Chapter 25 - Metabolism and Nutrition - Part 1

PT Inquest is an online journal club for physical therapists. Nothing that you hear on this show should be considered medical advice. Medical knowledge is constantly changing. Therefore, this show is for entertainment purposes only. Bad entertainment purposes. As a matter of fact, you should probably turn this off now. I've come to my senses, but I've become senseless, and I could give you lessons how to ruin your friendships, and that brief lies conviction. I smug them all away, and I drink my frustrations down the drain out of the way. So I sit in the way in the water, 'cause anyone else feel like me, someone so tired of every change, and just a minute sounds from the streets. I'll sing love out, yeah with every emergency, just sing love out, I'm looking up at that surface, I'm so fucked up, that deep down inside I think it's fine by me, I'm all the most terrible. Welcome to another episode of PT Inquest. I'm your host Jason Torrin, I'm joined as usual by Megan Graham, but not Chris Juno, 'cause he's still on vacation. He's still on the toilet conference. He's at the toilet conference still. He's in Greece, I think. He's doing some island hopping. What else do you do in Greece? So you eat feta? Oh, he sent me a voice note. That's a real voice note this time. Let me pull it up and play it. Oh, sorry, that was actually just him from the toilet conference. Okay, we don't have any mail submissions today. We have the same joke two times in a row, so. Look, but I think it makes it even funnier. We're a toilet humor friendly podcast. We are absolutely toilet positive here. Yeah, all right. What do we got for? Do we have this or that? Do we have some clear to trivettes? We're going to have $4.61 for those counting. So we're going to do some special $4.61 trivia. You know what is interesting? What? Is that by next episode, I think I will have been on over half or more of the PT Inquest episodes that exist. Thanks. Probably retire. Yeah, it's probably retire. How much have you made so far? Like $50. Oh, like negative several dollars actually when a count. You're in the toilet. Yeah, maybe I should have gone to that toilet conference. Boy, but what do you have? What do we have for us? Meg. I was muted first time here. You guys can't see it, but we're going to share a screen and do trivia. All right. I'm going to zoom in because it's really small on my end. It's hard to do trivia with two people. I should have brought Kathy and on trivia. Day. Okay. That's fine. She would have two. We're going to do which came first vocabulary quiz. All right. And if you can't see, there's a little picture of a chicken and a neg. Maybe I'll use this as the picture. Picture in the post. Yeah. That would be good. So we're going to hit start. And we're just going to go first, first person guess. There's 15 questions. All right. Let's do it. Speed round. Let's do it. Hot take. Cold shoulder. Cold shoulder. For sure. Yes. Correct. Dad bod or man spreading. I think it was man spreading. I'm going dad bod. I really think that that that was first used in 2003. No way. No way. 2014. Dad got really popular like a couple summers ago. Well, that was 2003 for those of you that are listening. God. All right. All right. Bridezilla or Bay? I got to go Bridezilla. I think Bay. Oh. It was Bay. Dang. Bay was first used in 1983. Bridezilla 1995. Okay. Had I known that? I would have actually guessed right. So I didn't know that Bay was that old. I didn't either. French manicure or English muffin. Ooh. I'm going to go English muffin. That's going to be cool. French manicure 1981. The English muffin dates to 1858. Yeah. There we go. I'm not going to go back on track. Email or F-bomb? F-bomb for sure. Oh. There's no way. There's no way. Email 1979. F-bomb. Who was using email in this in the in 1979? That's absurd. I have no idea. All right. Podcast or earbud? Like earbud, like the thing that I had at the phone. Like a head phone. It has to be an earbud. Yes. Podcast first recorded, use was 2004. I thought that was a thing. Okay. Yeah. Clap back. Your buds, your buds, 90. Or twerking. Ooh. I'm going to go. I think twerking was older. You think? I think so. We'll go twerking. Oh. No. Clap back 1990. 1990. Yeah. I think that's why we're doing twerking 2001. I think this demonstrates just how not current with pop culture we are. Yeah. We're doing pretty bad. Lotus or swat? Has to be swat. Swat. First ladies. acronym Flotus was first used in 1983. Swat first saw print in 1968. Yeah. The obviously first ladies existed, but the acronym wasn't used as much. Hondo or Zillion? I've never heard someone say Zillion. So let's go Zillion. Hondo? Oh. Zillion has been used since 1934. Hondo, 1996. Well, Zillion has been used countless times apparently since 1934, except for every time I've been around, because I've never heard of that before. Zillion dollars. I hear it. It's like whatever. Whatever. EVO or CBD. You got to be the olive oil. Oh, no way. Look. CBD goes back to 1962. The abbreviation EVO hit kitchens in 1992. Sure. All right. Chilacks or dumpster fire? Chilacks seems older. Ooh. A blend of chill and relax. They speak to 1994 dumpster fire only since 2006. Yeah, that's a that's a bar Simpson stuff for sure. Both of these in our lifetime, unfortunately. Unfortunately. All right. Mom jeans are jeggings. This one's on you, dude. Oh, no. I'm going to go jeggings. I think it's probably jeggings. Oh, dude. Mom jeans have been used to describe unflattering pants since 1995. Tough. Jaggings 2009? That's late. That's later than jeggings. Yeah. Athlete or cosplay? You got to go cosplay. Yeah, I can. Athlete just knew. No way, dude. No way. Hey. Athlete, you're 1976. There's no way. I mean, this is a legitimate reputable source of a quiz. Yeah, right. Valley girl or flower child? I think it's flower child. Nice. It is. He's like, oh, he just knew it was wrong. All right. Last one. Meme or emoji? Meme. It's got to be meme. Yep. All right. Mem 1976. What? Richard Dawkins coined meme. Who's that? Somebody's got a fact check that. Richard Dawkins. Emoji first saw print in 1997. Richard Dawkins created memes. This is blowing my mind. Who is that? He's a British, like British philosopher zoologist. He's just like one of those British dudes who thinks a lot and says important things. Well, it says the internet is confirming. Well, all right. Cool. All right. Well, that was a. My thought he was. Well, I hope the listeners did better than we did. Well, fortunately, we have an article today. It has nothing to do with any of that, but it does have to do with ACL. So, Meg is excited. The number of the strength. There you go. Published in 2026, Scandid even journal of medicine. and science in sports. This is persistent human quadriceps muscle volume deficits following ACL reconstruction are associated with no detectable between leg differences in vast islaterals muscle signaling at rest or immediately following resistance exercise. Say that again. Wow. All right. I just realized how long that was. I was. Yeah. Sometimes you got to take a little breath before you. Where you get going? Background here. People still have long-term deficits after ACL reconstruction. Does that surprise you, Meg? No. Yeah. Neither does it surprise me. So this study was trying to quantify whether these could be detected with hypertrophy signal pathways and we'll get into how they tested that as well as global strength deficits and by global. I mean, 1RM single leg press testing and training. So they're effectively, they took this group of 12 participants, very wide range post ACL injury and they looked at muscle volume through MRI scans. They took muscle biopsies before and after an exhaustive or relatively strenuous leg press exercise intervention and then they looked at the biopsy signal pathways for both the resting and the post exercise. And effectively what they found were that there were still muscle volume deficits specifically in the vast islaterals and the rec fam. Right. Those were the those were full volume. Yeah. Full volume of the quadriceps, specifically rec fam and vast islaterals, not significantly of the other two quad muscles. And the there's no association with the leg press 1RM strength difference nor any of the observable hypertrophy pathways. So the main marker they were using was this M-TORC-1 RAP-MISIN complex-1 which is a indicator for hypertrophy with repeated pathway activation and reduced M-TORC-1 results in atrophy and decreased protein synthesis. So it's thought that this this is a valid marker of hypertrophy is it something that does that mean? Yeah, I'm fine with that. All right. So that was our domain here with us. Fair with us. Yep. So that was more or less that. Thoughts on the title? Too long. Oh my god. Way too long. That's all I have to say. Honestly, I wasn't really I knew this was going to be more like muscle biology one they said human meaning that a lot of this research is typically done in road. It wasn't done in mice. Yeah, it oftentimes is. So I appreciate this was a human study. Yeah. But it was just too long. Hey Chris, I've got a problem. I'm stuck on the International Space Station and I don't think the Dungeons and Dinometers guys are coming to teach a course here anytime soon. That's quite the predicament but I think I might have some good news for you. Dungeons and Dinometers is officially online. That's right. You asked and we answered. Dungeons and Dinometers, a force course, is now available virtually on the sciencept.com. All of the magic of our Dungeons and Dinometers course delivered right to your door and to take at your own pace. That's 15C use words for those of you counting. Oh, I am counting. Head on over to the sciencept.com today and check out the course, dive into all things force testing. Yeah. This episode is brought to you by CSMI Solutions. It's the first five minutes your clinical encounter a throw away on a bike. Enter the humac bike. The resistance is isokinetic as compared to isotonic like a regular bike. Isokinetic resistance accommodates each limb's output. It had given speed, pedaling harder increases the load rather than speed. You can also adjust the crank arm if you need to change the range on pedals. Maximize your patient's time in clinic with a new humac bike. Contact CSMI at www.humacnorm.com for more information. What do you think about the no detectable between leg differences? I don't that is kind of odd. I would just say are not associated. So yeah, I am and we're going to we're going to I guess we'll maybe talk about that when we get to the the actual testing side because they didn't detect like differences. But that doesn't mean that they weren't detectable because they didn't look at certain things like isolated knee sensor torque. Don't get me started on that. Yeah. Well then let's get let's get started on it. Get me started on it. Let's just get started on it. So the testing that they did for strength was one RM like press. Oh, we're going right to it. Yeah, we're just going to go right. Let's just get me started on it. Just go right to the leg press. I'm going to talk a little bit too about the biopsies when we get there. But yeah, we can always you know, we get there. The leg press one RM they did a traditional so prior to the trial day they did a traditional one RM test. This was on the same day. So figure one describes the flow nicely with cool pictures. But day ones the familiarization visit they do their MRI and lower limb muscle volume assessment and the leg press one RM testing pretty typical one RM they do between three and five reps. Then they rest for at least two minutes and then they keep increasing the load incrementally until they get to their true one RM. They based the exercise intervention off of that. So exercise intervention was six sets of eight reps at I was 80% of one RM correct. I think so. Yeah. So effectively that's that's basically failure right. It was eight are eight are theoretically 80% is eight reps right. Hold on. Let's see. Yeah six sets sit oh my gosh six sets of eight repetitions of a unilateral leg press using a load equivalent to 80% one RM for each leg. Yeah. So that's that should be theoretically six sets to failure at eight reps. It probably was a bilateral muscle. Yeah. This is the thing they took a muscle biopsy and they that was a four to five millimeter incision and 150 milligram of muscle biopsy on each quadriceps, bastoslyrails. Then they immediately went into the training and my question for you is actually going to be how painful would that be right after muscle biopsy? It would it would be not fun. I mean the actual muscle biopsy itself is I haven't had one emit has had one. We have been with patients while they have them because that's part of one of the studies that we do and like generally they are not coming into PT the next day like it freaking hurts they have to get local anesthetic. I mean it's not a super small procedure like people pass out all the time getting time. So I and I don't know off the top of my head how big we're taking versus what they're taking for a comparison. But I think that what we're taking is pretty standard. So to do that not on both legs right before to go immediately into it and then to have another one right after to me is kind of crazy. But yeah. I mean what it effect the results of this study. I mean they're doing they didn't speak to I don't believe that somebody couldn't do the prescribed weight. Yeah they did not say anyone anyone tapped out. So it may have been asked but but doable. Ask but doable. I mean they must have paid this these people a poop ton of money because like a $20 Panera gift card or it leave maybe 15 don't get too good. Yeah right right. You get you get paid for your entire soup bowl with one gift card. Yeah and those leave permanent scars those muscle biopsies. Yeah. Amit still has his and he's not a big scar. If you're of interested a woman I mean it's like they're right for that. It kind of looks like a scope scar. Okay yeah it makes sense. But it's pretty gnarly. Well they got them after in different locations. So you're leaving with four punch biopsy scars. Yep. That's brutal. Pretty good. But yeah I do wonder why I wouldn't have really had a problem with the leg press one or him testing if they're just using it as a means for the exercise. Oh I don't know that's what they were. They did though talk about that there were no differences in strength between legs. It's like a talking point. Well they said that it was not statistically different but when you looked at whatever table it was or was that not even in a table? They they said what the 1 RM was and it was the average was a little bit lower on the ACL side It just wasn't statistically significant. I think it was like 131 oh here we go No associated differences are detected a maximal strength like press between control and ACL our legs control 133 plus or minus 29 kilos ACL 125 plus or minus 25 p value 0.192 So it was trending towards significant no They have in the conclusion on the abstract that They're basically trying to say that there were persistent muscle volume deficits But no detectable differences between legs and unilateral leg leg press strength So I kind of feel like they're trying to paint up this picture that there's differences in size But their strength was similar But to me it's a little Like don't love that well, let's let's talk about it then because What is a leg press if not not an isolated quad exercise? It's a leg press. Yeah, it's it's not an isolated quad exercise and it's if it's a shuttle based leg press Let's say it's a shuttle because that's the picture that they drew and figure one That's a hip exercise For sure this at least for we're taking the figure for for what it is. It's like knee lined up over toe Hip flexion getting to like 120 at the end of the shuttle knee angle to like 90 or so probably pretty standard for a leg press So, you know, there's not much detail on yeah, the performance of it What would they have been able to do a leg extension? I don't know after those double biopsies But if you're testing strength then like that's true and we're trying to look at differences in that muscle in that muscle Specifically the quadriceps. Yeah, if we're looking at vastus lateralis hypertrophy Then why wouldn't we look at vastus lateralis strength? We didn't look at vastus lateralis strength We looked at single leg press to like activate vastus lateralis in a way that is Going to give you markers of hypertrophy within that muscle. It would make sense to do a more rectus and VL focused activity. Yes, so a leg extension I wasn't gonna say it but yes Yeah, because this is a big stensor. This is you know, glute hamstring There's some calf that can be making up some of that too. So that seven percent Volume deficit that they found in the rec famine the VL well What if there actually was a force deficit in that area and it just got covered up because the hip extensors took over a little bit more in their one They're a leg press testing. Yeah Hey, Chris, I'm sure you've heard about vault before their four-stex Dynamos and Nordboard are commonly utilized in PT clinics. Hey, don't forget about the four frames You can't forget about the force frame or the previous name of the force frame But what most clinicians don't realize is evolved also has a completely free and completely awesome exercise prescription platform called move health Move health is a one-stop shop for clinicians to create patient programs, track progress, and even monitor adherence and compliance to help justify RTM codes Not to mention you can also assign patient reported outcome measures directly to the patient profile to assign before or after they come in for their visit See you later paper forms no more paper L.A.F.S And if your clinic does have any vault systems any of the patients can view their own objective data as well So if you're interested to check it out head over to movehealth.com and mention PT inquest when you do and you'll get 33 days of any other system Oh, yeah, you're welcome friends All right now back to the podcast I got a little bit of beef with their graphs So like on figure two so this is a relatively small which is this 12 people Yes, if you're doing paired samples Like connect the dots of who's who yeah because the the p values are Low and it's clear that there's maybe three individuals Who are maybe around a year out who are really driving the relationships here Where they have a large loss of or persistent muscle volume loss compared to the people who are two plus years out and it's It's a little muddying to just see a bar chart Like it would just be nice if you're doing paired things to show The involved versus the uninvolved sides. Yeah, I agree Yeah, the yeah figure figure two Would have liked to I mean you have the individual participant data but to show the the link between the two um And then man as we get into figures four and beyond I'm good like I can't read this. I don't know what's going on It's too much It's very much really Muscle okay. I never was in the muscle biology world at all until I got to my lab and we do a lot of work with Obviously our neighboring muscle physiology lab and they always have this many figures Yeah, and they're crazy I'm like I can't it's too busy for me, but this is pretty par for the course For any sort of muscle physiology or Cellular type paper Yeah But long story short they didn't find any differences They did not but I want to I want to reference for your face signals, but your work on the Rear foot of the split squat if we can if we can uh kind of jump over to that being a single leg press sure You found that even in in the healthy side The hip extensors made up about 50% of yeah the work, right? And then in the ACL side it was a higher percentage than 50% Yeah, it was like six something yeah, so I think all when we say and that's why I want to go back to the like Me picking at no detectable between like differences. Well, yes They did not detect it does not mean that it was not detectable I think that's the semantics that actually matters to me is like you saying that something is not detectable indicates that you You left no stone on turn There was a very clear stone that was not Turn was was on was on turned was on turn Yeah, I also think it's interesting. I would have loved to have seen a Like control group that didn't have an ACL - because Is this some sort of systemic? Yep dampening that's happening bilaterally Or is this something that's only affecting one side versus the other If you had someone who had no injury history would Like their values be different Now mega you saying that there might be two flat tires or what no, I would never say that I thought it was time to retire to flat tires it is okay If they are retired that's not even a saying anymore. It's been wiped from the internet. Okay. Got it. Yeah Yeah, so what what came first two flat tires or chillax Two flat tires to either goes pre-1994 probably Probably one of the old heads. Yeah Inclusion criteria that are relevant here They did not strat five out graph type because obviously they all had 12 participants and that would be super underpowered as it already was underpowered The which we'll talk about shortly But 10 out of 12 had hamstring graft So do you think It was one of them had a bone patotanabone and the other they said was unclear Which means that that was probably one of the individuals who was closer to like the five-year mark and they were like We can't see a scar and they can't remember what kind of ACL reconstruction they have they didn't even have an ACL reconstruction The second was unknown like that's so weird maybe they had an aligraft and they couldn't remember from what I mean I guess but then it would be in the category of just say yeah, that's I mean that that's weird It is weird I also thought too if you look at the participant demographics or characteristics These people were doing freaking horrible. Oh, yeah, the IK IK DC 71 on average This is also where I feel like we're missing some context just having a mean and a standard deviation Yeah, when you have people that are ranging from eight months to five years post-op Yeah, like could we give a min a max a Mean and a standard deviation perhaps yeah ACL R553 IK DC 71 these people are not okay So also how are they getting that single leg press strength to be roughly equal to the other side? I don't I'm also like there were Two or three people that were really off on the muscle volume and I'm like were those people super outliers on these PROs. Yeah. And that's like someone put a zero for ACL RSI, which can happen. It definitely can happen. And then we are dragged. So I don't know, I hate when it's just well, a single standard deviation on their ACL RSI was 26 points. So basically, everyone between 25 and 75 was the bulk of the the the bulk curve there, which was obviously not normally distributed anyway, but that's so bad. That's really bad. Yeah. But the first thing that jumped out of me was the low IKDC. And then I looked one one row up and was like, oh my god, these people are not doing well. No, they're doing really bad. That's why they volunteer to get bilateral muscle biopsies. Yeah. Please help. Maybe this will help. Well, I was initially interested to read this because me and I met were just talking about this the other day with we do sometimes see that people have persistent atrophy. Even though their strength has recovered to a larger degree. So I don't necessarily disagree with what they said. They just didn't maybe test it correctly. But we do see that people don't get their full muscle volume back. But their strength is more symmetrical than their atrophy is leading to a cure. I agree. And actually, this is what I wanted to talk about partly is that it's it seems to be easier for us to restore force production than it does muscle volume. Now, yes, from the the performance, the strength and performance side, one of the first thoughts is like, but yeah, but if you just increase cross sectional area, then like that's going to be well correlated with the amount of force output anyway. And yes, it's the answer to that. But based on some of the other talks, like we had we had Chris Fryon for the Belgian blue episode. Yeah, there's some like hormonal stuff that's also going on that's probably down regulating the ability to hypertrophy that muscle in particular. But we can still reduce we can still restore force production. So what is the mediator that's most important to us? Would you rather have a full-size muscle with poor force production or a smaller size muscle with good force production if you had to choose between the two? Obviously, we want both to be good. But what would you what would you rather there? I mean, if I'm not playing sports, I'll take the size. I'll take the strength. Yeah, I mean, I would assume you see similar stuff with Achilles too. I mean that calf atrophy. It's even more it's even harder I would say to get because even in a healthy gastroxolius, it's a notoriously difficult muscle to hypertrophy. It requires like a ton of volume week after week. And then you also have this issue where like at least with the ACL, the thing that you're trying to to get bigger is not directly connected to the repair site. Yes, so that's very true. Yeah, with Achilles, it's like, hey, it's directly attached to the repair site. Yeah, you're a little rate limited because you're waiting for things to heal for loading. You're right. Exactly. The quad is, you know, you can strengthen the quad and keep the ACL fine. Yeah. But yeah, we saw this a lot and we were struggling. This is kind of what we started playing around with using myoreps within our rehab because we were struggling to people feel like a pump. The quad. Yeah, not that like a pump is indicative that you're going to get muscle hypertrophy. But when you're doing an exercise and you don't even feel it in the area or see maybe an acute kind of influx of whatever metabolites into that hospital, that worries me. And so we really started doing more of this high low or low load high volume stuff. It sounds like it's moderate load high volume stuff based on how you described some of the myoreps. It's pretty. Okay, around 60 to 65% one are in that's moderate load. That's okay. It's moderate in high volume. And that has been literally the one type of exercise that in cluster sets. But mostly myos. Yeah. That people are actually getting a quad pump. And I have nothing other than just anecdotal clinical experience to say that that is helping restore size. But I do think there's something to that that we don't do a lot of that in the rehab setting. We're doing more strength based. And so we may be missing some of that hypertrophy component, especially when we're dealing with all of this cellular mess that's happening that makes it even harder to do it. So I would love to look at that more. Well, and I think the aspect of training frequency throughout the week to have to talk about when it comes to hypertrophy. Like, yeah, the set rep scheme, the quality reps, like all that stuff is great. But if somebody's then only doing that twice a week, it's going to be close to impossible to get that level of hypertrophy that you're looking for. Yeah. We'd rather than like a three to four to maybe more than that times per week. I agree. We also struggle with people just not eating enough through rehab or being in maybe a physiological state to put on muscle, which I think is like that nutritional aspect is big too. Yeah, definitely. We have so many people lose mass amounts of weight throughout surgery, unintentionally or intentionally. Yeah. And it's like, okay, we will never build muscle if you are in a catabolic energy deficit here. Yeah, so enough. Yeah, those aren't good times. No, but yeah, I mean, I think going back to the muscle size versus output realistically in sports, we have just enough time through a store force output. Like, yes, it's cool if hypertrophy is one of our goals. But like you've seen so many long, long rehab cases. If we used muscle size as criteria to advance or criteria to return to sport, we would probably filter out a large number of people. It just like couldn't get there. Yeah, no, I agree. Even if they had the qualities like strength and rate of force development and these like kinetic qualities that we are associating with a successful rehab process. So it's like, yes, they're correlated, but to me, when I think about some of these like rate limiters of advancing to the next step of rehab or return to play, I also want to be careful not to set the bar too high. And I realize that that's a, that's an odd thing to say in an area where we're not setting the bar high enough as a, no, well, the more you know, I mean, we played around with, you know, all of this progressive return to sport versus return to performance criteria for ACL where it's like, okay, our basic return to sport is our horizontal hops, our strength. And then when you move beyond that, like looking at the different counter movement jump metrics, and I'm like, dude, if I held somebody until their RSI was symmetrical, we'd be there for 18 plus months. Exactly. So yeah. And there's no evidence to say that if I keep you and get this symmetrical before you go back that we're helping anything, like I think it's important. I lie on the, the side of continue to monitor it after you've gone back and make sure that it eventually gets there, but it may not be something that's keeping us from allowing you to play, but you just need to continue to try to close that last 10%. I agree fully because this is the, this is the conundrum that we're in. We have the technology, it's clinically accessible now to identify more deficits than we used to be able to do, but every deficit that we identify doesn't necessarily carry the same weight. The really good example might be like a hip abductor strength deficit versus a knee extensor strength deficit. We already know that one of those is more important than the other. It's the hip, right, Meg? So not everything that we find can carry the same weight as like a risk factor for secondary injury. The problem is that we don't know what does. We also don't know of these successful cases of people that go back how many deficits still exist and just weren't a problem. Maybe that's because of exposure and all the other variables for why they didn't retire, but there are a bunch of people running around without equal, you know, P2 propulsive impulse on their single leg conundrum and jump. I don't have the evidence to say that just because we still have this asymmetry, we should hold them out because then maybe you're talking about bringing somebody back at 18 to 24 months and that's just not realistic. So what are there? There are people on the end of the yeah attached to the data, which is hard because you're like, okay, everything to be perfect. But yeah, like I think we maybe had one person out of like 30 something who had symmetrical drop vertical RSI. - Yeah. - Single leg. And it's like, well, then it's not a realistic metric for return to sport. - Yeah. - Because one rehab wise, no one can hold me one that long from an insurance perspective. Two, I have not seen anything like that. - Not even in a professional sport setting. There's no way. - Oh hell no, they'd be like, they're good. - Yeah. - So yeah, I'm very much on, similar to you. It's like, it's important, I think, to know. - It's a board to know, - And to continue addressing it. - Yes. Eventually try to get there. - Yeah, but we have to have some threshold. It's like, geez, man, yeah, good enough. It's gonna have to be good enough here. We've addressed all these other things that we think are very big factors. And these other ones here, like, yeah, you're still having a little bit of hard time changing high momentum in a short period of time. That's understandable. We'll continue to work on that. But at a certain point, you're playing your sport is probably going to help work on that too. - That's, yeah, I agree. And I don't know. I think people that don't do that type of testing a lot may think differently, but like, Aspitar came out with their whole ACL return to sport checklist. I'm like, who tell me who can pass a 3D biomechanical assessment of a double in single leg vertical and drop jump with symmetrical biomechanics? We're not even just talking ground reaction forces. - I'm talking about kinematics. - Kinematics and joint level kinetics. Yeah, that's no freaking way. - It's not happening. Unless they're doing surgeries differently. That could be the only explanation. I mean, they are build different over there. - They are, but I'm like, that's just not, this is not gonna happen. - Not gonna happen. Yeah. - It's gonna happen. - We have to figure out what our non-negotiable things are. And then like you said, there are still gonna be deficits. We use those to guide what we're gonna continue to work on and just accept that there's some level of risk. Like that's all sports. - Yeah, like yeah. - Minimal effective testing. - MET, a couple of mats. - Couple of mats. - One last thing I wanted to highlight, this is about the paper in the limitations quote, "potentially being underpowered to detect between leg differences." And that was a very nice way for them to say that because they then admit that they absolutely were underpowered to detect between leg differences. Because the sample size calculation was based on detecting an exercise induced within leg change in protein and phospholoration status rather than difference between the ACLR and Contral Edel leg. So yeah, it's probably underpowered. But that's okay. - All that to say. I mean, I do think it's interesting, I like the question they were trying to ask. - Yeah, same. - Like in people who are farther out because I think there's a thought, they referenced a paper from Arlab, not Arlab, you are being UK, not my lab. People much smarter than me. But and I think a lot of people are looking this acutely that there's that dampened hypertrophy response. But I guess they're trying to look at long term. Does that change? And then maybe you are able to. But I just think there's so many factors going into it at that point that the muscle does change after surgery. - Yeah. - And I don't think it ever goes back to its previous state, but I don't think we really understand how to identify who is gonna have these enormous changes. Some people don't have very much at all and some people are seemingly not affected. So it's just like a range. I don't know. Some people look like poop two days post-op and everyone did the same thing. So. - Everybody looks like poop two days post-op. That's be real. - That's true, but some people look more like-- - Some of you, some are more of a, this is tragic, tragic. - Yeah. - Other limitations they noted, the later markers of hypertrophy that start to increase like between one and three hours after exercise, they can't comment on that because they just did an immediate 10 minute post exercise assessment, but-- - They didn't go squeeze a little more to a third muscle. - Yeah, they didn't put a fifth and a sixth hole in people's legs. - This is called the Swiss cheese trial. - Oh my god. - Get it? - Yeah, the Swiss trial. I'm just making the macronym. But yeah, otherwise, I think it was an interesting study. It had a couple picks, it had a couple things, but you know, another-- - Yeah, I mean, that's tough. Tough, really hard to get people to volunteer to do four muscle biopsies. So-- - Yeah, so. - I mean-- - You get a new data set next time. - Yeah, respect. - Good to be with you, bodies in the house. All right, well that's been another episode of PT Inquest We Made Jason Torrey as usual, joined by Chris, you know? Wait, we weren't joined by Chris today. - Wow. - And Chris is here. - He knows here. - He is here, Basil is somewhere in the room. - Oh, Chris actually did send me a voice note. One second, let me just pull it up. - Oh, I believe you every time. Every time, I think you're actually going to miss-- - Oh, sorry, that was just him from the toilet conference. (laughing) - Oh, honest agreement, we can reach out to PT Inquest. Chris is at same.js here, two, seven, magazine at next. And I am at jsonthorrey.dpt. Send your questions down the mail hole at mailhole. PTInquest.com and go check out the sponsors for the episode. See us in my solutions and follow new files. Don't forget to head on over to the website, ptinquest.com and check out our show notes for each episode. We also support us on Patreon, or you can join our Discord server and make suggestions for future episodes and also buy Meg a ticket to Greece so that she can go on vacation to that toilet conference too. Oh. Head to patreon.com/ptinquest every little bit helps. The opening of closing songs is the science of selling yourself short by lesson Jake. Thanks again for listening. We'll catch you next time on our episode of PTInquest. ♪ And I'm my lover's baby man ♪ ♪ 'Cause I'm my lover's baby ♪ ♪ And I'm my lover's baby ♪