Tendon Rehab Masterclass | Week in Review 57

From standout performances at the Pre Classic to a practical breakdown of tendon loading, this episode covers the biggest track and field headlines before shifting into an evidence-based discussion on tendon rehab, pain, and progression. We dig into how to load tendons the right way, when to advance training, and why timing and biomechanics matter.

Full Transcript

Beau Beard (00:00.238)

Harry Potter, the boy who lands, has come to die. you didn't get it. I know. My flashlight doesn't work when he does that. Literally won't work now. That's what she said. I hate technology. And it's because we got EMP'd last night. I don't want to go down that route. Wild stuff last night. Wild stuff. He was telling me about it. Maybe we'll tell about it at the end. I don't want to let's not.

Two off the rails in the beginning. I'll put up I'll get my tinfoil hat made. give us some track and field updates. Pre-classic. That's the big to-do in the last week. so Birmingham native Ethan Strand. He's been in the news a lot on our podcast, but pretty cool. His first year, professional year running for Nike. He did not win the pre-classic mile, but he did run the fifth fastest American time of all time. He got third. He got third. Yeah, he did. And

It in typical Ethan fashion, you watch the video, they're going in the last lap. Brothers in tenth place. He's not even in the mix. Now granted they're in a pack, but like he's way off. runs three forty six ninety-four. which I was I was looking back or thinking back, I really didn't look at the actual stat, but when his dad was running professionally, early two thousands, Alan Webb set the American record in two thousand seven.

ran three forty six, I believe, at pre classic in two thousand seven. Granted, you run three forty six in two thousand seven. I mean he won he won by like seven or eight seconds. different world now. You run three forty six, you don't even win, and you get beat by a twenty year old from Australia. Either either way. I mean he's running the American record for the time that his dad was was in the in the sport, which is you know, twenty years ago, but still still really cool to see him succeeding at, you know, such a young age. He's twenty three.

And we talked about this before though. Do we not think he could do much better if he didn't have to pull that crazy? I think now you're seeing well, because if you go look at the splits, they ran they ran the whole thing fast. They ran very even. 346 is fifty six five average. I mean, Cam Myers, the guy who won, was fifty six five first four hundred. So what was his last lap then? Probably a little slower than Cam's because Cam separated in the last one fifty. but

Beau Beard (02:23.758)

I mean, 'cause Cameron three forty six six and second place was between the two of them. Yeah. so I bet you they closed in fifty four high, maybe. No. 'Cause they were pretty even. They went one fifty three high, I think, in the in the eight hundred, so two forty nine, I think, through twelve hundred. But yeah, in in races in college it was very common for Ethan to close in fifty two, fifty one. but just 'cause he was sitting and kicking.

sitting and kicking or just waiting by his team. Can't you get like a half second more per lap and like better position, better overalls? I don't know. I feel like you can if you can kick that hard. And that's well, that's what I think you're seeing him run now because he ran two seconds faster than his college time and ran through those laps faster than he would have in college. Because he ran slower for his last lap than he would have in college. Okay. Two or three seconds slower. Yeah. But yeah, that was probably one of the most notable

on the all also on the men's side, the 200, not only was there high schooler that won, he ran U20, was it U20? Is number three U20 all time, which blows my mind that that's not I guess it's because GalCout is also under 20. but Tate Taylor, who we've talked about before, 18 year old out of Texas, he is foregoing college and running pro, but he ran 1975. and I don't think he had broken 20 at that.

What do think about that move? It's not many to go straight. I mean, I think in the sprinting world, you kind it's if you're running that fast and you're a sprinter, your shelf life is shorter. So to do it earlier makes more sense. But you know, you also now can make money in college. That's what I was gonna say. Like, I don't understand that. Yeah. Like if this was ten years ago and you weren't getting a You can still do as a track and field athlete, you can do almost do everything. Yeah.

What what's it preclude you from doing is it's no I don't know the rules now because of NIL because you see college people competing in Olympic trials like and not why wouldn't I not that it's a safety net, but why wouldn't I be on a team with a coach unless it's like he wants to use a coach? I don't know. You know what I mean? Like why wouldn't I do that and have that always to be like competing in? Yeah. And then if I got injured, I have a staff I can I don't know. Right. I would do that. Yeah. And I mean, 'cause it running nineteen seventy five is

Beau Beard (04:50.338)

competitive. Yeah. But you're not you're probably not winning a major world championship running nineteen seven unless it just happens to be a slow day. Now he he did beat Let's Late Tobogo. And like those guys have both been Olympic medal caliber athletes. So that was probably the other most notable. Lots of lots of fast performances in the sprints. and I mean women's steeplechase was pretty pretty quick. Also Hallie

Porterfield. Really? For Stevle Chase ran. No, not pre classic, but she put down I want to say Auburn's best time ever. have to kind of quote me on that. I was talking to one of her family friends the other day that she basically yeah, I think it was a school record and one I don't know, we'll have to look that up. Yeah. We'll get back to you on that. Yeah. Yeah. Yeah, that's probably the that's probably the biggest ones. We'll have

Josh Kerr is attempting to break the mile world record. It's the 2 2 2 project, 222 seconds. which I thought he was doing that at pre. but it appears that that is not it. And I think it's gonna be in London. I I think he could do it potentially. He's the kind of guy who doesn't need I don't think he needs a fast race to happen, like he could make it happen on his own. honestly the pre classic would have been a good one to be in, but

I mean he just did a workout a few weeks ago. I saw that he did four by eight hundred, five minutes rest. First two were at one fifty nine, second two were at one fifty and one forty nine. Yeah. And he wasn't, I don't think he was spiked up. To clean that up, Halley was the number two performer in Auburn history in the three thousand Siebel shows. ten ten twenty. Ten twenty. Yeah. Okay. Yep. Yeah. Yeah, these

Faith what was her name? Faith Chiratit, she ran eight fifty one. Yeah. it was funny seeing the results. The first American female I think was eighth, and then it was like eight Americans. Which not competitive. I mean I think the American record's nine flat. Nine one, nine Was that not in McCoburn. I think it's Snow Courtney Fredericks.

Beau Beard (07:15.532)

Yeah, Fredericks, Fredericks, something that. I thought Emma Coburn still had it. No, I don't keep up with the distance as much. I think she broke because they were teammates, I think. She broke it. I forget what world championship. No trivia, I would have said Emma Coburn, but Yeah, same. Yeah. Same. You got anything for us? Sandy Morris finally beat Katie Moon in the pole vault. so I mean I'm just throwing that out there since Sandy Morris did Vulcan Vulcan Vault last year, but we met her. Yeah. I yeah. We met her. Got picture with her.

But she will not be there this year, sadly. Tara Davis Woodall is remaining undefeated in the long jump this season. So I think she's going on seventeen meets undefeated and jumping over seven meters. There was somebody else you said was undefeated. Melissa Jefferson. That's right. She that was a nail bite. That was an insane final. She beat Shakeri Richardson by one one thousandth of a second in the final. Like photo finish. And she was going on I think that win was her twenty-fourth win in a

So she's also undefeated. Yeah. Ten seventy eight. I thought it was gonna listen. Absolutely insane. Yeah. What are we most excited about coming up?

I saw also 'cause we always do kind of the the lay person tracking field. I saw Truett Haynes put down a fifteen forty seven. Yeah. Yes. Five twenties across board or something. Right at five. Or five no, I'm sorry, he ran five twenties across board for a ten mile race. Yes, yes. Yeah. Yeah. Five five. What's the co who's the coach he's working with? He's like I guess someone I don't know him, but they act like he's like training Olympic athletes or something.

But I heard Cam Haynes talking I guess he's still at like a hundred and forty seven pounds or something and he wants to get down to like one thirty eight still. Cam does or trend true it. 'Cause I don't know how t he's not tall, but that's not unrealistic, but I like, Jesus. I just again we talked about this before. I think the process of getting rid of lean muscle is hard, but then that's gonna be deleterious to your training. That's I I think like like when I was in college running, I was five ten, one thirty five. Yeah. And like

Beau Beard (09:28.12)

To think about going back down. I mean, I'm one fifty. To go back down to one thirty five, I would feel terrible. Well to go up to one fifty wasn't wasn't bad. Like I gained muscle mass, I felt healthier, but like we were talking about Marco like running a P R and he was like nine pounds heavy at one forty four or something. Yeah, yeah. Yeah, you see Marco and you're not like that's not a skinny guy. Don't look at him and say he's a big guy. Right. He's not, yeah. but I was like, Jesus, I don't know. So that's

So what he's got a year and some change for trial stuff, which I mean he's so I mean you said he ran five twenties for a 10 mile. That's not even that's not even trials. Close, right? Yeah. For 10. Yeah. Sorry. And I've said before, and I'm I'm laying it down, I'll put money on it. And if somebody wants to post this on Cam Haynes' page, I'd love it. I think Cam Haynes can beat him in a marathon. Yeah. Also, Cam Haynes' testosterone is like 162.

He put up his lab results the other day 'cause people were, you know, trying to get him banned for BPC one fifty seven tests. And he was like he's like actually results forever. And he goes, I haven't taken that stuff forever. And he goes, This is what it is, which I was like, dude, you need to be on testosterone. Like screw the running and getting banned from US Tf events. Who cares? You're gonna die. Yeah. That's crazy. But he was making fun of himself that he could basically compete in the women's races. But yeah, it's I'm trying to think of any lay stuff.

Kind of western states. yeah. yeah, it's kind of the typical stuff. So now it's kind of become racing for ultras is like, you know, go out, blow out, and if you don't finish, like you put your effort into like Jim Walmsley, Hans Troyer, Killing Journey. Killing Journey went out with an injury knee thing that he's probably gonna have surgery on. We'll just see how that goes. Jim Walmsley said his hip hurt. which I was literally, I said that as we were watching the live stream, and someone goes, Bo, you've been complaining about your.

For like four weeks. I was like, Yeah, but it's different. It's different. God, why am I blanking on who won? that was a new guy. Yeah. He broke the course record. Yeah. Well, Tom. I'm blanking on his name. New guy, but then also the guy that was calling out, he got second. Poopy. His name looks like puppy, P P P I, but it's poopy. I believe he got second. He's the guy that was basically saying like Kocadona is an ultra race, which I don't understand.

Beau Beard (11:50.738)

so they're giving them shit about that. Women's record was broken by a first time ultra runner as well. So it's just like I don't know where the mark is. Now I have to change all my slides for my running thing for all the records. So yeah. anything else in the trail world? Not really. Next thing we got UTMB will be coming up in about a month. We got USA's outdoor track and field championships at the end of July. Yeah. And New York this year.

Worlds aren't in the even years. They're in the odd years. Right. All right. We ready to flip. Yeah. All right. We're going from track and field into tendons. So first of all, a reference a podcast. I don't can't remember how long I should have looked up how long ago it came out. over a year ago when the last season of the podcast was when I had Keith Barr on. I would I would say Keith Barr is one of the preeminent researchers in just

General tendon research, tendonopathy rehab, tendon reconstruction. And again, you have kind of OGs like Jill Cook. you have other people in the realm of kind of the soft tissue research, rehab. you have clinicians that are kind of high level at that too. But when we look at Keith Barr's work, it's kind of set the basis of like, you know, moving away from Alferson's protocol for tendon loading and like, okay, what do we do in the modern day? So I wanted to reference, okay, how do we three things.

How do we make sure when we're loading a tendon that we're biomechanically loading the tendon an appropriate way to not make it worse, but also make it the most advantageous way to load it? And we'll give some examples. Second would be what are we using in terms of if we had the a mere quoting protocol, how to properly load a tendon in terms of, you know, sets, reps, time, and then maybe some extraneous things. And then we're gonna talk about a few cases where we, you know, we saw this, how we used it, might even talk about Alex's Keelys as well.

So the first thing I want talk about is when we're talking about loading a tendon. well, let me think where to start here. One thing that Keith Barr surprised me with was saying that, hey, as soon as you can get somebody to go through full range of motion with little like a one to two out of ten pain max, right? Maybe a zero, that that's what we're going for. It's not this like, you know.

Beau Beard (14:14.538)

Isometric for analgesia, eccentric, concentric, which is very Alfredson, but he was saying, you know, I thought it was hey, isometric, then full range. He's like, as soon as you get full range, if it's not hurting them, you go for it. You're just using isometric because it's safe. There's no jerk moment, right? So that's the other thing with tendon stuff. You tend to want to kind of have an isokinetic movement. When it's the same, you know, we don't have this like initial start or a hard stop. So knowing that, we want to talk about okay, when we're going through, let's say, the full range of motion or hitting an isometric load.

Making sure we're not kind of breaking rules and then we're also, you know, having an advantage. So the rules that can be broken are if we c create compression on a tendon, that's kind of a no-no, right? That's how a lot of tendonopathies happen. Best example I would think for a tendon that's not gonna be an enthesophy or insertional that is gonna use that sheer force to kind of create a lot of disruptions around the like patellar tendon, right? So we what do you guys remember your biomechanics, the roll and glide of the knee?

first 15 degrees of flexion, what's happening? It's rolling. Yeah, it's just rolling. And then it starts gliding down the tibial plateau beyond that as it goes through flexion. Right. So as it glides, because it's rolling, it's moving in pace or place, right? It has an axis of rotation. we're not gonna get too biomechanic-y Rich Holmes listening at home right now, like yay. but it rolls and then it starts to technically glide. Well, what's stopping the glide?

Your quadriceps and your hamstrings is a synergistic action. Your hamstrings are actually kind of levering it forward, your gastrocks kind of levering it forward, but all of them should be working well enough where it's not just falling off the edge. What happens when it falls off the edge? ACL tears, right? But that glide, if it's uncontrolled, you haven't done enough of it up front. What are you doing? You're pushing through the tendon. So just imagine this is my femur, if you're watching my top fist, the bottom fist, the tibial plateau.

So I roll in place for the 15 degrees, and then as I keep flexing, it's gonna move forward in space, getting checked by the ACL. As it does that, it's gonna push through the tendon. That's normal, unless, like I said, that isn't adapted to it. you do it too fast and too hard. I guess those would be probably the biggest ones, or I add a lot of load with the same speed. and then let's throw in the biomechanical thing of other areas don't move well. So the knee gets overloaded. Typical one.

Beau Beard (16:37.742)

Right, ankle dorsiflexion. So now you have to really drive through the knee to get into that position, which is just creating more of the shear. So when we do that, we're not creating compression in terms of bone on, you the tendon, but you're driving through there. So it's more of a shear force. It's still giving us the, you know, kind of the mechanism of action. We can use that for rehab, but that's also how it gets hurt. So we want to make sure when we're loading things that we're getting the load on the part of the tendon that is actually.

you know, incurred damage, not responding because it's kind of scarred over, it's stiffened a bit, or we need to evacuate fluid if it's basically an acute tendinopathy, right, or a tendonitis. We need to kind of wring out the wash rag and apply even load. So let's go through just the knee for this example. So if I'm in those, let's say I have I'm gonna give three examples. I have an elderly woman that has a hard time just sitting doing the sit to stand test just because of mobility, right?

Then we have a high school football player that's been doing squats and jumps and all this stuff and is squatting and his knees starting to bother him. And then we have a seventh grade cross-country runner that his knee just started hurting him when he started running, right? They come in and we determine on our exam that all three of them have a mid thickness, like right in the middle of patellar tendon, tendinopathy, right? Whatever it is, tendon up acute tendinitis, reactive, whatever, but the middle part of the tendon is getting bugged.

We can talk about how the different parts of the tendinopsy can get affected differently. So that first woman that has a hard time squatting, let's say she can barely get past that first 15 degrees, just because of like ankle mobility, hip mobility, ability to squat, balance. It's gonna be really hard to apply that load and they're like, Well, how'd she get it hurt in the first place? Going up and down stairs, going beyond the threshold of what she normally does throughout the day. So it's kind of just picking a scab. So what might we have to or what could we do with her?

to make sure we're getting load through the middle part of the tendon as we might not be able to create a little bit of shear to basically like start stretching on that.

Beau Beard (18:43.904)

A wall a wall sit, right? Like we we have to get her knee to flex. So if she can't actively squat, imagine if we had somebody in a dead bug, I bet you know, we're just saying her knee moves, she just can't move around it well, right? Maybe she didn't have full range, but it's more than she can express in a squat, right? Or sitting in a chair or sitting on the toilet. And there's a functional aspect there too. But now we need to say, Okay, we need to get your knee in a position while you're still able to load it. Now, could we put her we don't have it in here, could we put her on a leg extension machine? Sure.

Like there's nothing wrong with that. Could we put a band on a PT table? Sure. But we need to make sure we're in a right angle because those first, you know, 15 degrees a roll, there's not any shear or very, very little shear. So that tendon's just getting stretched a little bit, but not much. And what do we know about a tendon? The area that gets stretched is going to be the healthy area, not the stiff area. And we got to apply load for long enough. So Keith Barr kind of pointed out, well, how are we determining we're, you know, loading the appropriate area?

You can feel it. It's a little bit sore. What's a little bit sore? He kind of said if they get above a three or four out of ten, that's no go. They need to be feeling it about, you know, a two to four out of ten. You know, while it's painful, when it becomes non painful, that's going to get a little different, which we're going to talk about with you. But that's what you're going for can you reproduce some of that soreness in whatever angle of the joint, whatever angle we're using, you know, if with the weight or the external load, and then also to dur duration.

Right. And I think that's something that's missed. That if we look at the Alfredson protocol that we thought it was isometrics and eccentrics, right? E-centrics may start driving compression and via bony, you know, approximation into the tendon. And people are having pain with that. And we just think that's the next step. And we're it's like maybe a five or six out of ten are like, well, you went through the isometric phase, just keep going. Right. And you're just kind of breaking a rule. So the first thing I would say is make sure if you're loading the tendon, you're getting load through the part of the tendon that needs it. Right.

One of the common ones that we talked about the other day was I'm still gonna call it proneus longus, fibularis longus tendon, right? So wraps around the lateral aspect of the ankle, it attaches on the medial aspect of the basically the first metatarsal and the first cuneiform. So if that thing acts like a stirrup, we think that that muscle does what? Everts and dorsiflex, right? That's what you think that does. When you're on the ground though, it's gonna basically control your tibia.

Beau Beard (21:11.938)

Go in the opposite direction. Right. So if you think it's doing, you know, bringing the outside of your foot towards your tibia, well, now it's controlling your tibia going out away from your foot. That's how it's working in gate. That's it's basically eccentric load. So if we want to start stretching that tendon, we need to take your tibia away from a loaded foot. Well, how do you do that? I think I don't know how else you do it to be honest with you, except maybe you're doing some weird stuff on a wall, like a curtsy lunge, right? Where your tibia is kind of deviating a little bit away from the center of your foot.

Safely, right? Go extreme, like we talked about, like a scorpion lunge with TRX or something. But that is creating stretch. There's a little bit of compression around the lateral malleolus, but that's we'll be okay with that in this scenario. Versus if I did the opposite because we think the muscle function is what we need, right? I'm doing, you know, e-version dorsiflexion for perennius or fibular slungus. It's like, well, that.

Is the shortened position of that? And is that ever gonna get to a tendon? And my analogy to Ethan the other day was that's like trying to load your patellar tendon while my knee is almost fully extended. Yeah. Like there's almost zero. Now you can have maximal muck muscle contraction, but the tendon it's a shortest position with no lever arm to put stress through it. When you're Dorsey flexing. Yeah. So if I had my ankle in full and you'd be well, I just take it down a little bit, and I'd be like,

That's great. You could we said you could do that with a band on a table for a knee. You can do that with a band on the table for that range of motion. I would say I would preferentially go after being loaded on your foot for function of the foot actually interacting with the ground, making sure the foot is functioning properly in this case. We're not just loading a tendon without like the functional kind of consequences, if you want to say it. You know what I mean? Like, can I drive force through a muscle and I still have a dysfunctional foot? I don't think that's awesome. So you can be doing two things at once.

Same thing with like let's jump up to like lateral epochondylitis, like very common one, right? That we have to start applying load can be very painful, right? To start, you know, doing a little weight off the edge of a PT table or a desk or something. But is just loading, you know, my wrist extensors by themselves changing anything functionally with the rest of my body? No. But it's a harder one to load. But how can you do it? You can load your

Beau Beard (23:31.768)

Common extensor group, if I'm close chain, how bear positions, hanging, right? Offloaded hanging. I can go false script to varying degrees and change the load on the extensor tendon. So again, you get creative with this stuff. And what do we we have rules? You get above a five out of 10, doing whatever. Okay, I can't do that. Okay, I'm on the table for right now. As soon as I can get that pain free, I can go to a higher level thing that's more functional. As soon as it's relatively pain free, I'm doing what?

Full range of motion with whatever external load I can tolerate. And we as we said, I think you kind of said, so when you're like working out, you're training tendons, we're like, yeah, hypertrophy training is hypertrophy training, right? Your muscle, the tendon, tissue, XYZ, they respond a little bit different to physiologic biomarkers, but we'll leave that for another day. Keith Barr talked about that. but biomechanically appropriately loading the tendon, I think it's missed a lot. I would say the biggest

misstep with like patellar tendinopathy is what I see all over social media I fix my patellar tendinopathy with astrograss split squats. So in the first 15 degrees there's relatively little load on the tendon. At the end of knee flexion, there's very little load on the tendon and most people think it's the most. It's not. This is completely compressed, right, against both tibial plateau and femoral condyles, or I guess the interrochlear notch, and across your patella.

You'd be like, well, that's load. This passive. You're quadd, like you unless you don't have the range of motion, you're basically resting on your joint at that point. Do I want compressive, passive load on a tendon? No. Right? So one thing that kind of I don't know, didn't I understand it until I listened to Keith Barr talk about it, not on my podcast, but previously, was if I have somebody do a wall set.

They're, you know, part of the burn that they feel. You're like, how does your quad start burning? Well, it's constantly shortening, right? Contracting as you maintain a position. So if I just do this with my bicep, my bicep isn't remaining static. It's continuing trying to shorten. It'll fatigue at some point, right? And it'll lose that contractile ability. As it's shortening, the tendon is lengthening. That's how you have an isometric, right? Create tendon load. The tendon isn't just staying still, it's winding up like a rubber band.

Beau Beard (25:50.38)

Right. Is that muscle keeps shortening? And then is the muscle loses contractile ability, you gotta take break. That's your, you know, your set. So when we see you know, things like an astograss squat like that, like, yeah, am I opposed to going through that full range of motion once it's pain free? No. But I don't think that's where I'd start somebody with tendinopathy. Right. And I'm not saying maybe they didn't, maybe they started walking uphill backwards or whatever. but I see a lot of people like that's their first go to.

A deep knee flexion, load the tendon. It's like we can be more specific as clinicians. If you want to be the lay Instagram person, cool, that's good for you. But I've also seen a lot of people, literally a guy came in with that book, no knock on Ben Patrick, and he's like, I've been doing this stuff, my knees no better. Like, you gotta kind of know where to start and you know how to weave your way through it. So any any input on the biomechanical aspect of making sure a tendon is being appropriately loaded.

Shoulders can be a little tough, I'm being honest. So let's say we think we have a non, you know, not a tear of one of the rotator cuff tendons, but you're like, it seems like you kind of got some tendonopsy going in there. And then we'd be like, well, how do we load that specifically? Maybe we're not so position dependent of like, okay, what's the mechanical lever arm of the muscle, right? Okay, we have, you know, infraspinatus. I'm gonna, you know, load extra rotation at 90 degrees and go from there. What is the action of the rotator cuff musculature in general?

Stabilization of the gonohemeral drug. Deep decompression in the subchromial space, right? Like they're gonna pull your glonohemeral head down so it doesn't smash into the bottom of your chromium, is your deltoid is trying to crush everything. That's their main MO, which is stability. When they get hurt, we lose that. That's why a lot of people get like, you know, impingement. so if we said, Okay, it's decompression, well, that the ability to decompress is the concentric ability of those muscles. You with me?

That's how they're gonna shorten and pull back towards their the scapula for most of them, right? So if we're like, okay, that's a short concentric. Well, that would be analogous to our e-version dorsiflexion for Peronius longus. Well, how do we do the opposite? That's where a lot of like for me, DNS comes in. You're flipping the script of I can get those active and go through a closed chain maneuver, which is just I think better because there's more tactile input and it's lower level for most people.

Beau Beard (28:14.178)

So for a lot of these, we you know, for extra rotators, you'll see us in like a sideline position moving through like five months, like rolling. Perfect start. How can you flip that for some of them? Now it gets position dependent on the arm. And, you know, am I gonna be in a start position? Am I gonna be, you know, I'm in a crawl position? But you can still use those lower level positions as long as you still listen. What? Somebody feels it. If you get them into that position, they don't feel anything, it's probably not enough load. So you need to graduate it real quick. and then if you can graduate it enough, you'd be like,

Because you know, I've probably been guilty of this of maybe your tendon's a little bit bugged, your shoulder hurts, and maybe I have ruled into an opathy, and then we get them into hanging off a bar. Well, you're doing the opposite to load the tendon. Right? The tendon's getting loaded, but in this like contract so the if we had again a mid substance kind of injury, that area is never getting loaded. Yeah. Cause I guess that would be the same example as doing the telotendon loading with a knee fully extended. Yeah.

You're just like in the shortest if you can get in the shortest position. You know, now I could work maybe some eccentric like scapular, you know, kind of protraction elevation stuff a little bit. maybe yeah, maybe that's the case, but I just think I've probably progressed people into positions just thinking I need general shoulder function. It wasn't as specific as I needed. Right. And I think it gets harder because of the anatomical, I mean it's just tiny tendons with a lot of different lever arms. I mean, think how

We also don't think Robert Lar Lardner is really good at this. When we look at these like orthopedic tests for our rotator cuff muscles, he'll do them in all these different angles because all of them are multi pinnate. Yeah. Right. I mean superspinatus is probably the least. I mean infraspinatus, I mean all these, like subscapularis, all these different angles of pination. And then we're over here like, you're good. So he'll go through arcs and just kind of test, which there's all I get multiple muscles in every arc that are available.

But anything else on the biomechanics part of it or I guess positional loading of that. Did we need well, were we gonna discuss this during this part about like when we talked about the Achilles yesterday with loading it in yeah, that's good point. Yeah, so you know the Achilles, most people in, you know, rehab physiology space know the Achilles kind of rotates 180 degrees for it, inserts on the calcaneus. But you have sub tendons within there as well.

Beau Beard (30:35.672)

That are ba so I always say the Achilles tendon's like a May pole, which nobody knows what that is anymore. or you're running around this pole and the you know, these ribbons are wrapping up around it and it kind of winds it up and tightens it as it goes. That's what your Achilles is doing. And then you have sub tendons that are doing the exact opposite. So it's basic two spirals going opposite directions that create tension, right? So you create torque through the tendon because that's gonna max out the angular velocity as you go off the ground. That's what that tendon was built for. So we could walk primarily and then

Some people would say not run, but I'd say run. so with that, because I have so much rotation in there and I need to create rotation for that spring mechanism, I have to create triplanar load on that. Even if I'm like, in this range, I do feel it. Okay, well, then we got to go to the other ranges. And maybe they don't feel it as much, but I'd still load it. But as we get further out, and let's say we're having that, you know, one out of 10 or zero out of 10 pain and we get into strength training.

Okay, now you to make sure you're hitting multiple angles because that tendon needs that load capacity, not just in one plane. And whether that's just force production, like legitimate like motor control, but also the tendon load. Whereas, like Keith Barr said in our podcast, say I again common extensor tendon. we'll play around with angles within maybe four sets of loading, right? Maybe we're if we're just saying curls, reverse curl, hammer curl, regular curl.

And he's like, you might not feel the pain in all those, but he goes, We'd still probably play around with a little bit of that. Maybe that's not like the hyper acute face. But he goes, Maybe three weeks in or something, you're starting to multi, you know, plane the angles and eventually you'd be doing that for tendon health in general. We wouldn't Hey, we're just always doing, you know, supinated curls. Yeah. Which makes sense. You just have to do it for the Achilles because of the nature of the Achilles. So I guess in your Achilles scenario, you could if you're primarily doing, you know, sagittal plane calf rays or eastern trick, whichever, you could

lean on like a landmine and have you can lean, you can turn your foot. So you can change, you know, you can change the angle of the load just by turning your foot. Well then you can also change the load on the tendon by changing the angle of your body, right? Leaning, you know, to the right. Say it's all right foot, lean to the right, rent lean to the left. Then I can change my foot angle. It changes it slightly. It also changes what muscles are synergistic to that action, right? Is it more pronation, more supination? There's so much in here, it's just variety.

Beau Beard (32:55.714)

But you should have variety in all this stuff. It's got me thinking of I used to think these were so dumb. When we were when we were in college, our warm ups, whenever we would s he would send us like our summer workouts, we'd see our warm ups and it would have like duck walk, duck toe walk. Like you you know you're walking with pigeon, like you're inverted and you got your toes adducted and then you're s you're standing and walking on your toes. I'm never thinking like that looks kind of Kelly's right, he didn't come up with it, but he

Probably popularize it quite a bit, you know, like the seven way squat, but it's I don't know how many variations, you know. If so if both feet were parallel and then both were turned in, both turned out, and then he can start doing one at a time. I think there's twenty one variations if you add them all together. He's just doing that for like motor control playing around, but he's like, you'll feel stuck sometimes in one direction. Could be anatomical, could be mobility, but he was trying to point out like play around and just see like what's difficult and warm up the whole thing before you could just go squat in the same position all the time. Yeah. I think that covers the mechanical part.

Yeah. Okay. So when we're applying load, whatever position we're in now, again, old school Alfredson protocol, we've kind of hopefully moved beyond that. Keith Barr, maybe we could get more general with this and still have probably the same effect. But you know, his loading strategy was, you know, tendons need time under tension, and the amount of time under tension was based on the amount of sets. And he would say if it was an isometric,

We would be holding that for around 50 seconds. Now it can go down depending on pain. I believe, and I'd have to review the own podcast. When he said you get below like 30 seconds of load because like the pain was too great, because you're not having a tremendous effect on the tendency. You need to find either a different position or less load. Right. It's just not enough. So that's that isometric phase. Why do we 50 seconds per set? Yeah. And why do we use isometrics up front? It's safe. Yeah. There's no jerk moment, right? A jerk moment is that fast moment that is

Very responsible or largely responsible for a lot of the tendon injuries in the first place. But there's potent analgesia from a neurologic standpoint with an isometric. So as your nervous system has to deal with, you want me to keep holding this position? You want me to keep me holding this position? You get a little bit of it's not an endorphin release, but you get analgesia that is primarily the fact that like this is gonna suck, like it burns to hold a a walc, right? So your body is saying, okay, I'll let you do this. That's also why.

Beau Beard (35:21.624)

Two reasons why is we get into like the fourth and fifth sets of these things, people are like, ooh, my elbow starts feeling better, both from that, but also the tendon is hopefully becoming a little more pliable, right? So in that first acute phase, say, you know, they come in, a tendon's red hot, you know, they got tennis elbow or whatever, and we're starting to load them. We're looking for that position where we can be below a five out of 10. Right. That might be very little load. It might be you applying load, it might be them applying load manually, might not be a

Dumbbell or kettlebell might be a band, but we got to find a position, right? First, we talked about. Then we need to apply lodopropy. That would be around two to three minutes of total work, right? So that's around four sets of this. Now the off time is about 30 seconds minimum. Sometimes people would say it's one to one, right? But 30 seconds. So 50, 30, 50, 30, 50, 30, 50, 30. You're done. You can do this twice a day. So the recovery window is 10 to 12 hours.

Per again, Keith Barr et alus research. So you could do it in the morning, you could do it night. I think you can do that early on because it's such low load. I think as we move through it once a day is fine, and then we talk, we'll talk here in a second about how to move beyond that. But as we said, as soon as you're using these isometrics and say you're up in the weight, you're up in the weight, and we're like, okay, it's hard to reproduce the pain, or it's a two out of ten. Okay, now I need to play around four range motion. It's not leaning on eccentrics.

We used to think that, we need a bunch of load through that. We know eccentrics are more taxing from a motor control standpoint, more taxing from basically like a a lengthening ability from motor control so it can be more deleterious and there is more muscle damage with an eccentric, right? From a recovery standpoint. But that's not exactly how a tendon gets loaded. Right. So we want to kind of make sure we're moving through the full range motion. a, because it's better, it's easier. We don't have to sit there.

But that gets us into normal training again. And as long as it's relatively pain-free to pain free, like that's what we go after. And then the variety comes back in. So again, lateral condylitis. I'm just using a stupid example, you know, reverse curl, hammer, regular curl, I don't know, tricep extension even. Right. If I'm doing a skull crusher, there's still extensor tendon involvement there. like that could be your four sets. And now we could do what? I don't know how long it takes you. We want an isokinetic movement, right?

Beau Beard (37:44.354)

Kind of slow for the most part. So if I can do eight reps and that's about 50 seconds, cool. There you go. So now you're strength training, relative pain-free. And then what do we do? We talked about this yesterday. We were like, I think you just go back into strength training. Right. Cause we're like, well, how many days a week can you do that? Probably three max. So you have about two days in between. and then eventually when you're getting into enough weight, okay, now we're having muscle breakdown that we need to recover from as well. That takes about

48 hours, depending on, you know, age and what else you're doing. So now it's just weightlifting. It's all it is. And that's there's you know, everybody, you know, on social media would say, well, you know, just full range of motion strength training is tendon rehab. It is, but if somebody's tendon hurts and you tell them to go do curls, they're gonna give you the middle finger. Like you gotta have this like clinical approach up front. Also for safety stuff. Somebody that's got a mid thickness tear of their Achilles tendon that isn't hobbled.

Do I want to go program sled pushes for them thinking that's rehab? Probably not. That's not the smartest thing in world. Could that be good if it's really controlled well and done well? Probably. But to tell them to just go do that, I think is just a misstep. So we're just trying to give you the re the research is, I guess my interpretation would be talking with who I think is one of the foremost world experts, and then also, you know, what we're actually using in clinic and what we see results with. so on that, so we've kind of talked about like the upfront pain.

you know, painful range, moving into a pain-free range, getting back into training. Now, another part of Keith Barr's work, which we are highlighting with Alex, who's been dealing with some McKee stuff, is he has a slide, which I use. Maybe I'll put it up in here as a graphic. He has a slide out of this preeminent research article that was looking at how to load a tendon appropriately, really for getting a response out of a stiff tendon versus a stretchy tendon.

And it came down to he tried to dumb it down in this, you know, this picture, that if I have a stiffer tendon complex, right? If that's just somebody that's a little stiff or sprinter, whatever phenotype, that tendon is going to get a little more pliable by applying heavy loads slowly. That's the rule of thumb. If I have somebody that's maybe higher on that bait and scale, you know, we got a kid that's a little flexy, we got somebody coming out of dance or ballet.

Beau Beard (40:04.28)

They're going to respond better to more of a plyometric or springy load because that's what stiffens tendons. This also makes sense if you just looked at like the sports that people do and like the outcomes of what's going on. So if I looked at, you'd be like, well, Olympic weightlifters have four range of motion. They already had the full range of motion. It's not like they probably are getting better. but if I look at a sprinter, I look at a runner, a soccer player, yeah, people lean into those probably because of it, but it's also building that throughout. You will get stiffer.

Vice versa, if I'm doing slow loaded stuff like yoga, you know, ballet, yeah, they're springiness in ballet, but a lot of time spent on flexibility training, I'm gonna get that tendon to stretch a lot. I see the exact opposite talked about on social media. I was talking about some jump influencer, his whole social media, which whatever is increasing his vertical jump. And he was like, I'm making my tendon stiffer by doing the heaviest loaded, he was doing seated soleus raises. Like that's not now if you're ballistically doing it, cool. He wasn't.

And as we said, the heavier you go, the harder it is that power behind something. It's pure strength. That's not happening. Are you getting stronger? Sure. Is your tendon getting beefed up or stiffer? It's getting beefed up, maybe the cross sectional area of tendon and muscle pace together, right? but it's not making it stiffer. So if we talk about pliability, which is the quality we're looking for, you have to tune that with athletes. So we said a sprinter.

You want a lot of stiffening around the foot. I mean, that's one of the hallmarks, right? Is like, can I get my foot to hit the ground, just boop, turn to a brick, and then create force. If that gets too bad though, you don't get the mechanical lever arm of your Achilles and your planar fashion, all that stuff to work for you. Vice versa, if I have my seventh grade cross country runner and he's flexy as all get out, he can hit huge range of motion. So he's got a big slingshot, but he has a hard time controlling stuff in space. So he needs to stiffen that foot and tendon and

whatever else up a little bit to give them a little bit of just passive recoil. That's all we're talking about. And then that's what you're doing as a yourself as an athlete or practitioner is kind of saying, you're more in this vein. So we could lean your training or rehab towards that. And you know, vice versa. So just so people know that. Now, like I said, it's a rule of thumb. is that gonna be what we do for every rehab scenario? So Alex was kind of, you know, doing a

Beau Beard (42:21.29)

A little bit of running, a little bit of kind of baby plyo stuff and loading. And we're like, hey, I think we need to take the plyo stuff out because your tendon's still bugged and go with the heavy loading still to get after that area. Cause we said as you load the tendon, you start pulling on that damaged area and that takes time under tension. But Alex has ran for how many years now? He's got some stiffness built in. So we don't need more plyos right now to create more jerk around a stiff tendon, you know, pulling on the damaged area but not giving enough load to

Stretch that puppy back out or reorganize. What do we think about for the dancer? So in terms of programming, the the one that would need and need to lean on more heavily the plyometric to stiffen the tendon. Would we let's say they've gotten through the isometric phase and they did some heavy loading? That person's phase for the heavy loading would probably be shorter, maybe pain-dependent, but shorter before we get into the plyometrics, and then even still.

I would expect we're not doing plyometrics with them every day, it would be maybe on the same frequency of three days, two to three days. A lot of that's probably neurologic with plyos, right? You need that like recovery because that's power. Right. So yeah, one thing we talked about yesterday, because you're like, well, when do I start doing plyos again or start running again? Again, there's I was talking with Nikki Kirk yesterday, and he goes, if we just explain to more patients that basically almost anything physiologically from an injury standpoint or even physiologic change, muscle takes about three months.

Because you would do yourself such a service because it buys you time of saying, It's not on me. Yeah. We are I'm allowing or helping get you out of pain, get kind of some motor control, allowing the physiology to express itself the best it can, but still takes time. So we could probably say from let's say we went from an acute tendinitis. We'll talk about a case here in a sec, where somebody had an incident, they felt that they had swelling, they had some redness, they had pain, to when do we think we could start going

you know, phenotypical training, right? The stiff person versus the stretchy person, it'd be six to eight weeks with most people. Yeah. Does that mean that we just have a protocol we run or off? No. People respond different. Like you're going off of the rules of thumb. Pain response, range of motion, right? what is the soft tissue around that area doing and responding, right? If I've got a bunch of tone and trigger points and the tendons feeling better, it's probably not the greatest scenario to just be like, Yeah, you can go do some more apply metrics with a bunch of stiffness there. Like

Beau Beard (44:45.688)

Like, let's make sure we're being clinicians and not just being like, we're at six weeks. Let's now we're gonna do playos. So I'd say we could again rule a thumb with that. But the I'd say return to play criteria comes in here of like it, let's say we got to a point where, like, hey, we're gonna use a single leg pogo jump for our dancer of like, hey, do you have any pain with this now? And we're getting them to the point where they're like, no. But let's say we're also seeing like we don't like how you do that. We still might not.

Go there yet because we're like, it doesn't make sense to just train something you're not great at. So right, all those factors play in. But yeah, I think we could just say six to eight weeks. You know, a lot of people show up with critic chronic tendonopsy. So it's gonna be a little bit different. It's not white hot. You can get about pain pretty quick. The thing there is, you know, there's clinical exams that you can do it in the Keeles, it's harder to do elsewhere, where you can kind of feel like pliability of the tendon itself, right? So if one side feels wildly different, so let's say

I don't know. You'll see a lot of people like one tendon's bigger, thicker, stiffer, right? Dominance, injury, something. And they're out of pain. They're four weeks into care and that tendon is stiff as bricks. And you're like, hey, we're just gonna start loading the snot out with some heavy, like I don't know if I just like, hey, go into training now. Like you might feather into it. Same thing if I had that kid that's the baby giraffe that's a little clumsy and we've gone six weeks, he's feeling awesome. He doesn't have any pain with a single leg pogo.

I don't know if I just be hey, go home and just start jump roping every day. Yeah. I just feel like we're we're missing pieces there. Right. So there's always variability within all these. Yeah, that part of the discussion feels very pertinent to I mean, I I'm thinking of three tendon cases that I have right now and obviously my own, because like you said, it takes time. Yeah. I've been three months now. And three months of looking back, a lot of that at the beginning was probably fine. And then kind of picking a little bit of thinking like, okay, it's going to adapt.

Nope. I'm gonna I'm gonna stay at this level of three, you know, maybe four out of ten. And then the frustration came with, well, I'm doing all the things that I think I need to be doing, however, this in years past 'cause this is Well, can we tell what you were doing? So Yeah, yeah, yeah. So I was going initially isometrics, then move to heavy heavy loaded slow resistance.

Beau Beard (47:05.686)

And it did start to feel better too. Started feeling better. So then at that point I was okay, I'm gonna add in some plyometric loading that's not running. And back up, you had an initial incident, like you felt yes, I had a I was doing hill repeats and it was actually a combined what I thought was a hamstring strain and Achilles, which hamstring was neurogenic, it went away in a week and a half. but I have also had this happen twice before and it's probably been five or six years since then.

So six weeks off of running in that time, started isometrics, then went through heavy resisted loading. I was basically alternating days with that. And then started adding in some plyometric loading in the form of jump rope every other day. So maybe like three, four days a week. and was doing a lot of it. Like I would basically just replace jumping in a workout or running in a workout with jumping. So I would I might do 10 to 30 minutes total of one minute.

repeats of and if I'm right, you thought that was a better choice because you were thinking some of the mechanics of running were bugging potentially and not just the plyo. Yeah. Yeah, that's that's what I was thinking. It was, you know, I'm not I'm not having any forward movement with it. and it would respond similar to a tendon where it would hurt initially, warm up as I went throughout that workout, and then towards the end start to hurt again. But don't lose your train of thought, but to double click on that, this highlights the point of

Looking at somebody's running mechanics first and start going after that if you've made a clinical decision, which we always talk about, this little triage checklist of like, is an engineer not? Yes. Don't what's the last thing on that triage list? Can they apply the movement to a skill or you know, activity? You shouldn't even think about that until you're like, like Nikki Kirk just said, have you had the physiology take place, take change? No, but a lot of people would start to be like

Four weeks in it's not getting any better. Hey, we're gonna look at your running now, make sure you're not bothering it. And it's like you just start pulling on threads that never even mattered. But that's I'd say ninety percent of injuries and stuff is we just kinda we miss that initial. What is actually going on? And with you n I my take on anything would be if you have a really good grasp of what's going on and you understand the basic sciences, you should be like, I can I can write a plan for the next six months for you. Now, will it go to a T no. Yeah.

Beau Beard (49:30.082)

Variability is cooked in because you're fucking human. Like, but I think we just kind of start going, Well, we're four weeks in, it's not better. Like, let's go over here. It's like takes time. Like, as long as you have a good plan and like again, you're like, Well, I was doing something. I didn't realize that was picking the scab. Yeah. But then like having that forward thought of like, maybe if it wasn't how I ran, I had an injury. Very freeing to know I'm not like a shitty runner and I gotta work my gate. And is my gate wrecking me? Because why? When you go back to running, what are you worried about? That. Yep.

So you tell somebody that that's now you're creating this whole map in their head. No bueno. Yeah. Which has happened, you know, and the fact that it's happened before. The thought crosses my mind. The other thought though that is comforting is like, well, I know when this happened in grad school, I had a stiff foot. Yeah. I know my foot is not as stiff as it was then because it's moving better. so yeah, the pivot was okay, I'll do less of all this and I'll basically load it on that day. So instead of having I'm gonna do this

Five, six days a week, three days a week. I am I'm now at this point gotten to where I could add in some running instead of doing the jumps. And that was tolerable, like one, two out of ten. Slowly added volume of interval time, not total time. So total time 20 minutes, started one minute on, one minute off. And then that started getting worse. The running started getting worse.

That's when I was like, okay, I'll just do this all in three days. So I'm only gonna do my plometrics and heavy resistance loading on the run days, which is three days a week. The other days I might do isometrics if I feel like I need it that day. Started to help a little bit, then it got worse. And so I was like, did that for three weeks and then we convened this week. So what we came up, we basically just broke down, okay, go back to heavy loading, you know, basically three days a week. So you got a little space because you're kinda on like that barely hurts now.

Or while we were doing heavy loading daily. Or daily, right. Because we're not doing much else. Then we'll start spacing that out as we get you basically zero pain, heavy loading, full range motion. We'll start using pogo jumps as a litmus test first. Can you do thirty reps out on one leg and maybe through rounds without any pain, or we're talking one out of ten, but also you get done and thirty minutes later you're fine. Right. Right. That's also maybe you have a little bit.

Beau Beard (51:47.852)

We would make sure that you can do plyos without running, just because running, what do we get ourselves into? You go out a mile and then even if you gotta walk back, you're still loading your tent and shitty versus I can just stop jumping in the gym. Right. So control the scenario a little bit. And some people be like, that's too hyper protective. You're a clinician. You're an idiot if you don't think you should be like, I think this is what's going on, that's what you should do, versus like, yeah, go for run and like, I don't know. and then yeah, as soon as we say, you're tolerating plyos, maybe it's a week, maybe it's two weeks or whatever, we'll be like,

Go for a run. How'd you feel? I felt a little bit. How'd you feel the next morning? Totally fine. Cool. Take two days off, try it again. Yeah. And then we'll go to about probably one day a week of still strength training at this point, right? For that, right? Which would multiplane calf raises. And that's what we kind of said. It's like, there's a prominent coach that's getting a lot of notoriety now, and he's blaming all of the Achilles ruptures in the NFL on the lack of soleus training in particular.

So I just literally used perplexity to say, give me all the stats from the inception of the NFL on Achilles Terrace today. The two biggest spikes were when the NFL had the lockout, which was 2006 or no, 2002, maybe. and then COVID when they came back. So it spiked from like five or six a year to 20 in the after the lockout, tendons. So

We mentioned real quick I this is god, I'm blanking who's work. Cross sectional area of tendon and muscle goes up at the same rate with strength training, tendons fall off at twice the rate when you rest. So you create the same force production through the muscle, but the tendon starts to go down. This is like jumper's knee and MBA, right? Like I take a three month off season, I'm doing a little bit of stuff, tendon gets deconditioned. I come back, I got still a lot of strength production and muscle. Go back, tendon starts getting jerked around. Here you go, you got jumper's knee.

So that being said, shoot, I lost my train of thought. What was I talking about? The lock. Acheli, yeah. So looking at those, I and we were talking about this yesterday. I go, I think he's trying he's little bit of like salesy on that. I think you have less healthy organisms, less less healthy soft tissues. So strength training does help it, but it's like a supplement. Don't blame it on that, but the organism is different, right?

Beau Beard (54:07.202)

People were not doing heavy soleus training in the 70s, 80s, 90s, early 2000s, 2010s. And they were less. So you can't like that doesn't work for me at all. so yeah, that that is a side note. but when we get into it, we said, okay, so when do we stop? And we're like, we don't. It's just strength training, it's not tenory you have anymore. Yeah. Right? Because we're do you need to do it forever because you had some deficiency in your soleus strength? You were a clear runner. I highly doubt it.

Some people might and they're like, hey, we're gonna get you up to snuff. What's snuff? I don't know if this comes from Mashod or if he's highlighted in one of his reviews. I'm just kind of visually looking at the slide. You should be able to do about one and a half times body weight for like four sets of 10 of a soleus raise, right? That's pretty heavy. easy one is you should be able to do four sets of 25 with almost zero rest in between sets of just body weight soleus lifts, which we've talked about all the time. Once you can do that, like it's just maintenance.

Yeah. Right. But running itself, and this is one of the things this coach that I was talking about does talk about is the force production needed from your soleus is through the roof to offset both impact and basically create velocity upward and forward. So yeah, you need a lot of force production. Well, that's strength training and power training. Right. And then running is both of those with muscular endurance and aerobic capacity in it. Yeah. Running is training for that. Yeah. Right.

Sorry to say it, but if you need eight times your body weight and impact reduction and force generation with each step, yeah. That's called training. so do I need to go in the gym and train that more? I don't know. That I don't know. Maybe it's more so the controlled full range of motion that control would be the thing. So we think about non contact ACLs. What do we know if they're? So this is the interesting one. We know what? They literally have highlighted for years that it's the over

Basically over training or over hypertrophy of musculature around the joint, right? Whereas the ligament did not have time to adapt to that. So we see a high schooler just get like jacked and strong and then you know they're quick as all get out. And you know, a ligament takes about two years to kind of adapt to that and the ligament has it, and they can create a ton of force, put on the brakes, and that thing can't respond to that well. That's one of the big things we think that's just like excessive force production doesn't match what the soft tissue can compete with. Yeah. How do you train that?

Beau Beard (56:27.736)

Making sure you're actually loading those things. Where's Nacl lower the most? We already talked about this. The first Yeah. Like when that thing's trying to slide off a cliff, that's why, like, you know, heel elevated, like split squats, like when you hit that mid range, like, dude, that is a control mechanism. Now you do need to train power and deceleration. Those are two different things. But the ligament itself, besides acting as a brake, is gonna get, you know, stronger by pushing on it, you know, with force. And then I need to go out and, you know, have control.

That's like, I'm blanking on his name. Who's big ACL researcher out of Kentucky? blanking off his name. Doesn't matter. But what's his big thing is they need to learn how to decelerate, right? It's not four foot deceleration. It's basically rolling from heel to toe. So there's also skill built into this thing, right? It's not just stronger tissues. Yeah. sorry, we're kind of going off the train there. But yeah, so Alex is kind of that's his plan moving forward.

Before we jump off here, just talking about one patient case, then we're going to highlight something to pay attention to attendance. Like I said, I had a she's a physician, which does matter because her understanding is a little bit higher, right? Of the physiology here. She was taken off to run uphill. She was running with her husband. She hit tied her shoe and she wanted to catch up with him, takes off, feels something. Shouldn't go down like she got hit by a sniper. She's like, I felt something. I had to stop and walk. I had to walk home because it hurt. It swelled up.

She let it roll for about two, three months because she didn't want to do anything about it. She just thought it'd get better. She comes in, medial side of her Achilles. You can feel a little bulbous, you know, just kind of area. It's tender to the touch, mid substance, lateral side, nothing, right? So very specific, right? Area. What do we do with her? First of all, she had a giant trigger point in her medial gastroc, it's like no bueno, just constant tension. So we worked on that. we did a little bit of soft tissue around her Achilles, I think just with a tool for just kind of a minor kind of inflammatory reaction.

And started her out with what? Body weight, full range of motion because isometrics created zero pain. She also couldn't do the four by twenty-five of soleus raises. And guess what? When she did a soleus raise, she also felt her Achilles win. So that's what I sent her home with. Right. And you're like, well, that's not the exact one. Don't care. Like it's gone on for months. It was a one to two out of ten doing soleus raises. So I thought, well, let's see how fast I can get her to do that. Then I can start doing heavier loading with the, you know, 50 seconds on, 30 seconds off.

Beau Beard (58:51.022)

She came in, it was much better. She could do all the solecerasis, probably neurologic, right? She just needed a upper motor control. I was like, okay, now I'm gonna do a little shockwave, you know, around the tendon, through that muscle, make sure it's all chill, teach her that loading protocol. Do I need her to come in every week for the next six weeks or twice a week? No, I don't. Could I do? And I even told her they live fairly far away. You guys like or Mountain Brook. So

They just think it's forever away. It's not. So it's she was saying it's hard for her to get here. She's an ER physician. So she's like working, you know, four fourteens in a row and then she's off. What's so what's the realistic play there? Ma'am, I need you in here twice a week to do BFR with me and load your tenant. No. Go home, pick up a kettlebell, have your husband sit on your knee if you're, you know, sitting there, do your four to five sets of eight to whatever reps you can do. Make sure you can feel your tenant. As soon as you can't feel your tenant, you make it hard.

If you can't fill it at all and you're doing hard stuff, try some pogo jumps or come see me at that point or retest. That's where I'll probably see you next week. Yeah. So I try to give people a lot, especially if you're a physician, I can give you a little more leeway. I should be able to. somebody that, you know, a high schooler that's just running off the rails, won't get it back at it. I'm gonna rein them in a little bit. Like, yeah, no, I am gonna see you every week just to make sure you don't mess yourself up. So you're hate all the variety and nuances cooked into patient care, not just with like what we're doing with the tender but what we're doing with them.

So before we hop off here, we're running out of time because we've got to go see patients. I wanted because Ethan had a patient that's dealt with this here pretty recently, but highlighting the the use or maybe we could say misuse of fluoroquinolones and how they can wreak havoc on tendons. Yeah. So I saw her yesterday because it was like a reactivation and she was talking about like some shoulder pain that was coming on. She literally said like I went to go grab a half gallon of milk out of like the grocery store.

And she was trying to go from the shelf to her cart and her shoulders like kinda almost gave out and she was like it hurt a lot. And she also was like, My other shoulder hurts, but not as bad as my right. And then I've had this thing in my foot and my knee on both sides. They all started two weeks ago, but my right shoulder's the most like provocative. And I said, And Sloan knew this patient, so she gave me a little bit of a rundown before 'cause it was one of her patients. And December of twenty twenty five, around Christmas, she was in septic shock.

Beau Beard (01:01:17.63)

was on Levaquin. so if you're not familiar with Leviquin, it's an antibiotic, typically part of the fluoroquinolone re family. Prior to that, she had been hospitalized multiple times for C. diff for several weeks at a time. They'd also given her high dose antibiotics, including Leviquin during that spell. Due to a pick line with that, which is I mean, you're just getting bombed. So yeah. Basically like chemotherapy in antibiotic form.

So all this to say, she's had been exposed to a lot of antibiotics in the past six to months to twelve months, roughly. She's the last time she took Levaquin was January of this year. Mm-hmm. She comes in yesterday and she was talking about all this stuff and she had mentioned the Levaquin stuff. And she actually brought it up at first of like, could this be related to like the fluoroquinolones? And I was like, it definitely could be. Had she looked that up or she was curious?

She was just curious. I like Accutane, so things that have a black bot or a black label warning, they're supposed to read the warning to you as a patient. Nobody ever does, which I just why do we have That's the whole that's why it's called that. You're supposed to say, hey, in this scenario, especially athletes, hey, if they're gonna take Cypro, Levaquin, Accutane, they're supposed say athletes sometimes have issues with tent doesn't mean they don't give it to them, but they're supposed read it to Yeah. So

I had told her like definitely could be, but it's hard to say because I don't know all the research in terms of like the the timeline of when a fluoroquinolone reaction to a tendon would occur. So I did some research last night on one, just like the mechanism of what flu fluoroquinolones do to tendons, as well as like the timeline. And the mechanism of these antibiotics is to inhibit the topo isomerase number two.

So it therefore limits the transcription replication processes and pathogens. It's effective against obviously gram negative, gram positive bacteria. So it's going to just degradate that tendon over time. So that's you can't repair. Right. Right. The tendon. So the tendon is still, it's not like it's destroying the tendon. The tendon just going under normal load tolerances. Kim, I know it's not working out as much as she used to when you were from a gym back in the day. So you're just normal daily stuff, you just don't repair.

Beau Beard (01:03:38.562)

Yeah. So then I started looking to see like, okay, what is the typical onset of these type of symptoms? And some patients, I think it said in some of the research, like eighty five percent of tendons started to become related to the fluorocolmones after a week of use. And sometimes it can take as long as six months of concession of the antibiotic before you start to see symptoms from it. So ironically enough, July is the seventh month of the year. She stopped in January.

It's about six months and she just had these come on two weeks ago. So we are running with it as if it is related because she also was like, My gut health was horrendous. I've been working with someone on restoring my gut microbiota because of all the antibiotics. we just started with isometrics because before we had out this talk about like working in a full range of motion, I was like, Hey, let's just start with ISOs, try get that to calm down with any provocative movement. And like she wants to get back to CrossFit, but she doesn't feel comfortable because of like

can't really do anything. It doesn't want to make it a tendon rupture. Mm-hmm. But it's also upper extremity, so it's not like a patellar tendon or anything. So that's a little bit trickier. So we're we started with ISOs yesterday and some shockwave just to kind of like get a little bit of an inflammatory cascade to help repair and we'll see what happens come next week. Did you I'm just curious, did you look up anything on like gut health for cause that was my based on what that's saying and we know is that something you're gonna actually change with any other

you know, therapy or mediating strategy. I don't think so. I think it's basically like time, letting your gut kind of do its thing and letting stuff normalize, I would assume. I didn't look too much into the gut health aspect of it, but I just kind of looked more into like the possible like pathogenesis. And like they also talk about like collagen disruption, d degeneration with a proteoglycan synthesis reduction. So it kind of talks about like not being able to restore the tendon, but also like what the tendon has, it's like getting degraded but not regenerating at the same time because of

The interesting thing there is so if we think of our soft tissue techniques, right, and this is where you'd have to make sure you know what you're doing, one of the thought processes behind something like stecko is what? You're basically changing that proteoglycan matrix, right? you're bringing some of these things via the fluid matrix into those areas of soft tissue, fascia tendon, muscle. So with that, we could say, Hey, again, one of the I tried to take tenets out of something like steco and say,

Beau Beard (01:06:02.198)

One of the things we tend to do is work around the tissue rather than right on it, especially if it's banged up. I don't think in this case we should try to be making such a pro inflammatory like cascade within the tendon. We could tr for sure try to drive that proteoglycan, you know, and other matrix materials into those tissues through soft tissue around that area. So I think that's something to be aware of of like, we're again putting on our science hat and being like, okay, how do we extrapolate what the science is saying to use our tools rather than being like,

Okay, we're just gonna load it. It's like, yeah, we could also do this. It's safe. There's nothing wrong with it. We're not beating up the tendon and might, you know, help it. Yeah, I never thought about that. So maybe I'll try some steco fascial manipulation next week. Or even needling around it. I mean, all that is changing. Steco would say theirs is doing different. Yeah. I don't know. Yeah. Steco would say theirs is different, but I would say they're probably all doing a little of that. Yeah. So it was an interesting case to cut coincidentally that we were talking about tendons today, so wanted to bring that up and

And we've had numerous cases, you've heard on the podcast before, about a runner that, you know, never ran again after he got Cypro for multiple rounds. I was telling them about a guy that moved here from Canada and did mission work. And Cypro is the number one broad spectrum antibiotic they take prophylactically before they go over to places like, you know, Africa, East Africa for waterborne illness and malaria and all these things. nobody ever gets, you know, read the black box label warning of like, hey, by the way, this guy from Canada showed up with

Bilateral patellar tendinopy bilateral acules tendinopsy. And was like, what are we doing? He is also the guy that showed up with Ben Patrick's book and was like, my knees aren't getting better. Now there was a reason, but he was also almost a year out. So I was like, A, there's a time component, as we were saying here. I'm I'm gonna look more into like the gut health, like a because it kind of almost sounds like if you use like a gut health, leaky gut kind of protocol, it could help like stave this off in terms of like.

glutamine usage. So I wonder if there's research specifically on supplements for that, but then overall just like gut health for offsetting the symptomatology of that. Well I just quickly like s flip to a different spot of this research article I've been looking at, and they pr predict some of the chemical properties of fluorine and the electronegativity of it allow it to chelate, dye, and trivalent metal ions within the collagen matrix and the proteoglycan synthesis. Mm-hmm.

Beau Beard (01:08:26.498)

To downra regulate the activity of metalloproteinases. So what's that mean? So the the enzymes essential for proper collagen remodeling. So it's like so even like enzymes could be. Yeah. So it's basically saying like f if you're have like maybe like a lot of fluorine in your diet or something of that nature, and you are taking fluoroconolones, there could be like a negative cross reaction that allows it to de what's the word?

Not the enzyme, the destructure the enzymes for metalloproteinases, they'd be denaturing them to not work properly. Okay. So maybe even just like a f central amino acids. I wonder what it knocks out with their 'cause people think collagen, but again like

Keith Barr talk about this on the podcast too, of like whey protein is one of the better ones to take because of like the leucine and isoleucine that's available in there that is necessary for collagen matrix remodeling. And that same research goal with the picture of the the stiff and stretchy, it was also highlighted, which we talk about all the time, is like collagen with vitamin C two X'd the tinanopthy rehab outcomes. Anything that two X is something, as much as people laugh and get haughty about collagen, like you're an idiot. Why wouldn't you do it?

Besides money it costs you. Like, so that's my take on it. And most, as he said, most collagens have vitamin C cooked into it. His lab made these little gels and stuff or gummy things. But yeah, so you could take collagen. Is it gonna help? Doesn't hurt. And then you might want a you know, full spec or essential amino acid. But we'd have to look into that. We're just kind of spitballing on the fly here. Yeah. Yeah. Cool. That was a big rundown on tendons. So it's a big deal to me because a lot of people are dealing with

Get we didn't talk we don't want to get into it today, but we didn't talk about the specific, you know, enthesopathies, reactive tendinitis, t you know, all these things, tendinosis. That helps to be really specific, but even within those, yeah, there's some nuance to it. You're gonna get most of the bang for your buck with the same stuff we talked about, regardless of what that is. the nuance just comes in again where the compression is based on where the injury is. it's r reactive versus new of like trying to evacuate fluid out of it.

Beau Beard (01:10:45.88)

versus like really getting after loading it without responding negatively. but if you're interested in stuff like that, I'm not well, I'm trying to sell course here. My RX3 course, I go I go deep into the specifics of diagnosing tendons. and maybe I'll pull it out as just like a subset one hour course because I think it's I think it's really good. So yeah. let us know if you have questions on this. We have so we'll have we got an episode coming out with Nikki Kirk. Then we'll have another week in review. Then we'll have Lindsay Mooma.

then we have one more week in review and then I think we're done for the season. I think that's it. And we got one I got one surprise coming for you, but I'm not gonna tell you anything about that. See you later. Peace.