← BETTER! with Dr. Stephanie Estima | Strength, Body Composition & Perimenopause
BETTER! with Dr. Stephanie Estima | Strength, Body Composition & Perimenopause
The Lifting Heavy Trap: Strong Muscles but Weak Tendons & Why You Get Injured
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Dr. Stephanie delivers a comprehensive tendon masterclass: why these underappreciated tissues deserve your attention, how they adapt differently than muscle, common injuries women over 40 sustain (lateral hip pain, rotator cuff issues, tennis elbow), and the rehab strategies that actually work. Watch the full episode at https://youtu.be/9kGdzLbGN9g
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I know that muscles are super sexy and we get to build them and we can see them, but in my opinion, tendons are the most underappreciated tissue in the body. You can't just go out because I've said you have to sprint or Stacey Sims or whoever has had said sprinting is, is important, but you have to earn the right in, you know, from your tendons perspective, you have to earn the right to be able to do that. Well, you can't out hack tendon healing with just circulations. Like you can put heat on it, you can massage it, you can try to increase blood flow. Those things can help symptoms. But it's the mechanical loading of the tendon that is still the primary driver of remodeling. One of the best ways that you can heal the tendon is by actually moving it like we used to. I don't know if you ever remember the this acronym. Rice, Rest, Ice, compression, elevation with any type of injury. That is completely outdated. What tendons hate is spikes. They do not like sudden jumps in intensity, volume or novel activity. Just like me tendons, you are my spirit animal. Don't surprise me. And this is why people will say, like, there's just nothing like exercise. You know, it's like I can give you all the drugs and give you the corticosteroids to sort of temporarily blunt something. But if you want real remodeling, it has to come under heavy, slow resistance. All right, my friends, welcome back to another episode of better with Dr. Stephanie. It's me, your host, Dr. Stephanie Stima. And today we are going to be talking all about tendons, why they deserve their own episode. What are some of the common injuries and mechanisms of injuries for tendons? How they're different from muscle. And then maybe most importantly, some of the very common tendinous injuries that women over 40 tend to sustain. And what we can do to rehab our tendons so that we prevent future injuries. Injury. And if you are currently dealing with some type of, whether it's a tendinopathy or it's a chronic issue and you're starting to see degeneration in the tendon, we're going to be talking all about that. So without further delay, please enjoy this solo cast on tendons. Perimenopausal women are notorious for being magnesium deficient, which can lead to lowered hormonal production. More than 80% of us are deficient. And even just having suboptimal levels in the body can contribute to symptoms. And that's because magnesium is related to over 600 biochemical and enzymatic reactions in the body. Many of these reactions influence the production of these key steroid hormones in the body like estrogen, progesterone and testosterone. Insufficient magnesium levels can also disrupt your thyroid function and magnesium breaks down cortisol and other stress hormones. So if you don't have enough, you are going to have poor hormone production and a poor stress response response. Bioptimizers is my favorite magnesium supplement because it contains the seven best absorbed magnesiums along with cofactors like B6 that are going to help enhance the absorption of it. It's a simple, effective solution to a very big problem. I personally take two capsules every night for sleep support. For an exclusive offer, go to bioptimizers.com better and use promo code better during checkout to save 15%. And if you subscribe, not only will you get amazing discounts and free gifts, you will make sure that your monthly supply is guaranteed. Once again, that's buyoptimizers.com better and use promo better to save 15%. So I guess the big theme today is we're going to be talking about tendons, how they adapt, why they hurt, and how to train them for life. Because tendons really deserve their own episodes. I know that muscles are super sexy and we get to build them and we can see them, but in my opinion, tendons are the most underappreciated tissue in the body. And the only time that we really start to think about them is, you know, when one of them decides to ruin your week, probably your month, and in some cases, depending on the severity, your year. So if muscle is the engine, tendons are the drivetrain. They transmit force from the muscle to to the bone so that you can move. So essentially tendons tether, they're like the bookends of the muscle and then they wrap or attach the muscle to the bone. And just because I'm a nerd and I'm going to share all the nerdy things with you today, they also do something, in my opinion, that's even cooler than that. They act like a spring. So they are storing and releasing energy so that your movement is efficient. And that's why things like running and jumping and sprinting, all these sort of athletic pursuits are deeply tendon dependent. And in my opinion, I think that there are a couple of reasons why tendons deserve and are worthy of our attention and maybe this full episode. First, I would say that muscles, they adapt faster than tendons and we'll talk a little bit about that. You can Get a lot stronger, very fast, and very fit before the tendon. So the bookend of that muscle that's tethering it to bone has remodeled enough that it can tolerate new forces. And there. There's that mismatch, right, where a lot of random aches and pains can show up. So my hope with this episode is that I am going to give you almost like a tendon operating manual. Like, what the tendons are made of, how they respond to load, how long remodeling takes, and why this sometimes feels very unfair. Okay. What tendon pain actually means, what rehabilitation, uh, has strong evidence behind it. So I'll be pulling from the literature that I review personally. I'll also be pulling on my own clinical experience to share with you. And then how to prevent tendon injuries with training strategies that make sense in real life. Okay, so, quick safety note. This is education, obviously. This is not personal medical advice. I'm a doctor. I'm not your doctor. If you have experienced something like a sudden pop, immediate weakness, dramatic swelling, bruising, fever, numbness, you can't move your limb normally, stop listening to the episode. Get yourself to a CH chiropractor, a physical therapist, or a primary care physician who can get your situation assessed, okay? And then you can listen to this afterwards while you're healing so that you don't ever get injured again. Okay? So what the tendon actually is, it is dense connective tissue that connects muscle to bone. So if you zoom in, it's basically a rope made of ropes made of more and more ropes. So the superstar ingredient here is type 1 collagen. And it is kind of arranged in this hierarchical structure. So the collagen molecule molecules form fibrils, and fibrils form fibers, and fibers form fascicles, and those fascicles bundle into the tendon that you can see and. And touch. So this structure, this like, rope upon rope upon rope, is why tendons can handle huge, huge tensile forces, right? So the collagen fibers in the tendon that are aligned mostly in the direction of the pull, which makes tendons just, like, supremely excellent at resisting stretch. Like, the tend is built for tension. So if you ever want to sort of remember, like, the primary goal of 10, it sounds like it's like tension tendon, right? They. Whatever. Whatever mechanical tension you are putting on the. On the muscle, it is really being transcribed into the tendon because the tendons are designed for that. Now, inside, a little dark, gross Betty here, but inside the tendons, we have something called Tennessites, okay? So these are basically fibroblast like cells. These are tendon fibroblasts. And these are the cells maintain and remodel the collagen matrix. So when we are talking about tendon adaptation, which we're going to talk about a lot today, what we're really talking about is what the Tennessites do in response to these mechanical signals. So one of the key learnings from this whole episode, like, you don't learn anything else, what I want you to remember is that tendons are bradytrophic, and that is a big fancy word for they have low metabolic activity. When we compare them to muscle, of course, muscle has a very high metabolic activity, very, very high blood supply, lots of nerves going into it, and tendons have generally less of that. They have less blood supply, less metabolic activity. And that really matters for remodeling speed, right? And it also matters for injury recovery when we look at tendon vascularization. And I'll put a lot of these for all of you dark roast Bettys that want to look at some of the review literature in preparation for this episode. I have reviewed tons of studies, so I'll put those in the show notes for you to check out. But when we look at reviews in the literature on tendon vascularization, they often will describe tendons as poorly vascularized and slower to heal compared to tissues like muscle or skin or bone. So let's talk a little bit about stiffness, right? Because this word tends to freak people out in everyday language, when we say things are stiff, you know, like it. It tends to conjure a negative state of being. Like when I'm. I feel stif today my tendons are stiff. I need to loosen up. But in biomechanics, tendon stiffness is not only useful, but it's necessary, right? A stiffer tendon will be able to transmit more force more efficiently, which is obviously beneficial for performance and for your muscle gains. The goal isn't soft tendons. The goal is stiff tendons and appropriate stiffness for that tendon capacity matched to your activity. And where things tend to go wrong is that stiffness will increase, but the tendon is irritated, or the tendon has been irritated for so long that now there's degeneration and reduced capacity of that tendon. Or the other thing that I've noticed clinically is that all of a sudden you have taken up lifting weights, or you've taken up sprinting, or you've taken up some new activity, and you're asking your tendons to store and release energy. So that elastic recoil in ways that it has. It has not been prepared for. Right. You have to train your tendons and earn the right, we'll say it this way, to store and release energy in an efficient way. So I never want you to think about, okay, I need my tendons feel stiff. I have to stretch my tendons. I need to stretch my tendons into submission so that they perform. What we're trying to do with tendon health as a. As a holistic goal, when we're thinking about tendon, tendon in tandem with muscle, is we're trying to build tendon capacity. Right? So that really means stronger collagen organization and better tolerance to load. Okay. Okay. So then if the tendon is slow to adapt, if it doesn't have the same blood supply or the same nerve supply, let's say, as muscles, then how does it adapt? How do you know if what you're doing is training your tendons for better capacity? So let's look a little bit about how they adapt, and we'll use some big fancy words here. Tendons adapt through a process called mechanotransduction. Again, fancy word. Just. It's a simple idea. It basically means that the. Those tenocytes, those tendon cells are going to sense mechanical strain. So strength training, let's say, or could be sprinting and converting it into a biological signal, often an anabolic signal. Right. So it is going to change the gene expression of the tendon, and it's also going to start. It's also going to start encouraging cell turnover, which I think is really. I mean, this is where you just have to stop for a moment and be like, tendons are the coolest. I mean, muscles do this too, right? It's like you give your muscle or you give your tendon some type of mechanical load, and your tendon, your muscle knows to convert that into an anabolic signal. Like, oh, my gosh, I have so much reference for the human body when I think about it here. And, like, the core idea is that tendon adaptation isn't about, like, any. There's no magical type of contraction that's. That's magical. It's the magnitude of the load. So you have to have enough load to make it, you know, make sense for the tendon to actually respond to it and how consistently that load is applied. Right. So this is where the f. Your feelings follow. The plan from Leila Hormozi comes in. If you ever follow her on Instagram. She talks about this idea. She's an entre female entrepreneur and she talks about this idea like, f your feelings, follow the plan. I actually think that that's very true in terms of tendons as well. It's like, f your feelings, follow the plan. The plan. You don't feel like training, it doesn't matter if your feelings get to the gym. Same thing here. Because the tendons really need that. They need enough load to actually get the signal to start moving that mechanical signal into those anabolic signals for growth and remodeling. And you also have to do it consistently, right? You can't just be like a, you know, a lackadaisical person at the gym if you really want strong tendons. So for those of you who want to understand where this appears in the literature, like, where am I pulling from this? One of the most cited papers in this area is a systematic review. It's a meta analysis. It's on tendon adaptation in response to mechanical loading in healthy adults. The researcher's name is Bohm and colleague B O H m. But they looked across different exercise intervention studies and concluded that tendons are basically responsive to loading. But the, the data strongly suggested that it's the loading magnitude that plays the key role. So it's like, it's one thing to. It's kind of like the Goldilocks story, if you remember the parable. You know, it's like the one porridge was cold, one porridge was too hot, and one was just right. You need to have enough magnitude for the tendons to actually get the signal. It's the magnitude of loading that's the most important thing. So when we translate that, it's not just like, does the tendon get thicker? But it's also, does the tendon tissue itself have better quality? So in the same way that muscle, you know, if you. It's not just how much muscle you have, it's the quality of the muscle that you have, right? If you look at someone who is obese or even morbidly obese, like, those people tend to have a lot of muscle, right? But it's the quality of their muscle that it's 10. It tends to be in. You know, there tends to be fatty infiltration in the muscle. The ability to extract glycogen from that muscle is very poor. There's very poor expression of certain glucose receptors to the surface of the cell. So it's the same here with tendon, right? It's like, is the tendon tissue itself better qual quality? And so when we look at that in terms of collagen, is it like, do we have better collagen alignment? Do we have good collagen cross linking? And do we have stiffness? Like, we want a stiffer tendon, the stiffness changes. Do those reflect. Do those reflect an improved mechanical behavior? Right, so let's. Let's break this down. Like, what do tendons like? I keep saying, like, heavy load and consistent load. What do they like? They. They like heavy load. Enough load to create a meaningful strain. Like, you need to stress them out a little bit. It needs to be repeated over time. So you need to be consistent. And the progression of that load is steady. It's rather than spiky. Okay, so for example, if you are like, hey, I want to sprint, you know, I've seen Stephanie talk about sprinting, or I want to do some whatever, strength training, and all of a sudden you go to the track and you start sprinting. Your tendency. Hate that because they are not used to it. It's just like, you know, tendons have a bit of a, you know, personality quirk. Kind of like my. Not. Not too dissimilar for myself. I can't stand surprises. So if you surprise me, I just have such a exaggerated response. It's a topic for another time, but it's, you know, comes from trauma. And I have a. Like, I can't even watch movies because I jump at everything. Tendons are very much like that. Okay. So tendons in some ways are my spirit animals. Like, they don't like surprises. They like progression that's steady. They don't like progression. They don't. Like, all of a sudden you're sprinting on the track and you haven't done that since you were 16. You know what I'm saying? So just keep that in mind with your programming when we're thinking about, you know, certainly we want to, you know, we want to polarize our training. The zone one, the zone five, those are great. But you have to earn the right to increase that load. You can't just go out because I've said you have to sprint. Or Stacey Sims or whoever has had said sprinting is. Is important. They're right. Like, Sims is right. I am right. That sprinting is incredibly important for you have to earn the right in, you know, from your tendons perspective. You have to earn the right to be able to do that. Well, noticing your hair isn't as full as it used to be. One of the absolute keys to thick full hair is scalp health. Good hair starts with your scalp. 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Langberg et al measured type 1 collagen formation in the peritendinous tissue and found that acute exercise increased the formation of that type 1 collagen. So your connective tissue, which your tendons are a part of, respond to loading even after a single bout. But it just takes an extraordinarily long time to catch up to muscle because muscles are also responding to that, to that mechanical load as well. And of course, we can see when we are consistently repeating that training exposure, we're going to consistently see that collagen turnover. There's also some sex differences as well in collagen synthesis. It's, which is potentially influenced by estrogen. And I'll, I have a whole segment that I want to talk about today in terms of really common injuries that women typically sustain compared to, compared to men. But we care about this because tendons remodel. Like they get stronger and stiffer through turnover. Like, you're not just adding collagen, you're not just adding a rope, right, to the, to the rope of ropes. You're, you're not just adding collagen. You're our collagen matrix. And in the tendon, this is a living, breathing thing that's constantly being broken down and rebuilt. Not unlike bone, not unlike muscle, right? So the goal is to bias the process towards adaptation, like stronger and better aligned tissue. So here is where you know, I know I'm beating this, this point to a pulp here. But like your dosage really matters, right? You have to be consistent. Your tendons respond to how heavy you're lifting, how often you're lifting, how quickly you increase the demand, right? So whether you're doing energy storage work like running and jumping, where you are asking the tendon to store and release energy in a very rapid manner versus slow strength work, right? So if you are going from zero sprinting, like you haven't sprinted since you were in high school, to sprinting twice a week, your lungs are going to adapt, your muscles are going to be able to cope, but your Achilles tendon is probably going to revolt, okay? Because it experiences high strain rates and high forces during sprinting, right? So that catch and release of that energy, like your Achilles is not used to that. And like I've said before, and I hope that this is another take home for you, is that tendons and muscles, they do not adapt on the same schedule. Okay? So to kind of drive this home, I want to Talk about what I like to call the six week trap. It's something like six to ten weeks, but I think, think the six week trap is a bit more of a juicy title. So we're going to call this a six week trap. Here's the classic pattern. You start training, you feel better, your strength improves, confidence improves, you're sleeping better, you're doing the program, you're building muscle, right? Then around week six, and it's usually for some people, like week six to week ten, you start to get tendon pain, right? And so what happens is people assume, oh, the training, like maybe this is not the right program for me or I'm too old for this. But the real story is often that your muscle and your nervous system, like your, the capacity of your brain to actually recruit more muscle fibers improved faster than your tendons capacity. Right? And usually when we look at the literature, it's something like, you know, if you, if your muscle is going to adapt, let's say call it within a couple days, like you do something new, your muscles are sore because it's a novel exercise, and then, you know, a couple days later you're kind of ready to do it again and you're not as sore the next time you do it. Your tendons, tendons for the same exercise and loading are going to take somewhere between 12 and 15 weeks, right? So like weeks to months we're talking about. And that meaningful change, like the meaningful change for tendons is somewhere in that 12 to 15 week range. So tendon adaptation of course is trainable, but it's not like a 10 day transformation. You're not going to get it in even in like a six week or eight week boot camp kind of, kind of scenario. Okay. Tendon stiffness changes also are like, they're slower processes biologically rather than like coordinated neuromuscular changes that drive those early strength gains, as I was mentioning. So the big take home here is that tendons don't hate intensity like you. It's not to say that you can't sprint, that you can't strength train, they just hate surprise. Okay? So we have to earn the right to increase that intensity. The other thing I want to mention here is blood supply, right? There is a big reason why tendon remodeling is slower and injuries are stubborn. And that is because of that relatively low blood supply when we compare it to muscle. And of course vascularity varies across different regions of a tendon. But typically when we look at tendon vasculature, poorly vascularized, slower healing Heel tissue often can become scar like with inferior, you know, performance and function compared to the original tendon. So even if you've had an injury, I'm sorry to say, but sometimes you can get scarring in that tendon and it, if you're not careful, it won't heal the same way and it will start to, it will start to move and operate differently after the acute sort of injury has, has passed. So let's, let's use an example here. Let's talk about the Achilles tendon. This is the, for those of you that are not aware, the Achilles tendon is basically the tendon that extends from the gastrocnem, so the calf muscle in the back and then it'll attach kind of to the bottom of the calcaneus, bottom of the heel bone. And it is one of the strongest, if not the, maybe the largest tendon in the body. It has a relatively poor blood supply and it actually has some areas that are like hypovascular. So somewhere between 2 and like 4 centimeters above the insertion. And this is actually where a lot of injuries happen. So, so 2-4 cm above the calcaneus, like kind of in the middle, the belly, if you will, of the tendon is where the tendon is most often injured because there's almost no blood supply there. Now there is some blood supply, but not a lot. So that means that the healing signals that come with the blood are slower to arrive. Removal of waste products are slower cell turnover, slower remodeling takes longer. So, so something to keep in mind certainly with all tendons but the Achilles, everybody can sort of, everybody knows generally where their Achilles tendon is. And there are areas of it, as I mentioned, that don't have any very, very low blood supply. So the healing is going to be very, very slow. And so when we have, and if you're someone who, let's say maybe the Achilles has been like a long term problem for you or maybe the shoulder or the, you know, you've had a lot of hip like some gluteal tendinopathy which we'll talk about today. If you've had this over the long term, your vascularization of the tendon actually changes in a healthy tendon versus a diseased tendon. So you can't out hack tendon healing with just circulations. Like you can put heat on it, you can massage it, you can try to increase blood flow, those things can help symptoms. But it's the mechanical loading of the tendon that is still the primary driver of remodeling. Okay. So, and this is one of my core thesis. I'm talking about this in, in my upcoming book as well. One of the best ways that you can heal the tendon is by actually moving it like we used to. I don't know if you ever remember the this acronym. Rice Rest, Ice, Compression, elevation. With any type of injury that is completely outdated now, particularly for tendons and ligaments that actually don't do well with inertia or they don't do well with inactivity. Anyway, we need to be mechanically loading them as soon as can. Okay, so let's talk a little bit about tendonitis. So we've already talked a little bit about Achilles tendinopathy. A lot of women are subject to patellar tendinopathy. It's often called jumper's knee. So you might even have, you know, if you have a son playing basketball or soccer sometimes. My son actually was dealing with this a couple years ago. At the inferior pole, like at the bottom part of the kneecap that there's a little patellar tendon that literally attaches to the tibial tuberosity, which is like a roughening of, of the tibia or the leg bone that that tendon can get really irritated. Tennis elbow is another really common one. So tendinopathy on the lateral or the outside part of the elbow, rotator cuff is another big one for women. Rotator cuff tendinopathy, maybe the most common, I'd probably say for women is like gluteal tendinopathy. And we'll talk a little bit about why that happens and then some. And then the other kind of big area for injury is a hamstring. So the proximal hamstring, which is the upper part of the hamstring where it attaches, attaches basically under the butt to the ischial tuberosity. So you'll get the hamstring tendon, we say proximal because it's just closer to the center. So the upper part of the hamstring. Now what we want to think about is tendinopathy usually involves changes in tendon structure and in pain mechanisms as well. So a tendon can become like really reactive when it's overloaded. So it thickens and becomes painful as a short term protective response. And if the overload continues, like you're not giving yourself adequate recovery or appropriate loading strategies, which we're going to talk about, the tendon can enter an even more disorganized state. Like it doesn't remodel quickly anyway. But if you keep overloading it like you've, you've surpassed like your maximum. Some people will call this like your maximum recoverable volume or your mrv. What can happen is the tendinopathy or that pain, occasional pain, or that sort of niggle that you might have in the tendon can progress to more degenerative changes, right? So now you have a degenerating collagen. You have a degenerating tendon that has less collagen, that's organized properly, that collagen matrix is going to be altered. And then of course, that mechanical capacity, like the capacity of the tendon to hold that tension is also going to be reduced as well. So the one thing I will say as a, from a clinician who's dealt with thousands of thousands, God, thousands of tendon issues is that what is important to note is that pain and imaging don't perfectly match. Like, I can image your shoulder, I can image your knee. I'll say it this way, you can have structural changes without pain and you can have pain without any like, dramatic imaging findings either. So I could send you for an X ray, I could send you for an ultrasound if you have it available. MRIs and I can see changes or not. And they very, very poorly correlate with pain, like the absence or presence of pain. So when we think about tendinopathy, the key sort of clinical presentation, like the, you know, clinical findings tend to be that the tendon, it gets like the pain gets worse with demand, right? So it tends to be load related. So if there's like an overhead, like if we're talking about the shoulder, if like an overhead press with your, you know, palms facing outward versus inward, it tends to be like, with the demand of the palm facing outward, it tends to be worse with load. It often follows a pattern. So a warmup can help. But then it flares like either during the workout or even after the workout. And then it's super cranky the next day. Like it might be cranky overnight at like sleeping overnight or the next day it really, really hurts. Hurts. And knee, like jumper's knee or that patellar tendinopathy that I was describing earlier is a really great example of that. You typically have pain localized to the inferior pole of the patella. And the load related pain increases with demand, especially when you're jumping, right? So with that energy storage and release pattern. So with soccer or if you're, you know, you're in basketball and you're going up for a dunk or whatever, whatever. But this is where clinical diagnosis actually trumps any sort of diagnostic imaging because literally like my son, I sent him for an ultrasound and it was perfect. Like he, but he like could barely, he could barely run. So imaging changes are, you know, can or can like they may or may not exist and you, you know if you're symptomatic or not. So yeah, it's, it's super frustrating. If you've accepted bloating cravings and that post meal energetic crash after eating as your normal. I am challenging you with love to feel better and I am giving you the cheat code. The Just Thrive Gut Essentials bundle. It pairs two clinically proven gut superstars, Just Thrive Probiotic and their digestive bitters. 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And when we think about healing, there's a couple of different phases, right? So we have, like, a short inflammatory phase. It's about a week, where you're like, oh, God, what have I done? And then we have this more, more. We'll call it like a proliferative phase, where the tendon is actively healing. This can be like, weeks to months, and then a remodeling phase, which is usually many months. And so there's these sort of three main phases for tendons. It's like inflammatory phase, proliferative phase, and remodeling. And I would even say from a clinical perspective, even after healing, like, even after everything's fine, the tendon, if you've developed scar tissue, often fails to fully recover some of those original mechanical properties. So it is really important, as much as we can to try to avoid injury in the tendon, because what you're essentially trying to do is you, like, you know, we'll assume that you didn't rupture the tendon. The remodeling takes an extraordinary amount of time. So it takes a toll physically. It also takes a toll psychologically. But really what we're trying to do is we're trying to rebuild capacity in the tendon. So what are those things, steps? The first step is load management. And this is what a lot of people skip. This does not mean rest forever. Okay? It means reducing the specific loads that spike the pain, and you know what they are, right? So even if the warmup helps and you can kind of punch through whatever the workout is, you know, which movements are aggravating. So we want to reduce the load. It doesn't mean stop. It just means reduce the weight, reduce the load. That's the spike that. That spikes that pain. We want to keep the tendon exposed to some load so it doesn't decondition, right? We don't want a degenerating tendon. So let's say. I'll give you a practical example. Let's say with your overhead press, your OHP. I don't know, maybe you're overhead pressing 50 pounds, let's say, and that's what spikes your pain in your shoulder the next day. It feels really cranky. What you can do is you can say, okay, I don't want the tendon to decondition. I still want to have some mechanical stimulus to the tendon and to the muscle so that I don't lose muscle as so maybe what I'll do is I'll reduce that to £30. Right? So you'll take like 40% off of that. And I know that that's really psychology. I know it's like when people hear that, they're like, no, but I mean that's what has to, that's what has to happen. Like you do have to reduce the load. It's somewhere depending on the severity of the injury, my clinical mind will tell me somewhere between 20 and 40% reduction in load. So you can play like you can if you're, if your OHP is like £50, maybe you want to try £40, see if that helps. If you're still getting a cranky tendon the next day, then it's got to come down to like, you know, 30, 35 pounds or whatever weight it is where your tendon is not agitated the next day. If your Achilles is bothering you, the biggest spikes in load and like that energy release pattern is usually hills, you know, speed, work, plios, a sudden increase in steps. Like if you're like, okay, I'm going to go from like 4,000 steps to 14,000 steps. That can also bother the Achilles as well. Minimalist shoes, if you are usually, I mean I' big fan of minimalist shoes, I wear minimalist shoes. But if you have all your entire life worn, you know, I'll say like some of the shoes that basically feel like you have, you're walking on jelly beans, like you can't feel the floor. That can certainly irritate the Achilles heel as well. Standing on hard surfaces for a long time. If you have like cement or something like non wooden or even sometimes wooden floors, usually cement is the thing that really agitates people. But if you, if you have like a hard surface and you're wearing minimalist shoes, like there's basically no impact absorption. So the Achilles has to take all of that load. So load management is the first thing that is the bridge that's going to let you progressively strengthen your tendon without degeneration. Okay. So load management's first. The second is isometrics, okay. Which is a consistent like squeeze or hold. And this is often used for pain modulation. So really cool paper by Rio and colleagues. I believe it was 2015. They studied athletes that patellar tendinopathy and found that a single bout, one single bout of heavy isometric contractions reduced pain immediately in that patellar tendon for at least 45 minutes. And it also increased their voluntary isometric contraction. And they also observed what's called Cortical inhibition, which basically suggests that the nervous system, it was a nervous system mechanism for pain relief. So, so isometrics are really important. So after you have the load management, we want to think about isometric contractions because they can help reduce pain enough to let you train. Right? And it's the training, it's not the rice, it's not the rest, ice, compression, it's the training. The load is what actually rebuilds capacity in the tendon. So isometrics are super important tool. It's not the entire rehab plan, but it's literally step two in, in the rehab process. Process. So when we look at this from a practical, like what does an isometric session look like? You might do something like three to four, maybe even five sets of like 30 second holds with something that's heavy but tolerable. So with the patellar tendinopathy for example, you might do, you might do like a leg extension machine or a Spanish squat for the patellar tendon or calf raise hold. If you're, if you're dealing with the Achilles like you might, you know, standing and you're lifting the heel and you're holding that and squeezing for 30 seconds. Once you have dealt with load management and you're consistently doing isometrics, then we want to talk about heavy slow resistance. And again, this is the crux of my argument. This is the backbone strategy for remodeling. It in my opinion is the gold standard for rehab is heavy slow resistance. And I'm not the only, only one. When we, there's a paper, I'm not going to say his name right. Konzgaard, K O N G S G double a R D 2009 paper. They looked at corticosteroid injections and they compared that to eccentric decline squats and heavy slow resistance for the, for patellar tendinopathy. So that pain in the patellar tendon and corticosteroids were good, like short term, but really poor long term. The heavy slow resistance group had good short and long term effects and it was also a accompanied by improved pathology and increased collagen turnover. Uh, and this is why people will say like there's just nothing like exercise. You know, it's like I can give you all the drugs and give you the corticosteroids to sort of temporarily blunt something. But if you want real remodeling, it has to come under heavy slow resistance. Right. And this is a massive, hopefully massive teaching moment for you. That quick symptom suppression is not the same as remodeling. Okay? So if you want a strong tendon, you must remodel it. You must bias it to, to that anabolic signal that we were talking about before. Because your tendon health, long term, short and long term, is about capacity and tissue adaptation. Okay? And there are papers upon papers upon papers on papers. So looking at Achilles tendinopathy, same thing. Study comparing heavy slow resistance to eccentric training found that both produced long lasting clinical results. So heavy slow training tended to have greater patient satisfaction. At the 12 week mark. We can load the tissue in a lot of different ways, but, but it has to be progressive and it has to be appropriate loading over time. And you have to incorporate heavy slow resistance training. Right? So hsr, heavy slow resistance is heavy load, slow tempo, slow tempo, pardon me, a controlled range. So you're not like flailing, you like you control the weight. The weight does not control you. Okay, I say this too. I've said this to clients so many times over the years. You control the weight, the weight does not control you. And you progressively get put a little bit more weight on week over week. Right? You're basically telling the tendon, we're building you, you know, we are building you like infrastructure. Right? Because that is really what it is. When we look at your ligaments, which is the next solo cast that I'm probably going to put out. When we look at your tendons, this is the architecture, this is the scaffolding along with your bones. This is the scaffolding for your body. If these things are not working well, you cannot work well. You cannot squat if you have bad knees. If you have patellar tendinopathy, you can't squat, you can't jump, you can't run. So we really do need to be thinking about some of these tissues beyond muscle. Okay. And then the last thing the tendons love, this is sort of the fourth step, is eccentrics. You've heard me talk about eccentrics for hypertrophy of the muscle, but they have a wonderful, wonderful effect on tendons as well. When we are thinking about isometrics, they help. They certainly help when pain is high and they also help help with that energy storage and release progressions for returning to sport. Okay, so last thing I want to say, I mentioned it before, is that tendons are not just tethering muscle to bone, but they also handle loading, elastic recoil and repeated impact. So if you're sprinting, your tendons need to be really healthy. So when we're thinking about increasing your elastic recoil capacity, some progression might look like, you know, maybe you go from and this is actually part of my warmup before I sprint is like I'll do double leg hops. So feet are together and I'm just doing like bunny hops. Both feet together at the same time. A progression from there might be going to a single leg hop. You might go from running on flat ground or walking on flat ground to running or walking on hills. You might go from tempo runs, so like low, you know, steady state tempo runs to intra intervals. And then the other way that you might improve your elastic recoil is cutting. So this is very important. Basically in every sport you can think of, there's cutting is basically like stopping, coming to a full stop, which is deceleration and then changing direction. So if you think about soccer, you don't ever dribble the ball in, you know, if only it was so easy, right? You just dribble the ball from one end of the pitch to the other and you score the goal. No, you gotta like deke your way around other players, right? Same thing with basketball. You gotta dee your way around other players. You gotta do the same thing with American football. You have to do like any sport you can think of. I mean, the only two exceptions in my mind are like cricket and baseball because it's really start and stop. But any other, any sport that has two nets on either side in some capacity, you need to be able to cut, right? So this is like full speed coming to deceleration, coming to a stop and then changing direction. And if you skip this part. So this elastic recoil part is often where the tendon will re flare up because the tendon also needs to be trained for elastic recoil. Okay. Few things are as traumatic to women than losing our hair. As we age, we get hair thinning, hair shedding, and hair breakage. It's the worst. As we move through perimenopause and menopause. The hair thinning is not just cosmetic. It's a signal, right? So it's declining estrogen that is going to affect circulation to the scalp, the mitochondrial energy at the hair follicle and cel cellular repair. Hair follicles are metabolically active tissue and they require energy to grow. And this is where red light therapy comes in. It works by delivering specific wavelengths of light to the hair follicle that will stimulate mitochondrial function. So more cellular energy means better support for the hair growth cycle. So this is not about forcing growth, but it's about improving the environment so that your hair growth can can happen. Higher dose red light therapy is a FDA approved red light therapy device. For promoting hair growth and treating pattern hair loss. It stimulates the hair follicles and it improves density and reduces shedding. It's a hat that I use while I'm reading or answering emails. It's 10 minutes. There's no side effects, no recovery time. It's super easy to be consistent so that I can restore hair follicle health as I age. If you're interested in trying red light therapy for hair and scalp health, I've partnered with HigherDose to offer my community 15% off of their red light hat. So just head over to their website, higherdose.com and use code better at checkout. That's higherdose.com and use code B T T E R at checkout. Okay? So let's pull this together. Let's pull this together in our prevention checklist, okay? If you remember nothing else, what I want you to remember is that tendons love progressive loading over time. They love high enough load to matter. This is the Goldilocks principle. It's not just end light band work, right? It's not the, as Vonda, my friend Vonda likes to say, it's not The Mamby Pamby 2 pound pink weights, right? It's a high enough mechanical load to matter. It's consistency, right? F your feelings, follow the plan, right? Tendons respond to repeated exposure and then of course, developing strength and that elastic capacity. So the slow heavy resistance training and gradual progression in your energy storage and release, release work. Okay? This is consistent with how I practiced in clinic, but also what the adaptation literature suggests, right? So the tendon is responsible for loading and that loading magnitude is important. What tendons hate is spikes. They do not like sudden jumps in intensity, volume or novel activity. Just like me, tendons, you are my spirit animal. Don't surprise me. They don't like randomness. They don't like weekend work. Your patterns, right? You gotta be working out consistently through the week. And then they also hate painful overloading without recovery. You can't like, you can't bulldoze, you know your way through tendon remodeling. You have to give yourself appropriate recovery. So in terms of like a checklist, a general checklist, what I would say is keep at least if you're training, weight training, strength training, at least two days a week, at least two days a week of heavy, slow strength for the regions that you rely on most. So for a lot of women, that's going to be the lower body and I would say like heavy slow training for the glutes. Heavy, slow training for the hammies and for the quads. If you're someone who wants to sprint, I hope, even if you hate it. That's the other thing I get too, is like, I want to sprint, but I hate it. It's like, same girl I. But I still do it. So if you want to add plyos, sprints or hills, do so gradually, right? Treat it like a dose, your dose, dosing it up right. And then also just track some of the things that can increase, you know, pressure on the tendon. So if you've just recently gotten new shoes or there's new surfaces in your home or where you work, you've taken up a new sport, a new class, new speed work, new program, like, think about all these things and their impact on the tendon. I also want you to use pain as feedback, not fear. Pain is just a message. Okay? So, so stable pain that doesn't worsen day to day, so it's not worse after you train, or it's not worse at night. We can work with that. Like, I can work with that. But if you have escalating pain or the next day you can't lift your arm because your shoulder is blowing back on you, it means that the dose is too high. So the load that you lifted is with is too high. And then, of course, you know, your sleep matters, your protein matters, your overall training volume matters. Right? Like your tendon is living tissue. They're not fragile. Right. They're just slow to negotiate. Yeah, they're just stubborn. Like, again, very similar to me. It's like, don't like surprises. And I'm stubborn like a mule. So are tendons. Right. So train them like architecture. Right? Like the infrastructure to your body, not like decoration. All right, so the last thing I'll say is, I do want to talk about a specific female centric lens for women over 40. Not because your tendons are worse, worse, but. But because the inputs to the tendon, like tendon load, tendon recovery, and tissue behavior will change around this age. And if I asked you to tell me why you think that is, you could probably tell me. There's a couple of few major drivers colliding right at the same time. We have perimenopause and menopause, right? So we have these massive hormone shifts to which tendons and ligaments, you know, they have estrogen receptors. And estrogen influences tendons, tendon strength, tendon stiffness. It also influences ligamentous laxity or. Or lack of it. And then, you know, hormones can meaningfully change connective tissue behavior across the lifespan. There can also be for women over 40, almost like, like a life fitness mismatch and, and tissue capacity. You know, we have like kids, work, you know, we don't have, we're not recovering as fast and we're not giving ourselves more recovery, recovery. And then suddenly we're returning to intense training because somebody on Instagram told us that we have to lift heavy. Right. So I would say when we're looking at some certain anatomical regions, they disproportionately affect women. So and I'll say, like there's two really big ones, but I want to talk about a bunch of them but the lateral hip and the shoulder. So we're going to talk about those now and then. The other thing I do want to just mention is that there are generally, if you're not thinking about your tendons strategically age related degenerative changes. Right. So they are our tendons, our, our tissues as a whole generally remodel slower as we age. So the margin for those sudden spikes really shrinks. So as you get older, just like me, I hate surprises more and more and more. So let's talk a little bit about some of the more common ones. As I mentioned, lateral hip pain, often GTPS or gluteal tendinopathy, very, very common for women 40 plus. I, if I had to choose one signature tendon problem for women, it's this one. It's lateral hip pain. It's often like kind of grouped into a bigger clinical picture called greater trochanteric pain syndrome. Okay, who cares? It's just like lateral hip pain, okay. It's frequently it involves like the glute medius, glute minimus and the 10 and like the tendons of those two muscles. And it's widely, we, we see this very commonly. Anyone who has a musculoske practice, any woman over 40 has come in calling it like hip bursitis or the sun. I can't sleep on the, I can't sleep on the side of my, you know, at night. I can't sleep. It is usually, you know what, when we think about the mechanism, what's actually irritating the tendon. This one's not just weak glutes, although weak glutes do play into it. Again, it's about load and compression. So the glute tendons, they all work in a variety. Like they do a of lot, lot of things. They extend the hip, they help stabilize the pelvis in a single leg stance. So if you were to stand and just lift One knee up. Let's say the contralateral glutes have to work so that your hips don't dip anytime you're walking, going upstairs, running, standing on one leg to put pants on. Like your glutes are working when your hip falls into a deduction. So think like the hip dropping inward or when you load the hip while it's compressed, the tendon. Tendon can get both that tensile load and compressive irritation. So that combination together is usually quite notorious for flaring symptoms. So and then you add on like prolonged, you know, positions that compress the tendon. So if you're like side lying, you know, sleeping on your side, or you're sitting with your legs crossed, then you have this like kind of predictable cycle that happens. So for women who are over 40, obviously stop feeding the compression while you be, while you rebuild the capacity. So sleep with a pillow in between your knees. Avoid side lying on the painful side if you can. I would also say to temporarily avoid long stretches into the hip adduction. So if you're looking at like deep itb, like iliotibial band stretches, those can actually be a bit provocative. I would really work to strengthen the ab duct. So those are the, you know, you have the anterior and posterior fibers of the glute medius. You have the tensor fasciae latae, which is almost like that, that tumor. It's like, you know, when you, in lean individuals, it almost looks like a tumor at the top of the head, at the top of the leg. To which I love to say in my best Arnold voice, it's not a tumor, it's a tensor fasciae lata. So we have. Thank you for, thank you for listening to that. And hopefully you laughed. But yeah, so we have like the tensor fasciae latae as well, well as the glute abductors that are going to, that really need to be strengthened. So it's the same kind of thing, like isometrics, low irritation in neutral, progressing to weight bearing work and managing your, managing your load. Right. Things like step ups and lateral step ups as pain stabilizers. The goal here is to create strength, not just burn. Okay, so we know the difference between strength and burn, right? So the difference between strength training and pilates, when you do like a thousand reps, that's muscle endurance. That's when you feel a burn. That's not what we're after. We're actually after strength. So we are went on that abductor machine, I like to call it the bad girl machine. At the gym because you're sitting with your legs together and then you open them and you try to open them as wide as you can. That's your bad girl machine. We want to be actually working that as far as much as we can to failure because that is going to really help stabilize and create strength in the hip so often again. So thinking about, do you feel worse at night after a strength training session and that will help you sort of dictate your load. Another one I, I, I'll talk about briefly is the rotator cuff tendinopathy and tears. So this is kind of like the second biggest category for women. It's the shoulder rotator cuff tendinopathy, the rot and even rotator cuff tears. These increase with age. And there's, you know, when we look at perimenopausal and menopausal women, you can have structural changes again without obvious symptoms. So pain is never that perfect damage meter like you could have changes, have poor form or you're overloading it, or your maximum recoverable volume is being surpassed. But you may not know it until we get like some, some kind of tear or some kind of snap. So in terms of pain, often, what happens again? Load management. So sudden increase in overhead work, you're doing a new strength program, you're doing more pushups. All of a sudden you're starting to use kettlebells, you're doing pull ups. You can also have for a lot of women, degenerate, generative, and we'll say cumulative micro trauma. So you've had years of repetitive shoulder use, slower remodeling, poor technique. The other really big one is like thoracic stiffness. So like your thoracic spine is your mid back. Because we're all sort of sitting like the hunch of, you know, the, what's the guy's name from Notre Dame? The hunchback of Notre Dame. We're all sitting like that over our computers in that kyphotic or that flex position. We lose the extension, we lose that sort of thoracic mobility and that will affect our scapula. So if you don't have really good thoracic mechanics and the scapula doesn't like rotate well when you're lifting your arms up, the rotator cuff can get overloaded during elevation because your scapular mechanics are a little bit funny. So rehab considerations. Here is again, don't rest forever. Reduce the irritant, right? Manage the load. You want to keep your capacity work. Keep your presses like your overhead presses with modifications so you can change. Like if this is irritated, irritating. I'm putting my. If you're watching this on video, my hands are facing forward, change the grip. So if you want to bring it into more of a neutral or a Swiss grip, if that's helpful, you can change and load the rotator cuff a little bit differently that way. And then I would say build cuff capacity and scapular support together. So working on external rotation strength and endurance. So I did a Instagram video of this not too long ago. But if you're lying on your back, external rotation is if your arm is at 90, you just going to open up all the way and hopefully you can actually rotate a full 90 degrees and even more. So that's external rotation and internal rotation would be the opposite. So lying on your back and then bringing your arm all the way down and hopefully you can get your inter your forearm on the floor as well. The other thing that's really important for women is like scapular retraction. So being able to like I always say, like, you know, bringing your shoulder blades back and down on your back. And then again you want to be doing ice cream isometrics, slow, slow tempo, controlled range. We want to be doing moving even if you can't do full overhead presses. Let's say maybe you do like a partial rep, like a long length partial. So we want to be very, very careful with that. So those are kind of the big two, I would say other ones to consider. We talked about lateral epicondylitis or like the tendon, like tennis elbow is what it's often called. Not it doesn't just come from tennis, but a lot of women over 40 like that, 40 to 49, much higher incidence of tennis elbow than in men. And this is usually from, you know, we take a pickle ball, we're taking up tennis. It's that repetitive gripping, that wrist extension under load. So you get this, you know, you take up a new racket sport and all of a sudden the outside of your elbow starts to get a little bit funny. You'll notice it with like, like lifting a kettle or you know, shaking hands, opening jars. All these things are going to irritate the, the lateral epicondyle. So same considerations as before. Manage the load. Isometrics, heavy and slow resistance. Right. And then we want to modify the grip if we need to. And we gotta wait unfortunately. 4. I will say the other thing that's really helpful for the lateral epicondyle in particular is using straps for lifting your grip will always be the limiting factor for Muscle anyway, so I would dou definitely think about investing in a pair of grips. I. I have. Gosh, what's the brand that I use? I don't even recall. I think they're called Cobras, maybe. Lots of great, lots of great brands. So those are some of the common things. Gosh, I'm just looking at the time here and we've been going for about an hour or so, but this is hopefully a really concrete soliloquy and thesis on why we want to be thinking about tendons and this tendon masterclass, why it's so important. Because the biggest thing that I'll say for women who are, who are wanting to strength train and wanting to strength train for a long time. My biggest observation with especially very driven personalities like myself, this stubborn mule, you know, kind of personality where like, no, I'm gonna, like, you know, I'm gonna punch through. I think what ends up happening is when you ignore tendon pain, the tendon starts to degenerate and then your body just broken, you know, Like, I can't tell you how many 55 year olds I know that are literally the same personality as me, but just did not diversify their movements and did not take into account tendon and ligaments and now they're broken. Like they cannot do the things that they used to. So warning my heed for you if I can, you know, word to the wise is think about diversifying your training. Thinking about some of the things that we spoke about today in terms of the modeling length for tendons, how they're longer than muscle, and then what are some of the, you know, checklists that we want on, like managing the load, progressing to isometrics, heavy slow resistance training, and then practicing recoil. Those are kind of like the main four pillars that we want to be thinking about with tendons. Okay, So I want all of the feedback. So did you enjoy this? Was this technical? Too technical? A little bit. This is like my. This is the stuff that I think about when I have a moment to myself. I think about tendons, I think about ligaments, I think about joints. So let me know if you like this, if you want more of this. What was your big takeaway? Until next time, I bid you adieu and thank you so much for listening. All right, all right. I hope you enjoyed today's episode and I must give you the obligatory legal and medical disclaimer here. This podcast, Better with Dr. Stephanie, is for general information only. And the advice recommendation we discuss, do not replace medicine, chiropractic or any other primary health care provider's advice, treatment, or care. In the consumption of this podcast, there is no doctor patient relationship that has been formed and the use and implementation of the information discussed are at the sole discretion of the listener. The information and opinions shared on this podcast are not intended to be a substitute for primary care diagnosis or treatment. In other words, guys, be smart about this. Take it with a grain of salt. Take this information to your primary healthcare provider and have a discussion with him or her to make the best choice. That is for you. Remember, I am a doctor, but I am not your doctor and these conversations are meant for educational purposes only. SA.