Everything You Know About Knee Pain Is Wrong

Pain is influenced by factors like sleep, stress, and activity levels, making the nervous system more sensitive. Pain serves as a protective mechanism, not always indicating damage. The brain decides how to interpret pain signals, which can be influenced by past experiences. The key concept is 'load versus capacity,' where pain arises when the load on a tendon exceeds its capacity. Capacity can vary in different ways, such as tensile load, elastic activity/velocity, compressive load, and repetitive volume. The speaker also introduces the idea of 'sensitivity of capacity when cold'.

There are two types of capacity: actual and effective. Actual capacity is the point at which a tendon physically tears, similar to how a material snaps. Effective capacity is what we perceive as pain and is highly variable, influenced by factors like stress and sleep. Warming up increases effective capacity, making the tendon closer to its actual capabilities. Pain, especially morning stiffness, is often related to a reactive tendon rather than structural damage.

A reactive tendon is the first stage of tendinopathy, where the tendon protects itself. Tendon cells (tennocytes) release proteoglycans and glycosaminoglycans (GAGs) that attract water, causing swelling and stiffness. This water increases the tendon's volume, dispersing the load over a larger area and reducing stress. Morning pain and stiffness occur because prolonged inactivity allows water to accumulate. Movement, such as isometrics or resistance training, helps shift this fluid and reduce stiffness.

Isometrics increase the effective capacity of the tendon through a neural effect, not by changing its structure. They are low-risk because they involve non-repetitive, constant load. Isometrics desensitize nociceptive nerves in the tendon, effectively telling the brain that the tendon is safe. They also help re-educate the quad muscle to contract smoothly, which can be impaired in chronic tendinopathy.

Tennocytes produce collagen when stretched by the right amount of load. Too much load will trigger a reactive state. Heavy Slow Resistance (HSR) training builds the tendon's structure by stimulating collagen production. HSR is favored because it's measurable and controlled. While HSR builds structure, plyometrics are crucial for teaching the nervous system to trust the tendon. A progressive plyometric program, starting with low intensity and gradually increasing, helps adapt the nervous system quickly.

When tracking pain, focus on the overall trend over weeks and months rather than day-to-day fluctuations, which are normal. The speaker has moved away from daily morning pain tests, as they can be noisy and lead to unnecessary discouragement. Instead, he advocates for using the warm-up during training sessions as the primary test. If the tendon warms up and pain decreases during activity, continue. However, if max effort activities cause pain, stop to prevent further damage. The general progression for recovery is isometrics, followed by heavy slow resistance training, normal lifting, submaximal plyometrics, and finally, max effort jumping, gradually increasing volume.