This Tim Ferriss podcast features Dr. Keith Baar, discussing tendon repair and rehabilitation, focusing on isometric exercises as a superior alternative to eccentric exercises for tendon healing. The conversation explores the minimal effective dose of tendon loading, optimal rest periods, and the role of various factors like collagen synthesis, supplements, and hormonal influences on tendon health.
Isometrics Superior to Eccentrics for Tendon Healing: Isometric exercises (holding a position without movement) distribute load more evenly across the tendon, stimulating healing in injured areas, unlike eccentric exercises which primarily load stronger tendon sections. Velocity of movement is a crucial factor; minimizing it (as in isometrics) maximizes the therapeutic effect.
Minimal Effective Dose for Tendon Loading: Studies show a minimal effective dose of tendon loading exists; approximately 10 minutes of optimized loading every 6-8 hours is sufficient to stimulate tendon adaptation. Longer durations primarily lead to wear and tear.
Optimal Isometric Hold Duration: For healthy tendons, shorter isometric holds (10 seconds) suffice. However, for injured tendons, 30 seconds is more effective, allowing the stronger parts to fatigue and distribute the load more evenly.
Early Loading Post-Surgery: Early loading (within 2 days) after tendon surgery, using carefully controlled isometric exercises, significantly accelerates recovery. The traditional RICE protocol (rest, ice, compression, elevation) is critiqued for potentially hindering healing due to stress shielding.
Collagen Supplementation: Hydrolyzed collagen peptides (from skin sources) combined with Vitamin C, taken about an hour before isometric exercises, can enhance collagen synthesis, supporting tendon repair. The type of collagen is less critical than the source and hydrolysis.
Dr. Baar's Recommendations for Tim Ferriss's Tennis Elbow: Dr. Baar suggested a regimen of overcoming isometrics. These involved various positions targeting both extensors and rotators of the forearm. For extensors, a reverse wrist curl was suggested, holding the position for 30 seconds, with two minutes rest between sets, for a total of four sets. He also suggested using a tennis racket placed under a kitchen counter to work the external rotation component. He emphasized the importance of slow, controlled movements to minimize “jerk” and maximize signal to the tendon without excessive wear and tear. The rationale was to evenly distribute load across the entire tendon, stimulating healing and reducing stress shielding in the injured areas. He also recommended incorporating exercises to target the triceps, which also contributes to elbow function, by using a belt around a door knob to execute an overhead tricep extension isometric.
Overcoming vs. Yielding Isometrics: Overcoming isometrics involve gradually increasing force against a resistance until maximum force is reached and held for 30 seconds. Yielding isometrics involve holding a position against a resistance while slowly yielding to the resistance. Dr. Baar generally favors overcoming isometrics for initial tendon rehabilitation because they allow better control of load and minimization of jerk, reducing wear and tear on the injured tissue. Yielding isometrics, which may involve greater loading, are introduced later in the rehab process.
Risks Associated with Fluoroquinolones and AT-1 Receptor Drugs: A Finnish study showed that fluoroquinolone antibiotics increase the rate of Achilles tendon rupture by approximately 3-fold, and AT-1 receptor (Angiotensin receptor) drugs increase it by 7.6-fold. Therefore, individuals using these medications, particularly those impacting millions of Americans daily, should exercise caution and potentially modify their physical activity levels to minimize tendon stress.
Estrogen's Effect on Tendon Stiffness: Estrogen decreases tendon stiffness by inhibiting lysyl oxidase, an enzyme crucial for collagen cross-linking. This explains why women are more prone to ACL ruptures and less likely to experience muscle pulls compared to men. The cyclical nature of estrogen levels throughout a woman's menstrual cycle results in periods of decreased tendon stiffness and increased injury risk. Hormonal changes during pregnancy further decrease tendon stiffness to facilitate childbirth. Testosterone, in contrast, increases tendon stiffness by activating lysyl oxidase but reduces collagen content, leading to brittle tendons.
The conversation also touched upon several other related topics:
Rapamycin's effects on muscle hypertrophy: While rapamycin (often used for longevity purposes) has a minimal negative effect on muscle growth at typical dosages, it can interfere with muscle hypertrophy at higher doses. This is because it impacts mTOR complex 1, crucial for muscle growth.
Collagen synthesis, supplementation, and Vitamin C timing: The optimal timing for collagen and Vitamin C supplementation is before exercise to maximize delivery to tendons and ligaments, given their limited blood supply. Skin-sourced hydrolyzed collagen is preferred over bone-based sources to avoid heavy metal contamination.
Critique of BPC-157 and other injectable peptides: Studies suggest these peptides have limited direct impact on tendon healing; any observed benefits might be due to other factors, such as reduced inflammation from the injection itself.
Evaluation of orthobiologics (PRP, prolotherapy, stem cells): The evidence supporting the effectiveness of these orthobiologics in tendon repair is largely weak or inconclusive, especially for lower body injuries where immobilization is difficult.
JAK-STAT inhibitor drugs and their effects on tendon growth: These drugs (often used for autoimmune diseases) can promote tendon growth by inhibiting the JAK-STAT pathway, suggesting potential therapeutic applications.
Drugs that increase the risk of tendon ruptures (fluoroquinolones, AT-1 receptor drugs): The podcast discusses the increased risk of tendon ruptures associated with these medications, highlighting their significant impact on tendon health.
How estrogen affects tendon stiffness and injury risk in women: The cyclical nature of estrogen and its impact on tendon stiffness is linked to higher ACL rupture rates in women.
Testosterone's opposite effects on tendon compared to estrogen: Testosterone increases tendon stiffness but decreases collagen, resulting in brittle tendons.
Protein intake recommendations and timing: The podcast updates the recommendations for protein intake, focusing on total daily intake rather than strict timed intervals.
Ketogenic diet effects on mitochondrial biogenesis and longevity: A ketogenic diet increases mitochondrial content in muscles and potentially enhances longevity but may negatively impact bone density, limiting its application for athletes.
Comparison of ketogenic diet, low protein diet, and rapamycin for longevity: These interventions share similarities in their impact on mTOR and inflammation, all potentially influencing longevity.
Inflammation's role in adaptation and when to reduce it: Inflammation is crucial for adaptation and healing, but excessive or chronic inflammation needs to be addressed, preferably through controlled loading rather than pharmaceuticals.
Timing of ice baths relative to training: The optimal timing of ice baths is flexible depending on training goals and individual needs, but they are generally not advised for acute injury treatment.
These are additional topics covered which provide a more comprehensive understanding of the discussion.
The conversation mentioned several protocols, often implicitly within discussions of specific exercises or treatments. Here's a breakdown, categorized for clarity:
I. Tendon Loading Protocols:
Emil Abrahamsson's Hangboard Training Protocol: Involved hangboard training twice daily for 30 days, with 10 seconds of tension and 50 seconds of rest per repetition, totaling approximately 10 minutes of hangboarding per session. This protocol demonstrated significant increases in grip strength and hang time.
General Isometric Loading Protocol (for various injuries): Involves 10-30 second isometric holds, depending on injury severity and tendon health. For healthy tendons, shorter holds may suffice, while longer holds (closer to 30 seconds) are better for injured tendons. Rest intervals of 6-8 hours between sessions are recommended to allow for recovery and refill of the “tank” before the next loading cycle. The loading should be performed slowly to minimize "jerk" and evenly distribute the stress.
Overcoming Isometric Protocol (specifically for tennis elbow): This focuses on overcoming isometrics, slowly building force against a resistance over 3 seconds, holding for 30 seconds, then slowly releasing over 3 seconds. This process is repeated 4 times with 2 minutes rest in between. Multiple positions (elbow at 90 degrees, arm straight, arm overhead) are included to target different muscle groups contributing to the elbow injury.
II. Rehabilitation Protocols (post-surgery or injury):
Post-Surgical Loading Protocol (general): Advocates for early loading (within 2 days post-surgery), utilizing low-jerk isometrics to stimulate the native tissue, thereby accelerating recovery compared to traditional longer rest periods. This involves removing the immobilizer (cast, boot) briefly to perform short isometrics, reapplying the immobilizer afterwards.
Achilles Tendon Rehabilitation Protocol (post-surgery): This focuses on isometrics in a shortened position (plantarflexed), as the sutures used are designed to take the load when the tendon is longer. It involves gently applying tension with plantarflexion against a surface.
Multiple Position Isometrics (for tennis elbow): This protocol involves performing isometrics in multiple positions, changing the angle of the elbow and forearm to target different muscles and evenly distribute the load across the various structures.
III. Other Mentioned Protocols (not directly exercise-based):
It's important to note that these protocols are discussed within a larger context and aren't presented as rigid, one-size-fits-all instructions. Individualized adjustments might be necessary based on injury severity, patient response, and other factors. Always consult with a healthcare professional before starting any new exercise or rehabilitation program.
