How To Get Juicy, Pain Free Tendons w/ Jake Tuura (SSOF Ep 100)

Jake Tuura2:15

So jumper's knee is right below the kneecap. It's usually just from overload, doing a lot of jumping, landing, explosive things. Because when you do something explosive, that's what really pulls on the tendon a lot. If you do something slower like a heavy squat, it doesn't really pull on the tendon to the extent that a max effort jump would do, although powerlifters can still get patellar tendon pain. So it's a little muddy.

But you get more pain as you do something with more speed like jumping. The pain during is kind of weird because it can warm up. So you can feel really bad going into a session, do a little bit of warmup, tendon feels better, you go do your session feeling fine, you wake up the next morning and your tendon's blown up with pain again. That's kind of your sign that you have a tendon pain— is the next day pain, and what you did yesterday was not very good.

So jumper's, it's just thought to be an overload of the tendon. So you've done too much. It's every tendon issue— I think people could look at this, probably any musculoskeletal issue that's simple enough— like a tendon is too much too soon. It's all it is. Done too much too soon and you should have progressed a little bit slower. Now you're in this pain and you need to rehab.

When you do start going back, you need to be smarter. Do not do too much too soon. Because you see people with tendons— people do some crazy things with running hundreds of miles per week or lifting crazy amounts of weight, jumping 50 inches and doing it week after week. It is quote unquote too much. That is a lot of load, but they're not doing it too soon. They're fine because they've done it for many years or many months. They've progressed their body to that point, so they're never changing things too fast.

That's usually what you see with the tendon is you've changed something too fast. You went from no basketball for the last one year and then today you're going to play basketball for three hours. And it's like that could set off— it's usually going to set off your muscle because delayed onset muscle soreness— but you could also set off your tendon because it's just too much too soon. So that's kind of an explanation of jumper's. It's kind of— I try to pertain it to all other tendons because they're all very similar.

James de Lacey4:48

And then what would be the typical medical route for treating that?

Jake Tuura4:48

So I kind of— when people get pain I kind of encourage them to go get to go to a doctor to get a diagnosis because you kind of want to know what you're working with. You wouldn't want to treat a jumper's knee that ends up just being a plica irritation in your knee or just ends up being a fat pad irritation or a bursa or something.

You don't want to treat something when you don't know that's the cause. So everyone thinks they have patellar tendon pain or patellar tendinitis, they'll say— which should be tendinopathy— and it's like if you don't have that, I don't think your rehab is going to be that good. So I encourage people to go to the doctor and see what the diagnosis is.

What's the typical route? I think even the diagnosis gets kind of messy, man. It's like you go in— I've went many times. You go in for, when I was younger, patellar tendon, and they poke your tendon. They put their finger on it. They'll be like, "Does that hurt?" You'll be like, "Yes." And then that's often— that's enough for them. Well, they usually ask, "Oh, you're a basketball player?" They look at you, see that you're athletic, and they'll be like, "Yeah, you got jumper's knee."

But the palpation doesn't mean anything for the patellar tendon, at least, because you could take any Division One men's basketball program and poke all their patellar tendons, and I bet you all of them hurt because they're loading their tendons all the time. But a lot of them won't have patellar tendon pain. So it's like the palpation is kind of out.

You don't really need to use that for the patellar tendon. It does help because when you have patellar pain it's going to be in a tiny spot. You can basically point to it with a finger. Doesn't mean you need to poke it, but you can point to it with a finger. So it's a really small area.

The way that it's— basically they say it's a clinical, quote unquote, clinical diagnosis where it's just based off of signs and symptoms. How did this person— how did you come with this tendon pain? Did it come out of nowhere? Did you have a sudden event where something happened? And then you just look at the activities a person does.

And then I think what they'll do— so we'll finish for the diagnosis. Once they confirm that, is I think they'll usually give you— well, I can't speak. There's so many— it varies so much. Some places you go, they give you a PRP right away. They give you a PRP injection, which does not have good evidence for the patellar tendon. It does not have good evidence.

And I think what they should do is PT. Send someone to PT. The wait-and-see approach. Let's see if this resolved itself. Give you three months. I mean, even back to the '90s I read all these tendon textbooks and it's like time after time they're like, "Three months conservative management." You know?

I don't know why people are influenced nowadays with the medical system— other strength coaches are like, "Oh, they're so poor. They go right into injections or they go right into surgeries." And I'm like, ever since the '90s it seems like they've been doing conservative approach. For people comes in with pain, it's like, "Wait and see what's going to happen. Let's try a little bit of PT, see if this resolves itself," which usually it does because the tendon does heal.

So I think that's a typical route. But the thing is, many people do not get better with PT, and I think it's because most of the PT— if you're looking at someone like me who's 220 pounds and I want to jump about 40 inches and go dunk basketballs many times per week, the typical PT where I'm doing band exercises and stuff like that, there's no progression of that to get me back to dunking. That PT, the light-loaded PT stuff, is—

Going to be great and make me feel good. Obviously I'm going to feel good, I'm not loading my tendon, but it doesn't help me prepare back to play, back to basketball. So I think a lot of that stuff will help you feel good because you're not really stressing it. You're getting some activity in the area, but you're not really stressing it. You're not progressing it to get you back to sports, and that's where you would get failed rehab, someone just doesn't get better.

And then it's okay, let's start injecting it, let's start doing different modalities to the tendon. And I think in a lot of the cases you could have just done more aggressive rehab. Pain is tough, pain is tough, but I think in many cases I think you just got to look at the rehab and be like, the rehab usually has obvious flaws. So do better rehab, be patient, and the tendon pain for the most part should get better.

James de Lacey9:11

Maybe dive into some of the fallacies of taking complete rest when you have tendon pain?

Jake Tuura9:11

Yeah, so there's a lot of cool animal studies. Most of our understanding of tendons comes from animals because it's hard to look at a human tendon. They used to do biopsies—they do muscle biopsies. They stick that big needle in your muscle, pull some muscle out, they look at the muscle, the fast twitch composition, stuff like that. They do muscle biopsies still all the time.

They do tendon biopsies and a person's wrecked for months, maybe years. You can't really do tendon biopsies, so we can't get good understanding of human tendons because when you biopsy them you wreck people. And we're also not going to put people on severe rest protocols or severe overload protocols, like running a mouse on a downhill treadmill until it fails, then you can look at their tendons. We're not doing that to humans. So you can do the cruel, evil stuff to animals, I guess, and that's fine.

But when you talk about rest, it's fascinating that you have a normal tendon with normal activity level—you just go about your life. And then you have one extreme: overload, where you're doing way too much, way too soon, and you just cooked your tendon. And your tendon is in such a bad shape, you could image it with ultrasound or look at the histology, and the tendon is just going to look terrible. The cells and the collagen, it's all just a big mess because you've done way too much. You've just wrecked your tendon from overload, just from overload, overuse. That's on one end of the spectrum.

On the other end you could just rest your tendon—immobilize, do bed rest, do nothing at all—and your tendon's going to look pretty similar to the overload. So if you want to invoke tendinopathy, or you want to invoke all of these bad changes, degenerative changes to the tendon, if you want to invoke those in your tendon, just bed rest, just completely bed rest. It's the worst thing. Well, obviously overload—they're both the worst thing for your tendon.

Now I think the thing is, people will say, when I say rest, I mean that means complete immobilization. That means if you're talking Achilles, you're putting your foot in a boot and you're on crutches, you're not putting any load on the Achilles. Because if you put your foot in a boot and you still walk on the boot—because some people will do that—you still actually stress your Achilles, so that's not complete bed rest.

So when I talk about complete rest, that is you're not loading the thing at all. You're not really taking it even through ranges of motion, but you're not giving it any load. So that's complete rest.

So when someone does get a tendon pain and they want to rest for a bit, I think they're not going to completely rest like that. They're still going to go about their life, probably walk around, go do laundry, do dishes, load their tendons a little bit. So you're not getting that severe disuse of the tendon.

The thing that's happening, though, is when you have tendon pain—let's say you have patellar tendon pain on your right leg—everything you do, you're going to be shielding your right leg. You're not going to be loading your right leg because of the pain. So you have to get on some form of rehab to get your brain—because your brain doesn't want to load the side of pain—to get your brain comfortable loading that side again. And it's just this idea of shielding.

So you've shielded that whole side from load. But if you look actually at the tendon, you'd have little pockets of degeneration or fascicles that are more overloaded than other ones. So you have, I guess, systemic shielding where you're shielding the whole leg, but you also have local shielding because your tendon itself is not going to want to load those areas that are damaged. And I think those could also go all the way up to the muscle, and you might actually see muscle changes, the muscle loading in a certain way to avoid loading certain fascicles within your tendon or certain areas within your tendon.

So you want to get rid of the systemic shielding by getting on rehab to strengthen the leg, get the brain comfortable loading that again. And then you could do stuff like isometrics or slow heavy strength to try to get rid of the local stress shielding. Because when the tendon just gets pulled and relaxes, pulled and relaxes, but if you do an isometric, you can pull—or you do slow heavy strength, you can pull on the whole thing slowly and the molecules separate, and you could actually get some load through the degeneration, through the bad areas that are unhealthy. So it's all part of a good rehab program, though.

Someone gets a tendon pain, patellar, Achilles, you're going to get on some form of isometrics or slow heavy strength to get your brain comfortable loading, to get those pockets of unloaded areas loaded again. Yeah, it's just you don't want to completely rest. Most people are not completely resting, still walking around, doing things, loading the tendon. It's just, do you want to get this thing better? Do you want to really address all of the deficits, the clear deficits you have? Then just start rehabbing. Yeah, don't completely rest.

James de Lacey14:13

I hope you're enjoying the chat so far. Before we get back to that, I just want to let you know that Sweet Science of Fighting is more than just a podcast. We have a full training app with strength conditioning programs for strikers, grapplers, and MMA athletes, so you don't have to think about what you're doing and you're getting access to the latest scientific methods to improve combat sports performance.

We have programs specifically for judo, for jiu-jitsu, for wrestling, MMA, boxing, Muay Thai is coming soon. All these things are going to be in the training app. We also have a private community where some of the coaches that have been on the podcast are in there to help you with any training questions and any performance questions you have. For example, Andrew Asher and Casper Dietert.

We also have some online courses within the training app. They cover strength conditioning, mental skills, and weight cutting. And finally, we now have Ryan Vos in the community, a second degree jiu-jitsu black belt who is there to break down any of your grappling matches that you want seen to by a second eye. He's currently breaking down videos on a separate Sweet Science of Fighting YouTube channel, and he will break down your video within the community.

So if you have a match or a roll that you just recorded, you can upload that in there and Ryan will break that down for you. So what are you waiting for? Jump down the description, you can check out the Sweet Science of Fighting Underground. Otherwise, enjoy the podcast.

Pretty much all my tendon information I got from watching Dr. Keith Baar's lectures and work and different podcasts and things like that. It'll be interesting maybe, before we go to the practical side, go into what's happening at the tendon level. Obviously you mentioned some isometrics and things like that, with the tendon pulling. Do maybe just go into—maybe you talked about some of the degeneration with the pain—what are we actually trying to achieve when we're doing this rehab within the tendon?

Jake Tuura15:59

Yeah, okay. So I was recently reading a Nassim Taleb book. You ever read any of his books, like Antifragile, Black Swan? I've read Antifragile, that's the only one I think. Yeah, I mean I think they're probably all very similar. Antifragile seems the most popular.

But it was a thing, man. There was a part talking about people back in the day—we all say structure dictates function, structure dictates function, whatever. But it's like, that might not be the case always. Structure might not dictate function. And I've had to entertain that thought with the tendons, because you could have anyone who's a good—I'm in the basketball world—anyone who's a good jumper, a good dunker, you're going to image their tendons and they're going to look like trash. They're going to look awful. So that structure looks very compromised.

And looks degenerative and looks very bad, but what's the function? The function is they're the best dunker in the world, they're the best jumper in the world. So it's like you could take a tendon that looks amazing with like a 16, 18-year-old, whatever, who's not as good of a jumper because they haven't overloaded their tendon, and you'd be like that structure should have better function, but that structure does not have better function. So LeBron's feet, right? Is it LeBron's feet they have—

James de Lacey17:21

Maybe something like that, yeah.

Jake Tuura17:21

Yeah, well the feet, I don't even enter go into the feet because I'm like there're so, it's so complex. I don't. But yeah, the structure dictates function. That is true, yes, but like how true is it? And it's not true 100% of the time, so especially with the tendon.

So I say that because when you talk about the rehab, what are we really trying to do? And people if they get imaged, they could get a—you could get an MRI, but that's not going to really tell you what's—you could get an ultrasound, ultrasound will tell you more about what's going on, where the areas are. If you got like a UTC scan, you could see even more, but those are kind of rare probably, gaining popularity.

You could actually see how the tendon looks with the degeneration with maybe the swelling, and then you would want to progress away from that, like just common sense you'd want the structure to restore.

The thing is, you could have a really ugly looking structure and someone can't function, and you just do good rehab, strengthen the muscle, strengthen all the associated areas, give the tendon time to heal, they go back to sport completely pain-free, they're functioning better than ever, images are—it looks the exact same. So it's like, do you really, you know what I'm saying? So it's like, do you really need to focus on the structure?

And who even has the money to focus on the structure? Because you need to pay for frequent imaging to see how it's doing, and you need the same person to image you because it's also the individual—if you get a different individual to do ultrasound on you, that's going to be a different ultrasound scan.

So it's like, I don't like the focus on structure. There is—this is how one of the avenues how it's, it racks your brain. Because yeah, I'm always like that's what I believe, is like don't focus on structure, focus on improving the function of your leg, maintaining pain—you can go play just fine, don't worry about your tendon. But then I'm like, all these cases of tendon rupture, which tendon ruptures are rare, but all these cases of tendon rupture, they happen in people that already have pathology in their tendon, they have structural problems with the tendon.

So it would make the most sense for someone to want to avoid rupture to get their tendon as healthy as possible, get the structure as healthy as possible. So I'm like, this is where if you have—think of the idea of having, yeah, Keith Baar, he talks about that rock in the stream thing, you know, you have a pocket of degeneration and all the stress goes around the rock, all the stress goes around the damage, and you have many different pockets of degeneration within your tendon.

His idea with the isometrics is you hold an isometric that's like a heavy, a heavy enough load, the tendon gets longer and long, it creeps, the tendon creeps, the molecules move apart, the strong areas get weaker, so they can't really handle that load anymore. So then the weak ones have to get stimulated. So it's like that 30 to 45 second long isometric, and that's the idea is you're getting load to the tendon.

Because the tendon's such a dumb tissue, like all it does is, it has a, like a slack—it's slack when it's relaxed, and then when you load it, it goes straight, and then it just gets pulled, and then it goes back to slack.

So it's slack, pulled, slack, pulled, and that's all it does. And you can think of the whole tendon as being slack and then it getting pulled, and you can also think of the area of degeneration as being slack. Because that's what it is, it's you have the collagen might be damaged, the cells—the cells should be long in a tendon because they're stretched out, like the tendon just stretches. But when you have damage, those cells get rounded, the area of tendinopathy, they get rounded.

So all the things of tendinopathy point to that area being slack. So you want to get that area, you want to get just the force—tendon is so dumb, all you have to do is get a pull through it, through the whole tendon and through those areas. So that's where I look at with the isometrics is you're just trying to get a pull through that area because it's just rounded, it's shielded from load. So that's what you're kind of trying to do there to get the whole tendon structure healthy.

But it's not complete rehab. I mean, you don't just—you don't just get that area, say you spend three months doing only isometrics and you're a basketball player, and then it's like, okay, my tendon—you image your tendon, I'm completely healthy, I'm going to go play basketball again. Because what is that? That's too much too soon. You haven't played basketball in three months, too much too soon, you're probably just going to set the thing off again, and now you're going to have to start again.

So it's like, do the isometrics, sure, that's great for the structure, but then you got to start adding in some of those faster loads or some of those loads where you're pulling and then relaxing, pulling and relaxing. And that would be go from isometrics, then go to lifting, like slow lifting, you could also increase the speed of lifting, and then it is—it's basically what is the thing you need to do in your sport, and let's do that at a lower volume and a lower intensity and look at pain the next day, and then progress from there.

So it's like I look at rehab is someone gets a bad tendon pain, had it for months, stop doing the thing that's causing the tendon pain, which if you're a competitive athlete like you were with a lot of fighters, no way you can hold yourself back, there's no way. I can tell you, you've had tendon pain for many months, you can keep doing your sport, you can keep competing against other people, just try to go at 50%, because how do you go at 50% when there's another person in front of you? Like you can't do it.

So the competition is the thing that destroys your tendon. If you could just go do shadow boxing or something completely by yourself, then you can manage the intensity. But if you're with another person, you can never manage the intensity, that's what's going to set your tendon off again. So I'm like, remove the thing that's poking your tendon, remove the thing that's poking the bear, start at good rehab, do the isometrics, do the slow strength, and then slowly build back up the sport loads.

And if that could take you many—that could take you many months, but you also have to think in those many months your—that's your tendon healing process. Your tendon healing process doesn't happen in days, that happens in months. So if you give it time to go about its healing process without provoking it, it's going to get better.

I think that's the actually the biggest thing. I'm such a fan of addressing everything around the tendon, but I'm often like, okay, this person just spent three months doing good rehab, grading everything back to sport—did I just give the tendon three months to heal and I just like gave them time? Was I just biding time, you know? Not saying we could have just rested and done like whatever. I'm like, this person still wants to train, they still want to feel like they're doing, but I'm like, sure, I have strength and everything around the area and progress things as properly as possible.

But I'm always looking at what's the mechanism, and I'm like, was it really that I just gave the tendon time to heal without continually provoking it? I think that's what's going on too. I think that is a legit reason why tendons get better, is you've just given them time to heal without provoking them. And you've given them time to heal without provoking them, and you haven't went the far extreme of laying on the couch all day, because that's also not going to heal your tendon.

James de Lacey23:44

Oh, perfect. We actually have a question in the live chat. I think it'll be a good progression onto what you're saying there. Saying a friend of his experiences pain when trying to do a single leg squat, he can't complete it, and he is saying that he is feeling pain under his patella. What should be typically, what should be a typical progression, or is the problem bigger? Maybe go to, if you want to answer that, when you can, maybe go—maybe someone, your own experiences, rehabbing your own, a single leg squat.

Jake Tuura24:10

Like a pistol squat, I assume, something? And if it's under the patella, so I'm like, yeah, if that is a patellar tendon. Because like we were talking off-air of like, you know, it could be like patellofemoral pain. Patellofemoral pain is going to be the behind the kneecap and around the kneecap, and that usually hurts when you get into flexion. So I'm like, anyone who does squats and your knee gets more painful when you do squats, usually like patellofemoral pain, because it's just general kneecap pain, the—

Patellofemoral joint forces are higher whenever you bend your knee, whenever you squat. But let's just say this guy has patella tendon just for the sake of simplicity, it is right under the patella. And that can be a thing. Earlier I said it's with load. So if this person went cold and just tried to do a single leg vertical jump, that would probably be a 10 out of 10 pain if you're getting it with a single leg squat. That's not much load. That could be a three out of 10 pain. It shouldn't be much.

Yeah, and also it would take many paragraphs of back and forth of figuring out what exactly is going on. But this person, I think you don't need to—you often, most cases, you don't need to completely scrap everything and do complete rehab. You can just kind of manage the person where they're at.

So it's like you get pain with a single leg squat. We know that tendons warm up, so I'm like just warm up better. Just hop on a bike for 10 minutes, do backwards sledding if you're an ATG fan. You think that that's getting the most blood flow? It's not, because anything you do is going to get blood flow. Anything you do lower body is getting blood flow to your patellar tendon, to your quads, assuming you're just flexing and extending your knees.

So this person, they could just do a better warmup. They could warm up the exercise better by doing it unloaded for a little bit and then progressing to that point. Because that's the thing: stress on the tendon, because you're moving slow, so it's like just do a controlled tempo down and a controlled tempo up. If you have to do it really jerky and bouncy, that's what's going to be really yanking on the tendon. So I just say control those things.

Yeah, that's usually where I'd start with a person because I'm not about to explain everything about, "Hey, you need to start doing leg extension isometrics, you need to start doing calf work and everything." I'm like, with the limited information I have, it's like let's just manage what you said you have now, which is this hurts when I do this thing. Okay, warm up better and then slow the tempo down. Those are probably the best ways to decrease tendon pain for that actual thing.

James de Lacey27:03

Nice. And do you want to maybe go into some detail on your experiences there? You mentioned obviously the leg extension isometric, calf work and things like that. You want to maybe go into some detail into where that kind of fit into your own journey with your rehab and maybe some progressions on from there?

Jake Tuura27:03

Yeah. So man, my rehab was like, ah, for two years. That's the first time I had tendon pain was two years. And it was a lot of resting, not complete rest, but a lot of resting, trying to get back to basketball. Didn't work. A lot of PT that was light loaded stuff, didn't work. So I went through, I think two years, and then I actually got surgery, which surgery didn't help at all because I thought I had a partial tear. Didn't do anything.

So yeah, mine was quite a bit of just clueless. And it was back in 2011, 12, 13, where if you try to Google patellar tendon, you're not finding any good information. What I found was Kelly Starrett and he taught me how to do the couch stretch, how to stretch my quad, and I believed in it 100%. And then how to ice it. So it's like doing things—oh damn. Yeah, I mean those things are not bad. Icing is not bad. Stretching your quad is not bad. It's still things I, if people think they're beneficial, go ahead and do them.

But yeah, for me, because when you have tendon pain right in that one tiny spot and it's been there for many months, I can look at your quad strength side to side and see that it's weaker. I can look at your quad size side to side and see that that quad is smaller. Half, you can't really—I guess you can't really see it. It's hard to measure. I'm not a big Achilles calf guy, but I'm like the seated calf raise, standing calf raise—the standardization is so hard for me, so I don't know how to look at calf strength really with people.

But I could look at it with a function of hopping and I could be like hop on your healthy side, single leg, hop on your unhealthy side, single leg. And the unhealthy side is going to look awful. They can't even hop on that side. So it's like I look at, I'm like you got one pain in that one tiny spot on the tendon.

Who cares about that? Let's address everything around there, which is get that quad bigger, get that quad stronger. Let's get your ability to interact with the ground better because you can't interact with the ground at all. You're jumping really stiff, you're really hesitating to load that side.

So those are the things I look at where I'm like just that one pain in one tiny spot, but all the other areas, the massive quad is something that's weak. Probably the mass of hamstring in the glute, the mass of calf—these are all the areas we need to address. And that's just good strength and conditioning. So that's all I look at it is: your function in terms of strength is so poor.

Let's get the strength up and pain will probably be a delayed response. Pain might, pain will probably decrease slowly over time. Get the strength up function-wise, and then get the store and release ability up function-wise.

So that's all it is: strength and store and release ability, if it's an explosive athlete. You have to get the strength up first and then you have to get the store and release ability back, which is the tendon moving fast, taking load and then producing—taking the stretch or, yeah, going from slack to straight back to slack. Doing it, hopping is a good example for the Achilles.

So that's the way I look at it is just get the strength. And there's many ways for strength—like a strength coach, how many ways are there to strengthen your quad? A million ways to strengthen the quad. Just find a good one that works for you, one that you can progress really well, that doesn't really, really provoke your tendon or your joint.

But an exercise where you feel a massive hit in your quadriceps. That's why I love the leg extension, like a mid-range position with the leg extension. Because mid-range, you're getting some pull on the tendon, you're getting a pretty good pull on the muscle. The muscle works the best at the mid-range.

If you go to a completely straight leg, the muscle doesn't work that well. If you go to a 90 degree or deeper, the muscle doesn't work that well. You want the muscle to work as good as possible because the muscle is the one that's going to be pulling on the tendon. And you want the tendon to—you want the more slack tendon to get pulled out to get healthy again. So I'm like the leg extension is a great thing for the quads.

And then it's a lot more, it's single leg too. A lot of single leg stuff. So it's like split squats are amazing. I still love squats and hip hinges, but you kind of always need to keep in mind that you need to strengthen side to side. Because your brain—I heard this recently—tendon pains are good cheaters. That's we're the best cheaters in the world. You can, I can go squat 500 pounds with really bad tendon pain. And it's like do I even know if I'm loading that quad or that side? I could just be loading the other side.

So it's like when you train one side at a time, you can't cheat, or you can't cheat as much. You actually still can cheat, but you can't cheat as much. So yeah, those are the kind of the ways I look at the patellar tendon. For me, I was so detrained and I'm like all I really, I just need to address strength. That's all I need to do.

Address the obvious strength deficits, which size will come with strength. And then address the obvious store and release abilities. And if I had done that and it had taken me many months, let the tendon heal, I know I would have been back so quickly. It's just that in 2012 there was no information like that. I couldn't find it.

James de Lacey31:45

Yeah, fair enough. We actually have a follow-up question to the previous one. He's saying he was talking about pistol squats, but he's also asking can knee problems be connected with bad ankle mobility? Because his barbell squats are completely fine without any pain.

Jake Tuura32:10

Yeah, I would think that's more a bilateral versus unilateral thing. If you got less pain with a bilateral squat and more pain with unilateral, I'm like you're probably just loading the healthy side more on a barbell squat. Now could it be connected to ankle things? I think so. I think they've looked at, there's some research on ankle dorsiflexion, limitation in ankle dorsiflexion being associated with tendon pain.

But then I'm like, okay, I've worked basketball for many years and the best, the most explosive, best basketball players they often have the stiffest ankles. And stiff like in...

In a good way, like their foot hits the ground and their Achilles is so stiff they get up right away. But if you make them do like ankle dorsiflexion test, they're going to have tighter ankle and then like what, 10% of them have jumper's knee? Because like you don't get, in the basketball, maybe not 10%, but like not everyone gets jumper's knee in the basketball world. So I'm not a fan of like looking into the minute biomechanics of like, oh your patellar tendon hurts, it's because your ankle is stiff.

I'm like, okay, if you're 25 years old and your patellar tendon just started hurting, and you've had stiff ankles your whole life, then why didn't it hurt the other 25 years? We should start looking at that way, like why did it just come about now? Like you've always had these biomechanics. Maybe the biomechanics changed, the way you move changed a little bit because of the pain, because pain will make you change how you move. So it's like if we just remove the pain, maybe that restores.

So yeah, the ankle thing might be related, but I also think who is actually changing ankle dorsiflexion in any meaningful way? That's such a hard area, that's such a hard area to mobilize, to stretch, and it's always involved with the Achilles. So I'm like, I don't think you'd want that area to actually change. I'm more a fan of like whatever you got going on at the ankle, unless the things are stiff and locked up.

I think you go do some specific footwork, see like a foot person. Like Gary Ward is a big foot guy. I think he knows the foot really well, how to get the arches to move and the bones to move and everything. That's something people should look into if they think they got ankle problems. But if you're all about like putting a band on and stretching it into as far as you can dorsiflexion, I don't think that's doing anything. And I don't think it's really associated with jumper's knee.

I'm not, it's not something I address with jumper's knee. I address everything else. And I've had a fair amount of success getting people better without cranking their ankle in more dorsiflexion.

James de Lacey34:39

Where does say your eccentric training fit into this, or does it at all? I remember, well I think it was must be my teenage years when I was at the physio for various knee stuff, and the first thing they'll do if you had knee pain, you would do on a slant board, a single leg quarter squat, eccentric, 4 seconds down until you hit pain or until 90 degree knee angle, and then two legs back up.

And that would be your three sets of 10 every day, that would be the prescription for the knee pain. So I'd love to know your thoughts on that and where eccentric, or if eccentric, fits into this model.

Jake Tuura35:05

Yeah, well first of all, that is a great way to hate your rehab because who wants to do that every single day? There was actually, I think it was a 24-week study, Stefan Bråa, I think Bråa, what you say it, where they did the slow heavy, they did the four-stage process of isometrics, slow heavy strength, back into store and release, back into sport. They took that and they compared it to people just doing what you just said, of that single leg decline squat.

And I think it was 24 weeks, and I'm like those people seriously did that exercise for 24 weeks? They did that one. I don't know if they went down with one and up with two, I think they went down with two, I think that's all they did. Yeah, or down with one and then up with one, but they added like a backpack. But like it's so monotonous and it only addresses like the quads a little bit. It's not even a good quad exercise.

No, it's a good, there's even a recent study, they did a recent study on the patellar tendon loading index. I don't know if you saw that. They did one back in the day on the Achilles tendon loading index where they look at, and it's their way of doing it, so it's not completely, it's not going to completely represent what happens in a human being when you're moving, because you can only really figure things out in like a 2D manner or a really specific like laboratory manner.

But the Achilles tendon loading index, so basically they said a low loading index doesn't stress the Achilles much, but a high loading index stresses it a lot. And it was just common sense. Like at the bottom tier of the low stuff was like a double edge calf raise, a step up or something. Then as it gets higher and higher, it's like now you're hopping, now you're doing things faster, you're just doing something faster with the Achilles. Just made a whole lot of sense.

They did the same recently, like in the last few months, with the patellar tendon. And it was the same thing. You look at the low-level stuff, it might be like walking or it might be like a really light quad exercise. As you get heavier with the quads, it's going to be higher. And actually the very top exercise, the one that was the highest patellar tendon loading index, was the single leg decline squat, the one you just said.

Okay, which I'm looking at, I'm like the highest patellar tendon loading index, so it's like the most stressful on the patellar tendon itself. And I'm like that, so what that tells me, is that is a great way to aggravate the patellar tendon, an amazing way to aggravate the patellar tendon. And I actually use it in rehab as like a loading load provocation test to see how your rehab is going.

So every single day you just stand on that thing and you do one rep. Just do it, like one rep single leg squat, and you see how your tendon feels. It can kind of tell you if what you did yesterday was good or bad. I'm more a fan of next morning pain. Someone wakes up in the morning, you're just going to know how the tendon feels. You don't need to do the single leg decline squat, which is actually a thing that's going to provoke pain again. It's going to provoke your knee again.

Some people find benefit out of it, some people don't. But yeah, so I don't, I'm not a fan of the exercise. Not a good way to strengthen your quad and a great way to aggravate your patellar tendon. So I'm like, are you just aggravating it again and again and again? Now I think it's a different way of looking at pain, how I think they're looking at it. We want to keep poking into pain and maybe for some reason it desensitizes you to the pain. I don't really know what's going on.

But so I think why did eccentric become so popular? I think that was actually the old Achilles research, how I think the story went. The Alfredson guy did, I could have the story kind of wrong, so yeah, someone can look into this. But he had Achilles pain, he wanted to get surgery, they weren't going to do surgery. So he's like, well screw you guys, I'm just going to go tear my Achilles.

So he went and he started doing super heavy, like many times per day, calf raises thinking he's going to tear his Achilles. And I think eccentrics were involved in that. And he never tore his Achilles and his Achilles got better. So that's how he found out how loading was good for his Achilles. I think there was some like slow, slow heavy eccentric, some type stuff like that.

And then I think the eccentric stuff, I don't know why it carried over to all tendons. I mean, not currently, isometrics are big on tendons now, but it was probably, it was probably before Keith Baar, how everyone was still on about eccentric. And it's like, yeah, let's just go back to how stupid a tendon is. All it does is get pulled and then go back to slack. It gets pulled, go back to slack. It doesn't know if you're doing an eccentric or concentric or I guess an isometric.

The thing probably with eccentrics was that you can always load an eccentric heavier, and they were probably thinking like a tendon is more resistant to stretch than a muscle, so you have to get the muscle as high load as possible and you can get that better with an eccentric. I think the thing is, if you're doing that exercise you said and you're trying to load it heavy, you're just going to be provoking your knee pain every rep. And again, it's a different paradigm way of looking at things.

It can work. There's definitely been people that that type of thing has worked for. But I've had so many people where that has not worked, and I'm just like, I just, it's just dumb. Just don't do it. There's way better ways to do it without keeping, without having to poke into pain over and over. So I think that's kind of where eccentrics came from, and I'm like, I don't care.

I don't care, you don't need to do eccentrics for tendon pain. Like isometrics are amazing for the stress relaxation effect. And then when you get into, start doing heavy strength training, just do normal heavy strength training. Like control the tempo down, control the tempo up, don't bounce out of the bottom if you have, if you have bad tendon pain. If you don't have that bad tendon pain and you can manage like kind of a control tempo down and then explode on the way up.

It's going to be better for Athletics, so I'm just do it like that. But I don't spend any time focusing on eccentrics at all.

James de Lacey41:00

Hey guys, it's me again. I just want to let you know that I also have Sweet Science of Fighting rash guards and shorts so you can represent Sweet Science of Fighting on the mats and within competition. We have the classic, just like the shirt I'm wearing, rash guard, Sweet Science of Fighting on the front, and we have the logos on the sleeves and then X Marsh on the back. We also have that in a shorts variation, same thing with the Sweet Science of Fighting writing on one leg and we have the logo on the other.

But my personal favorite, this is my personal favorite far, we have this in black and white and it is the Taniwha Protector Guardian version of the Sweet Science of Fighting with the logo on the back. This designed by a Maori designer back in New Zealand, so a bit of my heritage on this jersey. It represents the acknowledgement of battle and war.

It also represents strength and stability and also has the New Zealand silver fern. But even if you're not a Kiwi, cop this. This is an awesome design. It is a custom-made design. You will not find it anywhere else. So check that. That'll also be down in the description with a discount code.

But back to the podcast. Regarding supplementation, obviously Keith Barr's popular for pushing the collagen vitamin C before, say, jumping rope. Have you played around with that at all?

Jake Tuura41:52

Yeah, I've done it off and on. It's just always like you get down to the very small level of collagen, which is like you can't even image. The closest thing you can image I think is a fibril, which is like way smaller than even a human hair within a tendon. And it's like, now we're talking about the very small level collagen, like what's happening there, and I'm like I don't know.

I think a lot of it's placebo. Someone takes collagen, "I feel my tendons feel way better." It's like, great. But this is the thing: if you want to start explaining the reason why you feel better, you're probably going to be wrong. There's not going to be any support for that. If you're going to be like, "Oh, it's because my tendons remodel in XYZ with collagen," I don't know if that's happening. And also, your collagen isn't producing pain. Your collagen can't produce pain. Collagen is just a protein. It's like a dead protein structure. The cells are what produce the pain in your tendon.

So the cells are all around your collagen, so it's like this interplay back and forth with collagen and cells. I think it's good because if you look at when you load your tendon, you're always damaging some of the tendon and then it's your body coming back to repair the tendon. So it's collagen degradation and collagen synthesis. And if you have too much collagen degradation and not enough synthesis, your tendon is just going to get worse and worse over time. It's going to get weaker and weaker because you're degrading all of the structure, the scaffolding within, which is collagen.

And I think you'll see issues if people have low protein diets, just protein in general. Just low, very low protein diets. If you're like a 250-pound male and I'm going to use pounds, I don't know if people use pounds, Wix, yeah. Like 250-pound male and you're doing really demanding sport and you're eating 100 grams of protein per day, I'm like, well, first of all, you're probably going to run into issues in other musculoskeletal structures.

But I'm like, it's definitely not good for your tendon. And you want to keep providing it. And all it is is the amino acids, so it's proline and glycine and I think five of them or something like that.

Which are more abundant in your tendon than you would get from muscle. Your muscle does have collagen, but it's not like the extent of a tendon because the tendon's like, that's all of it. So that's the thing with collagen protein: it's easy to get those amino acids versus if you eat muscle meat or you have milk protein or dairy, it's hard to get those type of amino acids that are seen in your tendon.

So, for the most part, it's usually dirt cheap too. If someone is having tendon pain and they're concerned with it, I'm like, just take collagen, just do it. And vitamin, just make sure you're getting enough vitamin C in your diet. Which, that's one thing too: you could probably be, at winter time, if you're not eating oranges or something because you're not in season for many months, I don't think you're going to see a vitamin C deficiency for quite a while if you kind of cut it out. And I think our body produces some vitamin C of its own as well, I think at least.

So if you want to do it, they could go ahead, take the collagen, take the vitamin C pre-training. I think it's like 30, 45 minutes before they do any type of loading, because the idea why you do it before is because a tendon is a low blood flow structure. Just, if someone was cut open their leg, the muscle's going to be all red, gets a bunch of blood flow, oxygen. The tendon is going to be white, not much blood flow, not much oxygen. But so then you'd think, "I take collagen, how is it going to go to my tendon?"

That's what exercise does. If you exercise, you increase blood flow to the tendon. It's like the only time you get increased blood flow to your tendon is from exercise. So that's why you take it before, like 30, 45 minutes before. It's in your bloodstream. Now you're stressing your Achilles or patellar, and the idea is it could actually get incorporated into there. I don't know how true that is, that if that actually works, because I'm like, if you've heard of fibrosis, you just get too much collagen laid down. The body's smarter than us just thinking we can just pack in more collagen.

Because I think when you have tendon pain, it's actually you have so much damaged collagen in there that needs to be cleaned out. So for you to keep adding in more collagen, not that you're even going to do that, but it's like that idea that you have, "I need to add more collagen," I'm like, I think you need to just let it clean up the damage. And this is, again, this is again the healing process of a tendon. It's going to take many weeks, many months to clean up all that damage and get to a normal state.

So it's like you, I don't think you're accelerating it by taking collagen and vitamin C. Maybe placebo-wise it's doing that. But if you're seeing like a pain decrease effect from collagen, vitamin C, I think you're wrong. You're not seeing that from those type of things. You're getting placebo, or it's some other thing that's decreasing pain, which is, which is probably, this is the thing: when someone gets in pain, they never do one thing.

They always throw the kitchen sink at it. So they're like, "Oh, it's the, once I started taking collagen, my tendons felt amazing." And I'm like, well, what were the other 50 things that you started changing in your life that probably led to your tendon feeling better? Probably, I want the collagen.

But again, I'm just like, if people struggle getting enough protein, which many people do, collagen is an easy way to get it, dirt cheap. And if you want to go the route of like, quote unquote, optimizing everything, then take it pre-training, 30, 45 minutes, 10 to 20 grams of collagen. Easy enough, doesn't taste too bad. Put it in your coffee or something. And I'm like, you're checking the box at least. You're checking the box of having enough amino acids for you to have collagen synthesis.

James de Lacey47:24

Nice. So for you now, how are you managing, I guess, staying pain-free after rehab? Is there something, obviously you talked about obviously not doing too much too soon, but are you still doing a lot of some of these isometrics and slower lifting in your training just to kind of potentially keep your tendons healthy while you're doing all your other stuff?

Jake Tuura47:24

No, not because I tore my lat tendon last spring. I did, I saw that actually. Yeah, it's like there's not many cases of that. So the, and I've went through probably like, I've had, it's in the armpit. I got an incision in the armpit, so it's been like getting infected off and on. So I went back for many surgeries. So I haven't dunked, I haven't jumped in like 10 months now, which is, which is crazy. I mean, when I'm healthy, I'm going to start again.

But yeah, so I can't speak for that. But even before that, yeah, I just, when people they go through good rehab, get their patellar tendon healthy, I'm like, all you really need is to stay strong. All you got to do, stay strong with the weight room stuff, which is like split squats are amazing because it's single leg. You know what, side to side. Stay crazy strong with split squats, with squats, with deadlifts. That's just making your muscles, your muscles are going to be able to take loads that your tendon doesn't have to now.

Because if you think when you're jumping and landing, your muscle has the ability to like, quote unquote, absorb some of that.

Which eccentrically take what's going on there. If your muscle can't do that, I think more of that goes to your tendon. So it's like if your muscle sucks, your tendon is just going to be exposed to more stress. It's probably going to have more damage. So just stay super strong with your lifting exercises. That's just what I recommend for people post most good patellar tendon rehab. And then you can use isometrics if you want, like whenever you want, if they're a good warmup.

If you're really sore the day after doing something explosive, isometrics can be a way to decrease pain. But if you don't like them, if you just want to stay strong weight room stuff, go ahead, do that. Otherwise, it's just being smart. And I think all of the stuff I released on patellar tendon, with my books or with the things I post, I'm consistently reminding people of, you want to keep getting load through the thing, whether isometrics, with strength, but it's just stop poking the bear by doing way too much, too much too soon. Avoid that.

And I think that little piece of information for people post good rehab of patellar tendon and they feel amazing and it starts to flare up again is, I think most of them will know too much too soon. They just did too much too soon. And they can look back at their training and be like, I did too much too soon. Let's let my tendon heal for a few days. I don't need to scrap everything and panic and go back to square one because that's just not the case.

And I think the biggest, well that's a huge thing, but one of the other big things is knowing when to listen to pain. That's one thing too. In 2012 when I was going through it, I had no clue about next day pain. I had no clue about the delayed pain response of a tendon. It just wasn't put out there.

But if I'm a basketball guy and I'm on my tendon, I go play basketball for two hours, I wake up the next day, my tendon's blown up, it's like those two hours of basketball was too much too soon. But the thing is my tendon didn't tell me right away. And it didn't even tell me that evening. It told me the next morning when I got out of bed.

And that's one thing where when someone's getting out of a patellar tendon rehab and they're feeling great and they get a case like that where it blows up, you just take that information, you use it, you don't play basketball that day. You take it easy that day. You might go do some iso, you do some strength. And then next time you play basketball, you don't play two hours. Maybe you play one hour. Or maybe you don't jump as, maybe it's just taking the common sense information that was not available 10 years ago and just putting it into practice for someone to use.

Next day pain with a tendon, pain for someone to realize the delayed pain response and use next day pain, that's going to be a complete game changer. You might not even need thorough rehab. All you have to do is listen to next day pain. And then you look back, okay, that's what I did yesterday, my tendon didn't like that, so I should change what I did. Next time I go back, I need to change things a little bit.

James de Lacey51:52

Nice. We've touched on everything basically with knees. I think elbows, another common one, at least within combat sports. Does the process change at all regarding isometrics, slow heavy lifting? So just as a very general example, you might do an isometric 90 degree bicep hold and then you might do very slow biceps curls or something like that as your slow lifting. It would be a very similar process I think, would it?

Jake Tuura52:19

Yeah. I think some of it, probably pronation and supination of your arm can be beneficial. There are a few, I haven't looked too much into it. There's also not too many guys on golfer and Achilles, or golfer and tennis elbow. You probably have other issues. I would think you'd have, you could have other issues in there too.

But I think the thing with them is there's such small tendons compared to the patella and Achilles. And they, I think they get compressed from the bones around there. They mash against different structures. And I think when you have tendons that are mashed against different structures, they call it compression. The tendon is getting compressed against something else. I think a lot of that's happening in tennis or with a golfer elbow. I think could be wrong. It's going to make me look into it more.

So you could look at other tendons that get compressed, like the quad tendon gets compressed when you go into deep knee flexion. Because the quad tendon that's running from the quad to the patella, when you get into deep knee flexion, the condyles of the femur kind of go, the quad tendon can press against those. So deep knee flexion can aggravate a quad tendonopathy. So if someone has quad tendon and we just remove the compressive loads by, say, let's not deep squat for a little bit, you let the tendon settle, you let it go about its healing process.

Same with the Achilles, the insertional Achilles all the way down at the heel. Most Achilles pains are mid portion, a little bit higher up. But some of them are insertional, where they get mashed against the calcaneus and that causes pain. So people see crazy results if they get heel lifts so that their heels are elevated. So they're not, every time they walk and every time they do, they're not compressing their tendon again. Their tendon feels better because it goes about its healing process.

So I look at those compressive tendons and I'm like, if you just remove the compression, they usually feel better, go about their healing process. So I look at the elbow tendons, and if they're getting compressed, find the things that are compressing them, which are usually going to be the things that hurt. You're going to know right away that it's compressing my tendon and it hurts. And try to just take a little break from those, try to relax a bit. I don't know how you can do that in combat sports. You really probably got to take away a lot of things.

But when you take away the compression, you let the tendon heal. And I think even with the isometrics, you might want to do isometrics in a position where you're not getting that, wherever the compression is, where you're not getting a lot of compression. So if it's the insertional Achilles, you wouldn't do isometrics in deep dorsiflexion because it's compressing again. For the quad tendon, you wouldn't do isometrics in super deep knee flexion, although sometimes I do push into it.

So it's this balance of giving it a little bit of a break, but then you always have to work back in the compression as it feels better. Because your tendons have to get compressed when they do sport. It might have been a thing of too much too soon compression. That could have just been it. So just remove the compression for a bit, then slowly build it back up.

But I think the rehab process is similar with the golfer and tennis elbow. And usually, not in your case, but you got to think for a tennis player or a golfer, is when they're hitting the ball, there is so much jerk happening at their tendons. They're just getting yanked so fast when you're hitting a tiny golf ball. There's so much yank on your tendon in that tiny moment. And I think that's what's causing that reaction of bad events.

But yeah, I think you can compare a lot of the lower limb tendons to elbow tendons. Shoulders a little bit different because they're not built the same way. Like rotator cuff, wrist tendons are like a lot of those aggravations are with the sheath of the tendon. Like maybe excess motion or something like that. But yeah, I think you can compare a lot of those things. And it's just listening to pain always. Next day pain. Like someone has those elbow issues, and it's just actually next day pain. It's probably going to be night of pain with those things because it's hard to sleep sometimes.

My case, I can only really pull from my case, because I had it when I was powerlifting. I had it from back squat and bench press. My elbows would hurt, like the inside inner elbow.

James de Lacey56:24

Is that the tennis or the golfer? I don't even know which one that is. I think I had the same issue.

Jake Tuura56:24

Yeah, yeah. So, but my fix, because I remember it hurt so bad I couldn't, I would wake up at night with pain. And I was trying to just get that thing massaged out, trying to do whatever I could, trying to change my grip, trying to not squeeze the barbell down into my back but just relax. And I'm doing back squats.

But nothing really, the only thing that helped was me stopping powerlifting. It's the only thing that helped. So I just got rid of all the compression. I got rid of the compression of a heavy back squat on my elbow tendons and a heavy bench with the pause at the bottom.

I just took those away, my tendon went in healing process. I've never dealt with them again.

James de Lacey57:13

Nice. I love the holistic approach here, Jake, coming to an hour now. Where can people find you and follow you and keep learning from you?

Jake Tuura57:13

Yeah, so pretty much all over, Jake Tuura, last name T-U-U-R-A. Instagram, Twitter, YouTube. Yeah, a lot of my stuff is patellar tendon because that's the one I dealt with the most, the one I care about a little bit, dabbling into the Achilles. And then as we said, I think all tendons are the same. There are definitely dissimilarities, but the concepts of rehab for the patellar, Achilles, they're going to work all the other tendons.

And I guess if they've listened this far on the show, they're just going to hear that it's common sense. It's just common sense stuff that they probably known all along, they just haven't been applying. Sometimes people just need a reminder, someone else.

The hardest thing is rehabbing on your own and thinking that you're making logical decisions. Sometimes you just need someone else to—someone else, you just need to tell your story to someone else who's kind of qualified and they can pick out the obvious thing, which is—I do, not to plug to anything, but I do phone consultations, most of the weekday, and people call in, they've had patellar tendinopathy, they've went through good rehab for a long time and they're wondering why things are still messed up.

And usually there's an obvious thing they're missing. There's a huge elephant in the room and it's just so hard for you to pick it out for yourself. So we get on a call, I find it within 10 minutes usually, and it's like, "Oh, that's what you haven't been doing." And they're like, "How could I miss that?" It's like, yeah, it's the hardest thing to be objective and critical of yourself. Usually helps just to have someone else to look at what you're doing.

James de Lacey58:56

I love it. So if you're having any issues, anyone, make sure you get in touch with Jake. I'll link all the stuff in the description too when this gets released as well. But thanks for coming on, really appreciate it.

Jake Tuura58:56

Perfect, thank you.