meeting people
giving them prescriptions that you would probably bias
with people who have chronic injuries at least overcoming isometrics versus yielding isometrics. Is that a fair statement?
I would.
Okay. Now the yielding
What I've actually done now that I'm looking at the pan.
It is not cast iron. It's a lighter stainless steel. But I've been part of what I like about the yielding is I've been adding at first I added a bowl to it to add some resistance and then I added a cup inside the bowl.
It's not the most elegant solution, but it's been working in the sense that I can add progressive resistance. I may be overthinking this on the overcoming isometric. Let's say I have a tennis racket.
My sort of elbows by my side, tennis jacket facing up.
I turn my
Palm down, stick it under, and we'll hopefully add some videos for this so people can see what we're talking about.
And then I start
Have.
Externating top. Yeah. Externally rotating, but it's not moving'cause it's under the kitchen ledge.
How do I think about the sort of rate of perceived exertion? Like should it be like a two out of ten, three out of ten effort if I don't have pain. So I don't have a lot of pain when I'm performing these exercises. Should it be
eight out of ten and by thirty seconds I'm like, wow, this would be getting close to like
my thinking around concentric failure. How would you think about
Answering that when it comes to the overcoming isometric.
First of all, this is again one of the reasons why we're developing the company is is so that when you're doing an overcoming isometric, you need to have something that tells you what's the load you've got.
And what's the load today versus tomorrow? So if I'm trying to do one of these moves, or if I'm trying to go against
A resistance. So if you have a rotator cuff and I have a cord or a belt.
There, and I'm gonna pull.
I have no way of knowing what kind of load I'm putting through unless it's instrumental.
That's where we're adding instrumentation so that I can go into a physical therapist instead of giving me a little
cord where I go back and forth, back and forth, back and forth, and it does absolutely nothing because it's a small dynamic move.
It mobilizes, it warms up that little area, but it doesn't actually fix the tendon. But now if I go and I do the isometric, if I'm
instrument I can tell you what you did yesterday, what you did today.
So I can get that progressive. So that's great because we do want to progress.
Mm-hmm. But for those people who
Will not have access to those things in the meantime. Absolutely.
So what you're trying to do is you're trying to go
For what we do is we say look
So what we Q on
when we're doing the the Abrahangs, for example.
Is we want to we say
I want you to feel tension through
That tendon system.
I want you to feel tension in the forearm.
And that's enough.
I don't have to feel like oh well it's like
Yeah, eighty percent of Max.
If I'm relatively healthy, tension through there is gonna be enough for me to get it.
Yeah.
I need to get a little bit more stimulus through there because I've got a longer term injury.
Or I've got stronger entry. So now what I'm gonna do is either I'm gonna go for longer or I'm gonna go at a heavier load, or I'm gonna push harder on my asymmetry.

I don't have to go to eighty, ninety percent for that.
I can do it at say
fifty percent so that my leg isn't shaking if I'm doing a leg based one or my elbow I don't feel like I'm shaking to hold it in that position.
It's just that it's
At the end of it, it's a challenge.
Mm-hmm. And it's not necessarily that I'm crushing myself.
We get into this whole thing
This is like this macho business with lifting weights is it
No pain, no gain, you gotta
There's no reality to that.
I took a photograph of this card at a coffee shop that I put up recently, which was it said
work medium, play medium. We're not as young as we used to be. Which I thought was perfect for my my new modus operandi around my training.
Yeah, but you can still train at high loads, you can still train at high forces if that's something that you really enjoy. Like when I get on the machines back there, I'm lifting a lot of weight.
But I'm doing it again, I'll use the machine because it's now got two things that I really like. One is that
I don't have to worry about the small muscles because we always injure the small muscles.
Because I'm trying to do a m movement. I'm trying to get big muscles.
But if I'm doing something that requires the small muscles to stabilize
If those are underdeveloped, I'll never be able to get my big muscles and I'll get a small stimulus on my small muscles. It's not ideal.
And the other thing that's really good about having a machine, if the machine is well designed, it has a strength curve.
So free weight doesn't have a strength curve. So if I'm doing a squat with a free weight.
At the bottom, where I'm my weakest because my muscle is the longest, and the length tension curve tells me I'm weaker in this position, the weight is exactly the same as when I'm in my strongest.
So
what the machines that are really good are gonna do is when I'm strongest, it's gonna be heavier. When I'm weaker, it's gonna be lighter. And so those two things allow me to work really, really
well to load the muscle in a very safe way. And I've done lots of
NFL consulting. And I always go into the weight room and I always see the rookies and the first second year players are over in the squat racks doing all kinds of dynamic movements.
All those all pro
Veterans, they're all over in the machines because they know that those machines are gonna keep them healthy. Those machines are gonna get them that thirty million dollar contract.
Yeah, you might get a half a step faster by being over there, but

The veteran, they know that if they're available for sixteen games of the year.
They're gonna get their next contract because they're gonna perform at a high level. So for sure. So
That's just kind of
As we go through the strength component.
The big difference for me when I'm looking at the musculoskelet system as a whole is when I've got somebody into control, I can now regulate the jerk better.
And so I can regulate that in such a way as that
I am not gonna get as many injuries in a weight room.
When I'm trying to improve myself.
Or when I'm trying to get stronger.
And I'm gonna be a stronger athlete when I go out and do my activities daily living, whether that's that I'm gonna go compete, play inner murals or or go out and play over forty soccer, whatever it is that I'm I wanna do.
Now I'm gonna be stronger when I'm doing that. I'm gonna have better balance, I'm gonna have all of those better things that are gonna allow me to perform at a higher level.
So w I'm gonna give people just a couple of teasers. You have an incredible breadth of
variety in your research. It's kind of mind boggling to me. I'm just gonna give people a teaser. We don't have to dive into it right now.
And you can't believe everything you read on the internet, but I believe you were involved in some research on ketogenic diets.
found that I think it was a one month keto diet in middle aged mice.
I feel like a middle aged mouse sometimes increased
muscle mitochondrial content significantly, though not in the brain or liver. So we could talk a lot about keto. I am going to stick with the isometric, so for a second here. So
I have
Just a few.
Two are on exercise examples.
Right. So we talked about the tennis elbow a little bit and the
overcoming isometric with say a tennis racket under the kitchen counter, is that the only movement that you would prescribe to someone like me for tennis elbow, or are there other varieties of movements isometrics
That you would throw into the mix. That's question number one.
So the thing for your extensors, so
The extensors of the forearm they're gonna be rotational.
And they're gonna be extensive.
So you have to do both.
So you wanna do one that's an extensor, you can do an isometric
And again, you can do it at any point along the chain, so
If the muscle is in a long position.
That helps a little bit.
Because now from that again.
Thinking of it as an overcoming asymmetric, the muscle and the tendon are longer, so I can get a little bit more relaxation there. So let me describe the visual for folks. So the extensors are on the top of the forearm. Think about doing like reverse wrist curls.
And you just had the wrist cocked down to demonstrate. So it's at the bottom of the wrist curl where I'm about to start doing my reverse wrist curl. Now I just pull it up a little bit with a weight that I couldn't really lift.
the whole way but now I can do that and I can hold it in that fist below my forearm position.
And I can try and extend my fist up.
And that's gonna get me that extension component.
And then I'm gonna need that rotational component, which we talked about with the tennis track.
Got it.
And the thing that drives my students crazy now is that
Almost every class.
I have them doing isometric lunges or isometric squats.
And isometric lunge, I'll have'em go down.
You know, hover the knee above, you know, and I do it for okay, whoever beats me gets an extra point, an extra credit point.
And we sit there and and it's like a two minute thing, but
By the end of two minutes, there's maybe one or two of us left and okay, that's enough time to
But the reason I'm doing it is because now I get my quad tendon and my patellar tendon.
And if I move forward and I shift forward and my knee is over my toe, I'm getting a good stretch on my Achilles tendon, or I'm getting good load through my Achilles tendon.
And I've also got it on my back side. So the
the knee that's in the low position, now I've got
Quad ten and
And
Patellar ten in there. And I've got a little bit on the plantar fascia on that foot.
So now in that one move, I'm getting pretty much all the tens of my lower leg. I'll switch and do the other leg.
And then I'll do like a
side lunge. Those types of things for most of us who are getting
You know, older like to run
So now what I want to get is I need to get my my knee and my Achilles. Those are the two things that are the primary thing for most people. Those isometric squats are amazing for it.
And that's the split squat.
Yeah, so it's like a Bulgarian split squat. So one foot in front of the other, just a long stride.
Go down.
Thirty seconds would be the minimum effective dose.
You can build up to that. So you start with 10 or whatever you can do, and then you build up and you get into that ten to thirty seconds.
If you've got existing injuries, we're going to go more like thirty seconds. If you don't have any existing injuries, then you can go for 10 seconds.
And what you're gonna find when you're doing these isometrics is your range of motion.
is actually gonna improve.
Much better than if we were to do a static stretch.
Because if when we're doing a static stretch, the muscle and the tendon aren't adapting in the same way.
That's when we're doing an isometric hole.
And that's
really important because my gym here
The next gym over is the gymnastics gym here at UC Davis.
And I always remind people that if
Passive flexibility.
was really important for decreasing
Tendon injury.
Then
The women's gymnasts who have the most passive flexibility
wouldn't be the N CAA sport with the highest rate of Achilles tendon rupture.
So that's telling us something about that passive movement where we're just
We can do things and make us hyper flexible.
So injury
Related to flexibility.
is a U shaped curve.
So our injuries are really high when we're very inflexible.
When we get into that sweet spot where we have good mobility, we can do the full range of motion.
Actually the entry rate is very low. If we become hypermobile
We actually have that injury rate go up as well.
And so that's really important because as you said, jujitsu martial arts, you're doing a lot of things in a very long range of motion. You have a lot of
In some cases hypermobility.
And that puts those tendons and ligaments at a little bit more of a likelihood to get injured.
Let me shift to just the timing question and the timing specifically makes me think back to
Professor Hayashi and his
Poor little rabbits.
Where he attached, I guess I'm trying to recall this here.
But basically some type of metal filament or wire.
Applied tension. Was this on the knee? This was on the knee.
And tell it to the Tibet.
Right.
And then lo and behold.
the adjacent natural tissue suddenly has all the indications of scarring and weakness and so on.
How soon after surgery
And you can choose your surgery A C L
Take your pick, dealer's choice.
Would you start loading
the uh site of injury slash repair.
So we do it the next day.
So we've had to have success in order for us to get there.
Because the first time we did this with
A rugby player, the surgeon was like six weeks without loading. And we were like, Let's load tomorrow.
And so we agreed that we would do it at like seven to nine days.
And that player got back fully a month.
Faster than that surgeon had ever seen a player get back from that injury.
And so that surgeon is now much more willing to do it at two days after injury because of that.
If you look at general populations, Michael Kerr, who I think is the world's best sports medicine doctor for musculoskeletal injuries. How do you spell that last name?
It's K J
A E R. He's in Copenhagen, so he's didn't realize that was gonna be that hard. She's it's sheer
But
He allows those of us who are language deficient to call him care, but he did a beautiful study with one of his
Trainees Monica.
And what she did.
Is she took a bunch of his patients that had injuries and she either had them load two days after injury
Or nine days after injury and then she followed them for when they got back to sport.
And what she found is the ones that they loaded at day two after the injury, they got back twenty five percent faster than the ones that they loaded at the end of the day. That's incredible.
That's typical. So
As you said before, what is our standard of care? Our standard of care is rice.
Okay. And so
I'm gonna go a step further. If you go and you sprain your ankle and you go to the doctor
Very good doctor, very well meaning. They're gonna give you a boot.
And what is a boot?
So I told you that a scar forms when we get stress shielding.
What a boot is. It is.
A mechanical stress shielder. What it's designed to do is to take the stress off the tissue you've injured.
If I've told you that the thing that's gonna cause that tissue to get a scar is that you take off the tension.
What I've just done is I've made the problem worse.
I always tell people that the first recorded
Immobilizer for an ankle or a leg.
is from Egyptian hieroglyphs where they showed pictures four thousand five hundred years ago.
If I took you and you said you had cancer, you would not want a treatment that was developed four thousand five hundred years ago. You would hope that something new has been developed in the last 4500 years.
That is where we are for our orthopedic situations.
I understand that you cannot put full load on a surgical repair immediately.
But what you can do is you can take it out.
At the beginning of the day.
You can remove it from the boot and I can do some isometric loads with low jerk. So I'm gonna develop four slowly.
I am going to make sure that there's zero pain and I am going to hold that.
And then I'm gonna let that off slowly.
And I'm gonna do that four times, thirty seconds. Now I've given load.
And then I can put it back into that boot.
Stress shielded.
I'm gonna take the boot off at night and I'm gonna do it again.
Just doing that, I'm getting those two loads on in this case the Achilles tendon that we've ruptured. Now what I've done is I've accelerated my return to activity massively.
Again.
The key is
We're not trying to be
I'm the strongest in the world.
We're trying to say I'm putting a little bit of load through that.
That is the key is that you don't get all caught up in the machismo of it and you just say, I just want to feel tension.
Across the area. What we say is if you can feel it an ice pick, that means there's a very specific spot that hurts.
Stop.
If I feel like a warm
Burning area. Like I'm muscle soreness after exercising.
That's totally okay.
That kind of soreness not
Point specific pain.
That's okay.
What we're doing
Add the load slowly.
Hold it.
Take the load off slowly.
Now what we can do is we can get those individuals back much, much, much faster.
So just a question for a friend, because a friend of mine literally just sent me photos of his Achilles tendon surgery, former super high level volleyball player.
has not played volleyball in a long time, but is still very physic or I should say muscularly strong, went back for an alumni.
volleyball game, and you guessed it.
Pow snap and into the OR.
That's very recent, last few days. What type of
Asymmetric
Would you advise
for that particular Achilles.
Rehab.
This becomes one of the issues that we have.
And orthopedic surgeons
They
Hate me.
Okay. And the reason they hate me is because the thing that they want to do.
is they want it to be really strong when you leave the operating room.
So what they do for that is they use
All of these reinforced sutures that are going to stay in that tissue for a long time.
Okay, so now I've got a really strong suture going through my

So if you load that, where do you think the load is gonna go?
Yeah, it's gonna go to the sutures. It's gonna go through the sutures. So what happens is we don't actually load the native tissue.
But the way that the surgeon does it is
They don't do it so that you can't load the tissue at all, because if they did that, you'd never be able to bring your toe up.
Never be able to bend your ankle.
So what they do is they have it so that the sutures will take all the load when you start to bend the ankle.
Or you start to
What we call dorsiflex the ankle.
And the tendon becomes longer.
So what that means is we have to work in the shortened position.
So we have to be in the plantar flexed, or our toe is pointing away from us.
So what you do is you do that.
So I'm gonna get
So he can take his boot off. And this is again, this is from the science. I don't have the medical components. I always work with medical professionals who do this who
Actually put the program into place.
But what the people that I work with do is they say, Okay, we're gonna have you go in a relaxed position.
You're gonna take the boot off. I'm gonna just have you be there. And now all I want you to do.
Is against
You can slide yourself against a wall so that where your relaxed position is
You're just gonna lightly put tension on that.
You're just gonna apply a little tension.
On the bottom, but like the ball of the foot. On the toes to the ball of the foot. Yeah.
And so all I'm gonna do is push against that little wall.
And now all I'm gonna do is make it so that I feel a little bit of tension through the area. Not so that I feel it pulling, not so that I just want to feel tension.
And all I'm getting is I'm getting a stimulus to whatever
Little bit.

Brought together.
And what that's going to allow me to do is that's going to allow me to get that tissue just keep active.
Because what can happen if you have these really reinforced sutures?
And you're loading
in a kind of traditional loading program where you're doing kind of faster movements, or you're doing
Maybe I
E centrics or whatever it is.
But you're not getting loads through the native tissue.
is that the native tissue becomes smaller and smaller over time. It's like Hayashi did.
That's exactly what Hayashi did. And so what ends up happening is the native tissue doesn't
become strong.
And then eventually
We're putting so much load through the suture that the suture will eventually wear and tear and will break down. And when that happens
If we're not ready for it, we'll rerupture the tissue.
If there are, which I'm sure there are, some curious open minded orthopedic surgeons out there.
who are asking themselves, well
Keith.
I'm open minded. What would you recommend we do instead of suturing the way that we've been taught to suture?
What would you say?
So you can do the same procedural suture. So you can go up and through the muscle, you can do all the reinforcement.
But all we do is we say use a resorbable suture. And so we've got data now in rats. Said reabsorbable.
Is that right?
Yeah, it gets resorbed into the body. So it's ones that you can see all of my scars. Those are the ones that I got that were inside the skin.
So that they didn't have to open up the skin and go get'em again? So they just become
Lactate, basically.'Cause a lot of times it's the polylactate that they use to make the
Anyway, so I have a PhD student, the same one who's my rock climber who's worked with Emile. We've got a paper that she's the first author on, basically showing that the Abrahan's increase strength the same as much as Max Hangs in a population of about five hundred climbers.
But she's also an incredible surgeon. So what she did is she went into rats.
She cut the Achilles ten and and sewed it back with either a resorbable or a non resorbable suture.
And then she at four weeks she cut him out and just saw is there a difference in the strength?
And there wasn't any difference in the strength.
The surgeons are really worried about two things with an Achilles tendon rupture.
One is that we're gonna lengthen
The Achilles tendon because it's not gonna be strong enough
To
the suture, if you used a resorbable suture, it wouldn't hold on long enough for it to
Prevent the lengthening of the Achilles.
And what she showed is that even though we let the the rats
Start walking right away.
There was no difference in the length of the Achilles based on whether she used a resortable or a non resorbable.
We saw that the resorbable actually had better
Collagen synthesis markers.
than the non resorbable, just kind of like what we would anticipate.
So you can do the same repair.
Just understand that
If you use a suture that's gonna resorb
That's going to allow you to then get the native tissue back. If you are working with a team.
Who is really good at
Then
Providing the load.
So the best tendon surgeons in the world tend to be in Finland for some I don't know why.
Never would have guessed.
There's a history of studying tendon in bin.
For some reason.
And so
A lot of the Finnish surgeons use
Resorbable sutures.
And they do early loading.
They do that.
Because they know that
What they're trying to do is all they're trying to do is attach the two ends.
So that the native tissue can become functional.
So that's really
What we would tell your friend is that in two positions, you have to do it in two positions now, because remember the soleus and the gas truck both come into the Achilles.
The soleus muscle we use when we bend our knee.
And we push down with our toe?
Like a seated calf raise. Like a seated calf is for the soleus, a straight leg calfres is for the gas truck.
We need both of those.
Or
Properly loading the Achilles tenant.
So what you would do is
You take off the boot, or you could even do it if you were worried about it, you could do it in the boot.
And just
push down on your the ball of your foot in the boot.
And you should feel tension across the back of the leg.
And that should be enough to give you a stimulus.
Hold it for thirty seconds develop the tension over three or five seconds. Hold it for thirty seconds. Let it off.
Three to five seconds.
So
Again, you can begin to do it even in the boot. You can do it with a straight leg in the boot as well.
And then you're not doing anything that your doctor didn't tell you to do. You're still keeping it immobilized if you want.
But we're actually loading that tenant.
So quick question on
The tennis elbow.
Because you mentioned the soleus and the gas truck.
And I was watching a video actually.
Surprise, surprise, if you look for one tennis elbow video on YouTube, you're gonna get seven million of them served to you. But I did watch one from
Venus Williams. And uh she mentioned something that I had been playing around with intuitively when I was doing some of these exercises, which was
Let's just say with the external rotation, like the tennis racket. I've been doing yielding and not overcoming, but I'll switch that. I've been experimenting with
having my elbow bent at ninety degrees.
doing it with my arm completely straight, doing it somewhere in the middle.
Is that advisable, inadvisable?
So one of the things some of the baseball teams that we work with, they're like, Oh yeah, we were doing some stuff for the rotator cuff using your isometrics and we were loading the rotator cuff and everybody's ulnar collateral ligament was feeling better.
When you're loading one thing.
you're going to get one response when you're isolating that muscle and that tendon, that muscle tendon unit.
When I change
which joints I'm moving, now I'm getting a slightly different combination of muscles and tendons.
And both of them are probably contributing to the pain that you're feeling.
So if you're going to use that
position. So yeah, a lot of people do the bent arm because
That's what we're doing when we're doing a backhand.
But you also have to think that
If I do that with a straight arm, it's also going to
have different contributions of the upper arm musculture, which then feed in and load the tendon differently. Yeah.
And in my case it's
Arm extended typically.
for the rock climbing, hopefully using my legs and
pivoting more than pulling, but eventually it's this and that's where I start to feel it really get grumpy. Just to get really in the weeds here for a second. So would you do one position per workout?
Or let's just say it's four sets of thirty seconds, would you do a different position for each of those sets? What would you advise?
So I would rotate through.
So I would do
A thirty seconds.
On the
External rotation with my arm.
My elbow is bent at ninety degrees.
One when it's straight, and then I could come back. I could do one with my arm up over my head. It sounds like you've got a lot of
Tricep involvement. So what I would do is actually do something where I'm extending the tricep. So
have a belt that goes down to the floor. And I'm trying to push up, like do
Almost like a head crusher.
But
Over.
Yeah. So I'm gonna do it from here and I'm gonna push it up.
So it's on like a doorknob me, I put my belt around the doorknob and now I'm gonna push up on the
So what I'm getting is I'm getting the forearms, but I'm also getting the tricep because that's also inserting on that joint.
It sounds like for you, you've got contributions on both sides. So what we're gonna do is a party. So I'm gonna have maybe a a little thirty second rotation where each one goes thirty seconds by the time I get back.
Now I'm ready to do the first one again'cause I've done the three other ones.
And so that's
Perfect for the rotator cuff'cause I need to do
Elbow abducted.
Internal rotation, external rotation. That's two. And then I need to do elbow adducted internal rotation, external rotation. That's another two. So I can go through those thirty second isos and then rotate back through that.
And I get the whole system in ten minutes.
Yeah, that's amazing. Let's talk about collagen synthesis because you mentioned that, I brought it up as well.
At least in one two thousand seventeen study, athletes who took
Correct me if I'm getting this wrong. Roughly fifteen grams of gelatin plus
somewhere around two hundred to two hundred fifty milligrams of vitamin C one hour before doing brief exercise. We could talk about what that brief exercise is, but had double the markers of new collagen formation.
in their blood compared to control. Now
I've heard you talk about elsewhere some of the nuances and complexities of these markers.
And how you might find that one goes up and one goes down from the intervention. So how do you evaluate that? But
Based on everything you have.
learned, researched, experimented with, reviewed.
What would your current recommendations be, if any, for
collagen slash gelatin consumption and not all products are created equal. There's a lot of garbage out there.
But what would the parameters
Or criteria B.
So the first thing is to address the last issue because what you're looking for in any collagen supplementation.
Is that the source of the collagen
Is from a skin source.
From pelt of the animal. So fish skin.
Povine skin.
The reason that we say a skin source,'cause a lot of people use bone broth and bone broth is a great source of collagen.
The problem is that most
Mammals.
We store our heavy metals, we sequester the heavy metals.
In our bones.
So when you do bone broth you're also getting some heavy metal.
Okay. So you just keep that as a background thing so that what we're gonna if you get it from the skin.
There's not gonna be any heavy metal.
So that's the only thing that we would say about a collagen supplement.
Oh. You know, I accidentally got the right thing. I was looking at the back of this. I'm not gonna give them a free product placement because I don't actually know what the quality is here, but this is a
Hydrolyzed grass fed type one and three collagen pepti powder, but on the back I was like, wow, will it even indicate and it does say ingredient, bovine hide collagen peptide hydrolysate.
Yeah. If I'm saying that correctly. Okay. You're saying it perfectly. And so that's the only thing that we really are concerned with.
Because
You can say oh this is a type one, type three
Doesn't really matter.
absorbing the collagen as a whole molecule and just sticking it into our tendon.
We're breaking it down to its building blocks. We're breaking it down to the amino acids.
And the thing about collagen is it has tons of glycine in it and lots of proline in it.
And so when we take just milk protein like whey protein
If we take that after a heavy lift

In the period after eating it. And so that's
Worth it.
Luke Van Loon has done where he shows that there's a drop in glycine, probably because we're synthesizing more connective tissue protein than we have glycine.

The hydrolysed collagen is we're trying to go in and we're trying to give building blocks.
So it doesn't matter if it started from type one, type three.
You want it from the skin.
And that's gonna be mostly type one and type three, but that doesn't matter. It doesn't matter if they've done a super high.
Secret.
peptide isolation, because the peptides don't seem to play a big role. Cause we've had some companies come to us and say, Oh, well you're going to have to use a lower dose of ours because we have the special peptide.
And it never works. And we always go back to the to the other dose.
What dosing and
Timing.
Do you recommend
Both for the
Collagen and for the vitamin C.
So we recommend taking those things together just because
The vitamin C is
Absolutely essential for your body's ability to synthesize collagen.
Most of us have a perfectly
normal level of vitamin C. We're not gonna get scurvy, we're not gonna get any of these things.
But what we wanna do is if we're gonna increase protein collagen synthesis, we wanna also make sure that the co factor for the enzyme that's gonna allow us to make and export that collagen is also present at a high enough amount. So we take them together.
So we know for sure.
From studies that I was involved in when I was on sabbatical with Luke Van Loen in the Netherlands.
The
If you give a blend of
Whey protein with five grams of
Hydrolyse collagen.
You're gonna increase muscle connective tissue protein synthesis.
And that's the
first measure that's shown that oh, connective tissue protein synthesis is sensitive to the diet.
When is that being consumed?
So that one was consumed afterwards. But that was because it was a study on muscle.
The reason that the timing might matter is if I'm trying to target it to a tendon.
The tendon doesn't have good blood supply.
If I'm trying to target it to cartilage or ligament, it doesn't have good blood supply. And the way that those tissues get their nutrients is by getting either compressed or stretched and the matrix gets squeezed of the liquid.
And then as it relaxes, it's going to bring liquid in from the environment.
If the environmental liquid has more of the amino acids and the vitamin C that we need to build more collagen
Having the collagen base before you do your exercise, that's the ideal situation.
Now
It's not always possible. It's still okay to take it afterwards, but if you're really trying to target it to one specific spot, take it before.
About
Thirty minutes to an hour before.
And then those amino acids are gonna peak right when you're loading, say, your rotator cuff. And now
More of what you have eaten is gonna be delivered to your rotator cuff.
I've heard you
describe some of these injectable peptides, BPC 157, I could name others as magic elixir. And I'd love for you just to describe briefly
Putting placebo effect aside, I mean we could spend hours talking about placebo effect.
But
Putting that aside, why people might see benefits.
But not for the reasons they think they're seeing benefits. And then I'd love to ask you about some other
Sort of ortho biologic.
Stuff. If you have time.
For PP one fifty six, we know.
The at least for the tendon and ligament cells themselves, it doesn't do anything. And we know that because we've engineered our little engineered ligaments. They're engineered human ligaments.
From human A Cl cells
We then have treated them with VPC one fifty six or one fifty seven.
And basically there's no effect. It doesn't change, it doesn't improve, doesn't impair.
So if somebody wants to spend their money on that, I'd prefer that they just spend it send it to me.
I can send out a
A little link to the gift
for my lab, and you can send it to the lab and we'll do research with that money instead. And that'll be much better for your tenants.
So the reason it might have a positive effect is one of the treatments for teninitis and teninopathy has always been pithing.
Pithing is where you take something or debridment.
These are these really cool
Medical terms. De Bridman means I take a scalpel and I go
Like this and I make little lines in your tendon. I cut up your tendon and I make it weaker.
Pithing means I stick your tendon with a needle a bunch of times.
All we're doing is
Remember, we're getting a scar because of stress shielding.
If I start injecting
a bunch of times into the strong part of that tendon.
What I've done is put a whole bunch of holes in the strong part of the tenant. Now I can't stress shield the weak part.
And that's actually
Potentially beneficial.
It's actually the reason we think that there's any benefit at all to immobilization.
'Cause if by immobilising I have made
Whatever strong parts weaker.
Now when I start to load properly afterwards.
Maybe it's going to be beneficial. Like we've done experiments in animals where we've got these 3D printed casts that we can stick on to a mouse.
And it just looks like the boot that the doctor gives you.
Three days later, if we take out the tendon, we've lost fifteen percent of the collagen, fifteen to twenty percent of the collagen in that tendon. It's mechanically about thirty percent weaker.
That's three days.
The muscle mass decrease is actually smaller than the decrease in collagen within the tendon.
So
What we're doing when we do some of these things, like we're jabbing it with a needle, or we're somebody's gonna scrape you with a spoon and it's gonna push there. What we're trying to do is we're actually trying to
They say they're trying to break up scar tissue.
What we're actually doing is we're actually damaging the healthy tissue.
And the reason that that could potentially be beneficial is if I've damaged her just enough
Now I can't stress shield. Now maybe
I'll get a little bit of load through the weaker part of the tissue.
Now let me stand in for some folks who are super fans of BPC one fifty seven.
Okay.
Just for a second. If I go on uh let's just say PubMed and do a little bit of a dig around, there are a few studies.
No.
This is not
Ultra recent, but
Two thousand fourteen. This is uh Molecules November two thousand fourteen.
Pentadeca peptide BPC one fifty seven enhances the growth hormone receptor expression and tendon fibroblasts. Now
People might cite this.
Or something like it, but what you're saying is in practice you just have not seen it to make a difference.
That's a really fun paper because basically growth hormone doesn't have a direct effect on the tissue at all, anyways.
Okay. Let's hear more about this. This is interesting. It works on the tissue because
What it does is it increases the local expression of IGF one.
So whether your tendon cells have lots of receptors for growth hormone or not doesn't really help you.
What helps you with growth hormone is that
Either your liver
It's gonna make IGF one in response to it.
Or
the fat cells or other things that are in the joints are going to make IGF one locally around that tendon. And the IGF one has a positive effect.
If we take our integered ligaments and we add
Growth hormone.
Doesn't change their mechanics, doesn't change their collagen content. But if we had IGF one, we get this beautiful
Response.
And so
Yeah, the paper says you get more growth hormone receptors.
Ultimately, who cares?
Ultimately, who cares? And yes. Yeah. And so basically in that situation, what you're finding is.
If it's that specific.
What it means is they were looking really hard to find something.
And they found one thing that made sense with the story.
That's why we do things like we
We try and do things that are the things that that tissue does. So instead of just adding something and saying, Oh, look, I see more of this.
I'm gonna take it and I'm gonna put it into a a material testing
system and then I'm gonna tear it to shreds and I'm gonna say how much load that I have to put through it.
And if that changes me, and now I'll go and I'll try and figure out exactly what
is going on because that's something that's really worked.
V PC one fifty seven.
doesn't change anything, at least in the isolated ligaments.
Doesn't mean it's not gonna change maybe it decreases inflammation or does something else.
I don't deny that.
But it doesn't work directly on the tenant.
Are there any
Other interventions.
That you think
I guess thinking has nothing to do with it. Just believe based on the data, your experience.
could have some efficacy in terms of helping with
connective tissue injuries. So I'll throw out a couple. Prolotherapy.
PRP?
Shockwave?
Therapy?
I'm sure we could add dozens more to the list, but does anything uh pop out as plausibly credible or compelling to you?
Might depend on the entry.
None in the lower body.
So the reason that I say that is that
The lower body.
I'll go in, get my shot.
And then I'll walk out and I'll walk home.
As soon as I took those first three or four steps out of the doctor's office
Whatever I injected into my tendon.
I've just squeezed it out and it's gonna go everywhere within my body. It's not going to stay there.
The reason that the upper body can work is I can immobilize it.
Oh, I'm not gonna load my ulnar collateral ligament or my some of my
other tendons in my upper body, my rotator cuff. So I can hold that still.
And not put load through it, it has a chance to sit there.
So what you'd have to do for
orthobiologics to work in the lower bodies, you'd have to immobilize.
Now I've got the complication of if I immobilized for three days, I've lost. So that's where we get into the no part of it.
The best
physical therapist in the world is this guy Rob Whitley at he's out at Aspirtar in uh in Qatar.
And he's wonderful because he's an Australian who has just gotten
He's been there long enough that people he gets to do whatever he wants to do. It's kind of like the grumpy old man thing. He'll tell you exactly what's going on. He went to this super high end conference with all these orthopedic surgeons. He stood up and there he goes.
None of the crap that these guys are telling you about works.
Because they're all telling you to inject this, inject that. The only thing that works is getting load through the tissue.
And that's what he will tell you time and and he goes through the science of every single thing.
This is PRP, this is stem cells, this is prolytherphy.
And he goes through and he just explains the data.
The when there's been a randomized controlled trial
There's no benefit. So Patellar teninitis, there's been a randomized controlled trial.
Where they don't know whether they're getting PRP or they're getting sailing.
There's no difference.
There's no worsening, but there's also no improvement in your patellar tendon. It was lower body. Yeah, lower body. That was patellar tendon. Yeah. So lower body. So the one place where they've seen it, I think is in the rotator cuff where there's a small positive effect.
But
Again, we talk about collagen protein or whey protein.
That is
Going to whey protein will add about
Five percent, maybe a little bit less than that to your strength gains or to your muscle mass gains.
Collagens probably about that two to three percent.
If I give you the best muscle building supplement in the world.
And you take it.
And you just sit on your butt all the time.
You are not gonna get bigger muscles.
Ninety five.
plus percent of why we get bigger muscles, stronger tendons, all of these things is due to the loading.
There's gonna be
Maybe two, maybe five percent that's gonna be down to the collagen or to the whey protein.
But because it's a lot easier to eat something or drink something, people are gonna focus on that. Oh, all I have to do is eat collagen. I'm good.
You have to apply the stressor.
You have to have stimulus. Exactly. But now I'll just push back a little bit.
I totally agree that if you're just
rolling around on a bed of PRP injections and then uh chilling with Netflix.
Probably not gonna solve all your problems. But
I mean there's certainly things that I would imagine
And based on at least my interactions with some pretty high level athletes, I would think
can accelerate certain adaptations, right? I mean if you put somebody on Nandron and a little bit of Cytomel and human growth Roman six days a week, I I would imagine that might accelerate certain adaptations. I'm not recommending anybody do that.
But
We were talking about, I guess, the orthobologics like the PRP and the prolo therapy.
But
In addition to, let's just say, the collagen plus vitamin C, assuming that you're timing it correctly and applying a stimulus,
Are there any other
Adjuncts or
supplements doesn't need to be ingestible or injectable.
that can
accelerate the adaptations that we're hoping to provoke.
So we've got data on uh on an FDA approved drug.
That improves
tendon function. So basically what we did is we looked at
The tendons of rats as they were developing.
Between seven days and twenty eight days. And during that time there are Achilles tending to
Three times longer.
goes from three millimeters to nine millimeters. And their patella tendon gets twice as big. So it grows in cross sectional area by twice the amount.
And we did genetic analysis, so we did transcriptomics, so we looked at all of the RNAs in those things.
And in the patella tenon that was getting twice as big.
The major signal was inhibition of a protein called
Jack or Stat.
So the Jack Stat pathway is actually a growth hormone activated pathway.
But what we found is that when you inhibit it, it was associated with growth.
And so there's a series of drugs. If you ever watch TV, you see all of these drug commercials. And if you look up at any of your drug commercials and any of them
And then
N I B. So
Etasinib or baricitinib or any of those types of nib drugs.
Those are your Jack Stadt inhibitors.
They're used for rheumatoid arthritis.
And they're used for psoriatic conditions, so skin problems.
Yeah, psoriasis, etc. Psariasis. So two collagen based syndromes.
So what we found is that when we use those drugs
the tendons that we engineer got bigger and stronger.
Which of those drugs did you select and why?
So we selected three different ones. They targeted different jacks to see which of the jacks were important.
So we did a Jack One inhibitor, Jack One Two, and a Jack Three inhibitor, and all of them were beneficial.
So we don't know exactly which one it is yet, and that's something we're working on.
We just finished the study.
Just a quick study on
Development.
So what would happen if we gave these drugs to a developing organism? And we all know that part of the reason we grow is because we have collagen that
Works at our growth plates and pushes our bones apart so that we get taller.
And one of the first things that we found is that the animals were forty percent smaller.
So what that means is that they were getting bigger, they were differentiating the tendons, but they weren't
Able to push
The growth plays a part because the collagen was actually acting as if we're long enough. Now we have to get bigger.
And so what we think we're doing in that situation is we are
Adapting
So that
The tendon is getting a stimulus where it it can grow bigger and stronger.
But in growing it bigger and stronger, it prevents it from growing longer.
That's the first drug that we know of that's been identified that affects tenant properties.
We have other things that we're working on where I can give you a hormone that your body produces and you will have a stiffer tendon.
What hormone? It's a cliffhanger. Yeah, it's a cliffhanger because it's not published yet, so I can't really give you that. So if you had only, say, a thousand listeners, I would I would be okay. Stand by for round two, folks. Exactly. So you know, we can go through and there's also the opposite, which is drugs that
people already know about that caused an increase in tendon ruptures.
And those are super interesting as well because Cro
Yeah, Cypro, but CPR is actually only half
as bad as some of the other drugs that we found.
What are some of the other ones?
So there's a study out of
Again Finland.
And it's the first author is N Y Y is his
The last name of the first author. I can't remember the rest of it. All I have to ever search on my computer is NYY because there's nothing else with those letters together. Except for a finished name. But
What they did is they looked in the finish registry.
All the people who ruptured their Achilles tenon, what were the medicines they were on?
So you you find the fluoroquinolone antibiotics?
Yeah. They're there.
But they increased rupture rate about three and a half fold. I see. Of which Cypro Flaxen would be one.
Or is that
Yeah. Exactly.
And then they found another class of drugs, which are AT1 receptor drugs, so angioten receptor drug inhibitors.
They increased so they're taken by over fifteen million Americans every day and they increased the rate of tendon rupture seven point six fold.
Wow.
What would be an example? Do you know the
What if the names of certain drugs.
The start.
So if you're taking the certain drugs, again, you wanna be careful with your physical activity.
Because what we're finding and
This is not something that's really known. I went and did a a work in progress seminar at our orthopedics group.
And the chairman of the orthopedics department puts up his hand and goes, This could explain why I've ruptured this and this and and he goes through a list of like six tendons in his body that he's ruptured or ligaments.
It's like oh
Yeah, that's probably
possibility because a lot of people who are taking them
That's one of the most common
Things but it's not really reported.
And so
Again.
That becomes a bit problematic because they are used by fifteen million Americans. So Wow.
So we are yes, we're decreasing your blood pressure, but
Please don't exercise while you're doing it.
And so maybe one of the things we're working on is trying to see, is there a way that I can take
What I need, which is the decrease in blood pressure, and can I figure out a way to do that without putting all of our tendons and ligaments at risk?
Because as much as yes, blood pressure is gonna cause cardiovascular disease.
If you rupture your ACL, you are fifty percent more likely to have a heart attack than somebody who didn't rupture your ACL.
So again, is that because of the decrease in activity or what is because of the decrease in activity.
Yeah.
And so because of the
Habitual decrease in activity, we are much more likely to have diabetes and heart disease and all of these other things if we're not exercising.
The number one cost to the US medical system is actually musculoskeletal sprain sprain.
Strains and tears.
The back and the neck.
As well as the rest of the body. It's more than diabetes and heart disease combined.
Okay.
But
You talk to oh who's a serious scientist.
I'm not a serious scientist'cause I work on this stretchy material that is oh yeah, you're old, you have a bum knee.
That's just normal.
But if I worked on the heart, now oh yeah, super everything's about
Okay.
I understand that.
But at some point you have to realize that yes, you what your heart is doing in order for it to work optimally, I have to get rhythmic contraction of my muscles to pump blood back to it so it gets a stimulus so it can work properly.
If I don't do that because my tendons and ligaments don't work.
Your heart's not gonna work very well either.
And so we need to get into a much better understanding of the whole system. Instead of just saying
Well
You're at one thirty five over ninety. I better put you onto a drug.
That's not really gonna be that much of a stress to the heart.
But it could end up rupting your Achilles or rupturing your A C L or
We need to balance that much better.
That's really.
What we're trying to
Do a lot of work on right now.
All right. I would love to give uh wanna be respectful of your time. I know you got some appointments coming up, but
Before we start to

Give something to the ladies specifically who are listening.
Could you speak to
Injury risk, maybe it's A Cl specific.
And estrogen and maybe programming differences for men and women?
Absolutely. So this is absolutely essential component of what we do. So in our little engineered ligaments, so I had a student come to me and she was an undergraduate student. I think she was nineteen at the time and she goes,
I
really interested in what you do because I've ruptured three A Cl. And I'm like
You don't have three legs. Oh yeah. You've done
The same one twice.
Okay, so she's wanting to know why she's rupturing her ACL.
And you go to literature and sure enough, women are four to eight times more likely to rupture their ACL.
They're eighty percent less likely to have a muscle pulp.
Okay.
So what that is telling us is we get muscle pulls when our tendon is stiffer than the muscle is strong.
We get
A C L or other ligament rupt when there's too much laxity.
Both of those two things could be explained if the tendon or ligament was less stiff.
And so all she did and all I had her do was to take
Estrogen and added every single day that we were making the ligaments at the low level that you would have normally around menstruation and early into the cycle.
And then as you get to when the luteal phase would be, so that's when estrogen rises right before the woman's gonna ovulate.
That goes up.
Almost a hundredfold the estrogen levels.
During those three ish days there.
So all I had her do is add
A hundredfold more estrogen.
The exact levels that you would see in the in a woman's body.
And what we've found is that
The stiffness of the ligament went down.
And then we looked at the collagen content. The collagen content was exactly the same, maybe a little bit higher.
And so what we were fascinated by was this could explain, like if you did this repeatedly, and we did this, we inhibited
A specific enzyme like
what the estrogen was doing, and then we took that away and let them grow again. What happened was
The stiffness.
differentials was maintained as they got stiffer again after that period.
So what this kinda suggests is that girls until they get into puberty
They're
Developing the exactly the same as boys the stiffness of the connective tissue.
Now as they get into puberty, estrogen starts to cycle.
What we discovered is the estrogen actually inhibits a protein within the tenator ligament. And it's a really important protein because what it does
Say cross link.
The college.
And what that does is it makes it stiffer.
And so without changing the amount of collagen
If I cross link it, the tendon gets stiffer.
So when estrogen is present, we decrease the activity of that tendon.
And what happens is it becomes stretchier.
And so now as that twelve to thirteen year old girl starts puberty, she's already stronger than the boys when she starts puberty. Now she goes through these periods of intermittent
decreases in stiffness.
And now she can't transmit force as well.
The stiffness of her tissues is going down. So her power goes down relative to the boys who are continuing to increase.
And the result is a lot of the performance differences between the men and women can be explained by the
If we look at testosterone again.
You had mentioned earlier that it
You know, all you gotta do is take Nandron or all these
No, I didn't say all you have to do. I just like people who put together these cocktails do some pretty incredible things. Absolutely. And so a lot of statisticians can go back to major leageball
And they can say that person was taking steroids, that one, that one. Cause what would happen is their performance would go up and then it would drop off a cliff.
Because what testosterone does
It's the opposite.
It actually activates lysyl oxidase.
And it decreases college.
So what you get is you get a stiff tendon
It has less collagen and that's a brittle tendon.
So that's why all of these guys juicing on testosterone related
Products were getting stronger, bigger muscles, but then what they were getting is they were getting brittle tendons. So they would rupture a tendon.
Because this big muscle is pulling on a weak tenant.
And so now we've got this differential. It also that effect on
Lysaloxidase, which is the cross linking enzyme of estrogen and testosterone.
That's one of the reasons why men have higher blood pressure than women.
Because until women go through menopause, the estrogen that circulates monthly is actually decreasing the stiffness of the connective tissue in the orta and it allows it to stretch easier. So you have lower blood pressure.
So there's all kinds of these things that are related to this connective tissue.
that we know about that is related to estrogen or testosterone levels.
Is that fluctuation in
connective tissue stiffness in women an evolutionary adaptation for birthing.
Yeah, absolutely.
So if you know that at some point
That if you have periodic inhibition of stiffness.
The
There's also other hormones that will be produced late in
pregnancy that will decrease tendon and ligament stiffness. That's relaxing is one of them.
If you start from a lower stiffness at the beginning, now as you go to relax to allow birth to happen,
You don't have to relax from as high a level of stiffness.
And so the job of the relaxing becomes easier so that the individual can give birth much more comfortably and have less trauma associated with the birth.
And so yeah, evolutionarily it makes sense, but it's also one of the reasons why we see a lot of the performance differences that we do between men and women.
Because
Power is about how quickly we can transmit force. If I'm pulling on a stiffer
Tendon.
I can transmit the force faster.
If I'm pulling on a stretchy tendon, it takes me longer to develop force.
So that's directly power. A lot of the differences that we see that we see between men and women's athletics.
And injury rate are down to this connective tissue component where we have increased or decreased stiffness.
Keith, we've covered a lot of ground. I expected we would, and we haven't talked about a number of other things.
So I'm gonna make this one up to you.
Do you want to talk about
Depending on which you think will be more interesting for folks.
mitochondrial biogenesis and mitochondria in general.
Or
We could talk about
protein intake and what amounts of protein you would suggest in what intervals
People consume for different purposes.
As far as kind of the
protein intake. I think most people have got that pretty well dialed in.
What was the other one that you were suggesting I
Oh, I was just very curious about PG C one alpha.
And mitochondrial biogenesis, but also things that have come since then.
So I think that that's probably a good one because then we can get into the ketogenic diet component as well. Right. Let's do it. But we can address this at the same time as talking about the protein component as well.
Because I do. These two things are gonna be related a little bit. Cause what we talk about is we talk about the sciences.
And Stu Phillips has been talking about this for a number of years and now he's realizing that
A lot of that was a bit of um
a problem with how we were measuring things. So what he was talking about is this intermittent up and down of synthesis and degradation that happens in muscle that's corresponds to feeding.
That's really
really effective when we're looking at supplements like whey protein supplementation. It goes in, goes out.
We synthesize new protein in muscle and it goes away.
Yeah.
But as people started doing one meal a day.
And people started
Doing other things.
Where they're consuming a huge amount of protein in a small setting.
The question became is that going to really show a big difference if we look at this over time? And what
A lot of Stu, and to his credit, he says that no, that was just an artifact. When we look at it over more time, it doesn't really matter if you're taking every four hours.
That high protein.
Luke Van Loon just had a paper while I was in his lab in Maastricht, where basically what he was doing was he called it the barbecue study.
And it was feed people a hundred grams of stage.
And then follow them for twelve hours to see whether they were still absorbing the amino acids.
And the proteins from that.
And
All the way out as far as they were able to measure, they were still absorbing
The amino acids that were from that original stake.
The difference is one was a purified protein, a hydrolysate or an easily digestible protein. The other was a large amount of protein that our body's gonna take a much longer time digesting.
So the idea that we used to say every four hours you need to have point two five grams per kilogram body weight of protein and that's
Less the focus now. It's more just saying, look, we want to get in about
At least one point two grams per kilogram body weight of protein over the day.
So over one point six, one point six over the day.
So let's just do some math on this for a second. Because a lot of people listening are are gonna be like kilo what? So maybe just play around. So so that's like saying the twenty grams of protein that's in a bar always says, Oh, twenty grams of protein. The reason for that is the point two five grams per kilogram body weight.
And the seventy five
kilograms of the average American weight. Multiply those together, you get twenty.
And so what they were trying to do is get
The minimal effective dose of
Protein into that one.

So seventy five kilograms times two point two is 165 pounds. That must be outside of certain states in the United States. But but yeah, 165 pounds. And so how many of those twenty gram bars would you be consuming per day based on
the recommendation. If you were to do that as a young healthy person, you'd be looking at say
At least
At least four, maybe five of those.
Got it.
Okay.
Mm-hmm.
And that's gonna be anything that's twenty grams of protein. So again, a piece of meat the size of your fist is usually a goodest.
So that's this
Now we've got this one meal a day people who are doing oh yeah. And then you're trying to say, Okay, now I can play with these things.
And you were talking before about being with David Sabatini and talking about MTOR and Rapamycin use.
Well, one of the things that Rapamycin
does is it blocks MTOR and that's the core component of what it does.
But MTOR is activated by two things. It's either activated by growth factors
Or load.
Those are the two things that can activate one part of it. And it needs amino acids.
So the growth factor component is usually insulin IGF one.
The amino acids are from your protein that you're eating.
So now if I have
The amino acids without
The
Carbohydrates.
I don't get as much insulin.
And so I don't get as much amateur activation.
So that's the genesis of the ketogenic diet.
So the ketogenic diet, yes, it's been used for a lot of things for time, but that's when we started looking at it because for longevity.
A ketogenic diet is functionally doing what low dose of rapamycin does.
Which is it's gonna slow down MTOR activity. That's gonna decrease inflammation because we need mTOR.
For our inflammatory cells.
So we did studies in mice where we fed them either a ketogenic diet
And we did this by feeding them exact amounts. One meal a day.
And so they were getting time restricted feeding, they were getting
Slightly
Ten percent less fewer calories than they would need.
And
They were getting either normal chow
Low carbohydrate chow, but still enough carbohydrate that they didn't go to ketogenic or a ketogenic diet.
And what we found is that the ones on a ketogenic diet live thirteen percent longer than the ones on the control diet.
Our control animals lived longer than anybody else's control animals, because my colleague John Ramsey is probably the best in the world at these longevity studies. So they already living a long time.
The increase in life span corresponds really well to the Rapmycin effects.
And then there's Longo down at USC. And what does he say?
He says low protein diet.
The low protein diet is the other arm of that. Cause if I need both
Insulin.
And amino acids to activate MTOR fully.
I can either take away the carbohydrate and get rid of the insulin, or I can take away the protein and get rid of the amino acids.
And so both of the diets work to increase longevity.
One of them is gonna be much harder on your muscle mass.
And it's gonna be less applicable to humans and that's gonna be the low protein diet.
But they're both trying to do the same thing at a molecular level. All three of those things.
The Lodos Rapamycin
the ketogenic diet and the low protein diets. They're all trying to decrease indoor activity.
Quick interjecting question. We didn't have time to get into it. Maybe another time we'll get into it, but we talked about the Abrahangs.
Mm-hmm. Then we talked about Max Hangs. We didn't talk about Abrahan's plus Max Hangs.
Right, which seem to have an additive effect. Would you expect
That
ketogenic diet.
Plus rapamycin would have an additive effect, or are you already checking the box? So there's a null effect, basically, for
One of the that's one of the things that we're studying right now. To see whether that is gonna have an additive effect and that both things together are better than one.
We know that for the Abrahangs they're doing two separate things.
The same way that
MTOR is activated by insulin and amino acids.
Our muscles strength.
Is
Our brain's ability to turn on the muscle.
The size of the muscle as we talked about earlier, but also the other component is the force transfer.
And so what we do with the Aberhangs is we work the force transfer.
What we do with the Max Hangs is we work our muscle mass and our brain's ability to turn on the muscle. When we do them both together, we get both of the stimuli together.
So that's when we have the biggest positive effect. So the same thing could be true for the rapamycin together with the ketogenic diet.
But we don't have the data yet.
So again.
What we're seeing is that
One of the best things for muscle as far as the ketogenic diet goes is that
One, you have good amount of protein, so you're maintaining protein.
you're maintaining the muscle mass. The second really important thing is because there's no carbohydrate.
You have to use mitochondria to produce all your energy, so you produce
Better quality mitochondria.
And the other thing that happens is we decrease MTOR activity is we
activate a process called mitophagy.
Mytophagy is when you break down mitochondria.
And usually the mitochondria you're breaking down are the ones that aren't working as well.
The old and the weak, calling the herd. Exactly.
Culling the herd. And so now we're gonna keep that herd stronger because we're culling the weak ones.
And we're allowing
That
Mitochondrial mass to be maintained. So what we found in the old animals that we had on a ketogenic diet is their strength was actually at the level of a young animal.
And their brain function as well.
What are functions of mitochondria?
the people may not be
Aware of.
What a Monica do.
So the mitochondria, the most obvious thing is they produce most of the ATP for our body. So most of the energy for our body.
And so that's where you have to have mitochondria to break down fat.
I don't need mitochondria if I just want to break down carbohydrate, or I'd use the mitochondria slightly differently.
So it's one of the reasons why people go through the ket component when you go onto a ketogenic diet for the first time.
Because you're going onto a diet that has no carbohydrate. If you've been using carbohydrate as your primary fuel source,
And you don't have lots of good quality mitochondria.
For a few days there, you can't produce any energy. And so you feel like you're dragging and you can't move and you can't get out of bed because you're super tired like you have the flu.
Mm-hmm.
That then turns around once you get enough mitochondria to start producing more energy to allow you to do your activities of daily living.
The important thing is, and we wrote a paper on this, is that if I'm an athlete
Ketogen die is not for me.
Because I can't go fast. What I can't do on a ketogenic diet is I can't sprint.
And it doesn't matter whether you are a marathoner or an ultra marathoner, at some point
Or maybe it does on an ultra marathoner, but even a marathoner. At some point you're gonna have to sprint.
to go at a high quality level. And if anybody out there thinks they can run the four and a half minute mile per mile pace to run a marathon to be competitive.
And you're not using sugar and you're gonna use fat.
That's just not really possible. You can't go that fast.
And Professor Ron V Maughn, who's one of the original sport nutritionists.
He went through all the calculations for exactly how you can you're using carbohydrate to power that whole marathon.
And that's also why you need to take in supplemental
carbohydrate on your run because if you don't, you don't have quite enough.
You've got enough to get to about twenty two miles. And what does everybody experience at twenty two miles?
They hit the wall. So the reason that you can continue to the end is because you're taking in the carbohydrate along the way and your body can use that as a fuel.
So again.
We don't use a ketogenic diet if we want to go fast.
But if we're training for life.
We see that it increases longevity, that the ketones themselves are really good for brain function. The biggest downside to it is your bones. So if you have a history of osteoporosis,
On a ketogenic diet, bone mass actually becomes really a problem.
So the place that we see ketogenic diets
In
Clinical settings.
Is in kids with epilepsy.
Epilepsy, yeah. The epilepsy you take and that's Lorenzo's oil, this great movie about all of that stuff.
You take the ketogenic diet because the epilepsy and the brain function is deteriorating. And when you get rid of the carbohydrate, your brain uses the ketones.
You don't have that deterioration.
The reason that kids have to go off the ketogenic diet
and go back into an epileptic possibility is because their bone mass becomes so fragile.
that they're at much higher risk for if they were to have a seizure, they would break multiple bones in the seizure.
So again, there are always trade offs.
And it's always about what are the things that are most likely to take you down. And those are the things that I'm gonna focus on.
You mentioned decreasing inflammation with the ketogenic diet.
A lot of people think inflammation equals bad, let me turn it off. Let me gobble
Ibuprofen or leave while I'm icing everything that hurts, but I don't believe that is your particular
Recommendation for folks. When is it right to inhibit inflammation and when is it not?
So again, inflammation is absolutely essential.
Two adaptation.
So there's a good study out of my former university, University of Illinois, Chicago, where they they actually knocked out the inflammatory cells and they then gave a stimulus for muscle hypertrophy and the animals couldn't muscle.
They couldn't hyperthy their muscles nearly as well.
We know that if you take high levels of vitamin C and high levels of vitamin E
You can actually decrease aerobic adaptations because part of the stress.
is the reactive oxygen. So we know that. We know that if I take ibuprofen and I'm young and I I've just done a heavy lift.
I can decrease some of the adaptations, or if I sit in an ice bath, I can decrease some of the muscle protein synthesis.
It's gonna lead me to bigger, stronger muscles.
What we have to do is we have to find that balance between inflammation and anti inflammatories.
And what we tend to do
is we tend to again, we're gonna go full circle to the start of the podcast and say, I am not going to use anti inflammatories that are pharmaceuticals or other things.
I am going to use load as an anti inflammatory.
The reason that your muscle feels sore after you've done a heavy lift is because
There's inflammation within the tendon. The tendon has a little
Sensory organ called the Golgi Tenon organ.
What it does is it senses tension on the tendon. So if I put a whole bunch of
Water in there or
fluid. Now there's more pressure, and that's telling me
Did I have got
more load on the muscle, I don't have a pain sensor, so I interpret that as pain.
So if I do an isometric contraction
What I'm gonna do is I'm gonna squeeze all the water out of it.
And that's gonna get rid of the inflammation.
So what I'm gonna do is I'm gonna do shorter duration isometric holds, like even five second isometric holds.
Enough to squeeze the water out.
And then I'm gonna do that again.
Go back.
Five seconds.
So I can go right to left. So I'm gonna go five seconds onto my right leg.
Then I'm gonna go over and I'm gonna do a side lunge to the left, then I'm gonna do five seconds on the left.
What I'm trying to do there is I'm trying to use the loading
And the muscle
contraction to squeeze out the liquids from the connective tissues from the muscles.
So now what I've done is instead of using something that's gonna turn off everything.
I'm just adding a little bit of minor load that's not going to cause my legs to get heavy or anything. It's just gonna squeeze out some of the inflammation. And I start this.
The moment I twist my ankle.
I sit there and I'm doing
Alphabets. So I'm going and doing capital letters where my toes are tracing the alphabet.
And all I'm trying to do is I'm trying to make sure that I'm using load.
through the tendons and the ligaments that have just been
Sprained by that.
Pull when I've twisted my ankle.
And I can do that and I can
Twist my ankle really badly. And I've done this where I've had a really bad inversion sprain, playing inner murals here with my
My lab
At fifty five, that's not the best thing to do.
But you do that and then you're like oh crap, I sprained my ankle. But now at least I know I don't ice rest and and do any of that.
Stuff.
What I'm gonna do is I'm gonna do loads where I'm gonna put loads through those
Ligaments are going to pull on them, hold it.
Release. Hold on and hold it. Release.
And that's gonna pump all the liquid out the next day, you wake up
There's still bruising there, but the ankle is the normal size and I can go out for my run.
What it tells us is it tells us that we've gotten into a bit of a habit.
We're gonna do pressurize all
There's no harm in it.
So let's do it.
We're gonna compress.
All of it is trying to do something that I can do if I just put load through that system.
So
I don't use the anti inflammatories. I use load as an anti inflammatory.
Ice bath, just as a fan of ice baths, mostly for mood elevation, kind of Vincent Van Gogh style. Um, when they used to prescribe cold baths for melancholy. How much space would you provide after a workout or training stimulus before doing something like an ice bath?
So a lot of times what we tend to do, again, it's all about optimization. So if you
Our training for life and you don't have to be the best you that you can be.
Then what you wanna do is you can say look
Do your ice bath in the morning?
Lift in the afternoon.
That overnight you've got MTR activation all night long. Now you come out
If you turn off MTOR no big deal.
So that's kind of what we're saying. And then if I do that and then I go and I get out and I
do a warm up and I go out and do my aerobic or my rhythmic exercise, now I can actually go into that with maybe feeling a little bit
like the aches and pains are a little bit gone. And now I can do that aerobic exercise in the morning. And now I've got this split where I'm doing some of my strength when I'm my strongest in the afternoon.
And
For your supplementation question, right before my biggest protein meal of the day, because I'm gonna have most protein at dinner. So now my strength is close to my dinner.
I'm gonna then sleep and get all the recovery. Then I can get up and I can do my endurance.
in the morning, and that's gonna allow me to actually optimize those combination of strength and endurance.
All right.
To wrap up.
Keith.
You do not disappoint. You're a beast, a gentleman and a scholar. Thank you for the time.
And for people who can't see the video, you have all of the weight training equipment behind you, which I know is your next step.
And uh where can people
lear more about you, learn more about your work.
Find you online.
Racial people.
Find you if they want to learn more.
So I do things like LinkedIn and I do Blue Sky. So on Blue Sky I'm muscle science. So if you look for muscle science all one word.
You'll find me there.
You can keep an eye out for the company that we're developing is called Sinuous. And so it's Sinu S I N E W
So sinew like your tendons and ligaments and then
Us like US, so
I love it.
All right.
Keith, thank you so much for the time. Absolutely. I've taken a million notes.
I can't wait to go find a tennis racket or a pan or a golf club to do my overcoming isometrics. And for everybody listening, we will link to all sorts of goodies.
Everything we've mentioned, including
Where you can find Keith in the show notes at Tim.blog slash podcast
Just search Keith B A A R. Is there anything else, Keith, that you would like to add before we wind up?
No, so that's great. And I'll send you the
'Cause a lot of people don't understand necessarily the isometrics, what they look like. My medical school just came down and filmed a video of it and it's up online. So I'll send you that for the show notes as well.
Beautiful. We'll put that in the show notes and everybody be safe out there. Train smart.
Perhaps incorporate some isometrics. I don't know how you couldn't be tempted after this conversation.
And until next time, be just a bit kinder than is necessary.
To others also to yourself and thanks for tuning in.
Hey guys, this is Tim again, just one more thing before you take off, and that is Five Pulit Friday. Would you enjoy getting a short email from me every Friday that provides a little fun before the weekend?
Between one and a half and two million people subscribe to my free newsletter, my super short newsletter called Five Bullet Friday. Easy to sign up, easy to cancel. It is basically a half page that I send out every Friday to share the coolest things I've found or discovered or have started exploring over that week.
It's kind of like my diary of cool things. It often includes articles I'm reading, books I'm reading, albums perhaps, gadgets, gizmos, all sorts of tech tricks and so on that get sent to me by my friends, including a lot of podcasts.
guests and these strange esoteric things end up in my field and then I test them and then I share them with you. So if that sounds fun again it's very short, a little tiny bite of goodness before you head off for the weekend, something to think about. If you'd like to try it out,
Just go to Tim.blog slash Friday. Type that into your browser. Tim.blog slash.
Friday, drop in your email and you'll get the very next one.
Thanks for listening.
This episode is brought to you by Shopify, one of my absolute favorite companies, and they make some of my favorite products. Shopify is the commerce platform revolutionizing millions of businesses worldwide, and I've known the team since 2008 or 2009.
But prior to that, I wish I had personally had Shopify in the early 2000s when I was running my own e-commerce business. I tell that story in the four-hour work week.
But the tools then were absolutely atrocious, and I could only dream of a platform like Shopify. In fact, it was you guys, my dear readers, who introduced me to Shopify when I polled
all of you about best e-commerce platforms around 2009 and they've only become better and better since. Whether you're a garage entrepreneur or getting ready for your IPO, Shopify is the only tool you need to start, run, and grow your business without the struggle. Shopify puts you in control of every sales channel.
Doesn't matter if you're selling satin sheets from Shopify's in-person POS system or offering organic olive oil on Shopify's all-in-one e-commerce platform.
However you interact with your customers, you're covered. And once you've reached your audience, Shopify has the internet's best converting checkout to help you turn browsers into buyers. Shopify powers 10% of all e-commerce in the United States. And Shopify is truly a global force as the e-commerce solution behind all birds.
Rothys, Brooklyn, and millions of other entrepreneurs of every size across more than 170 countries. Plus, Shopify's award winning help is there to support your success every step of the way if you have questions.
This is Possibility Powered by Shopify.
established in 2025.
has a nice ring to it, doesn't it? So sign up for your$1 per month trial period at Shopify.com.
Slash Tim.
all lowercase. Go to shopify.com slash Tim to start selling today with Shopify. For more time, shopify.com slash Tim.
Listeners have heard me talk about making before you manage for years. All that means to me is that when I wake up, I block out three to four hours to do the most important things that are generative, creative, podcasting, writing, etc. Before I get to the email and the admin stuff and the reactive stuff and everyone else's agenda.
For my time. For me.
Let's just say I'm a writer and entrepreneur.
I need to focus on the making to be happy. If I get sucked into all the little bits and pieces that are constantly churning, I end up feeling stressed out. And that is why today's sponsor is so interesting. It's been one of the greatest energetic unlocks in the last few years. So here we go.
I need to find people who are great at managing, and that is where Crescent Family Office comes in. You spell it C-R-E-S-S-E-T. Crescent Family Office, I was introduced to them by one of the top CPG investors in the world. Crescent is a prestigious family office for CEOs, founders, and entrepreneurs. They handle the complex financial planning.
uncertain tax strategies.
timely exit planning, bill pay, wires, all the dozens of other parts.
of wealth management, just financial management that would otherwise pull me away from doing what I love most, making things.
Mastering skills, spending time with the people I care about. And over many years, I was getting pulled away from that stuff, at least a few days a week, and I've completely eliminated that. So
Experience the freedom of focus on what matters to you with the support of a top wealth management team. You can schedule a call today at crescentcapital.com slash Tim. That's spelled C-R-E-S-S-E-T.
Cresitcapital.com slash Tim to see how Crescent can help streamline your financial plans and grow your wealth. That's Cresit Capital.
And disclosure, I am a client of Crescent. There are no material conflicts other than this paid testimonial. And of course, all investing involves risk, including loss of principle. So your due diligence.