HRT Can’t Fix Your Ligaments: The Diabolical Role of Estrogen on Connective Tissue

This system runs on a completely different timeline and adaptation window than muscle. It is a system that has been accumulating debt for years. And finally, you know, on a random day decided to collect on that. And this is why so many women in midlife, they describe midlife as like falling off a cliff. They describe it like all of a sudden, my body doesn't feel like mine anymore. The half life of collagen in a tendon is something like 50 to 100 days, which means that you cannot rush connective tissue adaptation. You cannot catch it up after a week of hard training. You can't compensate. The difference between those two states is what adequate mechanical loading does for tendon collagen and what inadequate mechanical loading does for tendon collagen. You want uncooked spaghetti. Okay, friends, welcome back to another solo episode. The tendons episode was such a hit that I thought I would do another solo episode about my favorite ligaments. And I want to talk to you all about ligaments. I want to talk about hypermobility. I want to talk about all of the things that all the questions you have ever thought about these wonderful tissues. Let's get into it. Okay, I want to start by telling you about a patient. We're going to call her Claire. Okay. Now, Claire came into my clinic. She was 43. She had been training consistently since her late 20s, three, four, sometimes five days a week. You know, she knows her way around the gym, right? She was not someone who ever skipped leg day. She didn't avoid weights. She didn't treat exercises punishment. You know, so she was somebody who genuinely loved working out. And I remember she came into the clinic. It was a camera. It was like a Monday morning. It was in the morning, my morning shift. And her right arm was slightly pulled in towards her body. You know, the way that you hold an arm when you're sort of nursing it or your shoulders a little angry and you're trying to give it a reason not to be angrier. When she came into my clinic, she had been up since four for in the morning because of her shoulder. Now, obviously, it asked her what happened and she said to me, nothing, like I can't figure out what's wrong. Like I wasn't doing anything new. I wasn't doing anything extreme. I went to the gym the day before and she was pressing like the weight that she's pressed, like, you know, a thousand times before that. And then all of a sudden it just wasn't right, right? And then she showed me like, and now I can't lift my arm, you know, without it screaming at me. And for Claire, you know, in that moment, she really looked at me like she was waiting for me to like find the thing that she did wrong, you know, like she was looking for me to do all the ortho exams for me to show her the error, you know, the mistake that would explain why such a strong and well-trained committed woman suddenly had this like shoulder that had decided not to work in the middle of a completely, you know, ordinary workout the day before. And, you know, as a doctor, that's what you do. You run through all your orthopedic testing. You run all her range of motion, active range of motion, passive range of motion, you're trying to test for muscle insufficiency, etc. I end of the story is I never found an error and never found a problem because there isn't really a test to test for ligaments, right? And I'm giving you a little spoiler there, right? What Claire had is what I would see like some version of that every week in clinical practice. It's not like bad form or reckless training. It's a result of a system that nobody told her existed. Other than me, of course, I eventually told her, right? And finally, you know, on a random, you know, day decided to collect all that, right? And that's what this episode is about. It's that system. If you have ever had a joint that started hurting for like no obvious reason, you know, a knee that suddenly hates the stairs, an elbow that suddenly is bothering you while you're playing tennis or a hip that starts, you know, talking back to you during your morning walk or your leg day, this is the episode for you. And I will start this episode off by reminding you that this is not because you're aging badly, you're not doing it wrong, you haven't done anything wrong. But this is because society, and I would say, health at large for women has never taught you that muscle and connective tissue are two completely different systems, right? They are in two completely different timelines with completely different training requirements, okay? And until you understand that, you will keep asking, what's wrong with me, what did I do wrong? Or you blame yourself and you'll say, well, I guess it must be paramedicos. I guess it must be because I'm aging. And you're never gonna find answers because you're never gonna find answers with that, okay? Really what's happening is that your system, the connective tissue system, just ran out of runway, okay? So before I get into the biology, which I know you're frothing at the mouth to talk about ligament biology, I want you to do something for me. I wanted to just think back. So over the last two years, right, of your training, I don't want you to think about the wins, although I do love talking about wins, but I want you to think more about the friction, right? I want you to think about maybe it's an ankle that started, you know, you started noticing your ankle during loaded carries or squats and you just started like working around it, right? Maybe it's your shoulder that gets a little twitchy, a little janky, not an official term, by the way, I just love the word janky. It gets a little janky or a little twitchy, doing an overhead press. And maybe you've started like compensating. Maybe you're starting to keep the weight a little lower on that one side where it's starting to bother you. Or maybe it's your knee, right? It's a knee that doesn't exactly hurt. There's nothing wrong with the knee, but on a random day when you're doing Bulgarian split squats or lunges or maybe you're even going up and down the stairs, you start noticing it, okay? So what I want you to do is I want you to think about how you've explained those things to yourself, right? Most of my patients, most of the women that I talk to have some version of the explanation they use the same language. It's like my body's getting older. Oh, I just need to stretch more. I slept on it wrong. I would jokingly inclinic talk about these sleeper injuries, right? I was like, oh, I turned the wrong way. Now I've thrown out my neck. I stepped out of the bed and now my ankle, I rolled my ankle, right? I want you to think what has the explanation been? And even I've even heard, which breaks my heart because it's not true. I've even heard the explanation of like I just don't think I'm built for lifting weights or even lifting heavy, right? The reason why I'm taking you through this exercise is because I want to offer you a different explanation, right? I'm not lowering the bar for you. I'm not coddling you. I'm not trying to give you reassurance. You know, it's not there there. This is more of like a clinical fact. You're not training in the right way, right? You were training only one system, the muscular system, while another system, that system that actually holds the muscle in place is falling behind, right? And that system, the connective tissue system, doesn't really come with obvious symptoms until you're significantly behind, there's a significant delta between the muscular system and the connective tissue system and you don't even realize this happening until you start feeling pain, right? So muscle as you probably are aware, works on a completely different timeline than connective tissue does, right? Completely different requirements. And honestly, for, I want to say 20 years, but it's probably like forever. The fitness industry has really sold, like we'll go back to the 80s, right? It's like the fitness system, like the fitness industry has really sold women a protocol that just served your muscular system, even your cardiovascular system and like completely disregarded your connective tissue system. And so we're gonna give that connective tissue system a name. This is something that I refer to as the JTL, okay? Then you can start using it too, right? It's the JTL and that stands for joints, tendons and ligaments, okay? And we need to talk about the JTL, okay? So here's the story that I feel needs to be unwound, right? This is what we're always told. We need cardio, we need to tone, we need light weights, like I'm getting an angry tick already, but okay, we need light weights, high reps, Pilates and bar. And it's like all of this category of movement that was essentially marketed as like, all the benefits of exercise, none of the intimidation of a barbell, you know? It's like, it's like in the same way that, you know, when you think of like meat, it's very like meat, fire, barbecue, man, you know? It's like, no, actually meat's really good for women too, right? It's the same thing here. If you were in a gym, you needed to stay away from the heavy side because that was for men. And you know, lifting heavy weights is gonna make you bulky, right? It's like, I'm gonna give myself an eye roll so hard that I'm gonna give myself a lobotomy, you know, if I say this again, it's like, ugh. We're not gonna spend too much time in the anger here, okay? Even though I think that this is done a huge to service to women, but the anger is not useful. I do think that clarity for you is very useful, okay? And so clinically, here's what I wanna tell you. repetitive low low low. movement without progressive resistance does not strengthen your connective tissue. Okay? It actually uses it, right? So every spin class, every bar session, every walking lunge with the pink three-pound dumbbells, none of that was ever building infrastructure of your joints, your tendons or your ligaments, right? It was really drawing from them on repeat for many, many years. So let me tell you about another patient. We're going to call her. What are we going to call her? We're going to call her Diana. Okay? She's 51, okay? She's been a dedicated exerciseer her entire life. She spins five days a week, better part of the decade. Maybe she was at one point, a member of Orange Theory. Does some yoga and nothing wrong with. Nothing wrong with Orange and Theory. Don't come after me. I'm just saying. You know, it's like the high intensity stuff all the time. Maybe she was doing body pump classes, right? By any external measure, you know, you'd call her a fit woman, right? X-care of herself, never been sedentary. I remember her coming into my clinic, she had bilateral knee pain that had been building for like a year and a half. It was like 18 months where she was like, something's not right. It's not acute. You know, it's not like she fell, she had a misstep. It was just progressively getting worse and worse and worse. She was under the care of physiotherapist who'd been treating her symptoms around the knee. Her GP had told her, you know, take it easy on the knees, you know, as you get older. This is like kind of what happens. She had had, by the time she came into my clinic in orthopedic surgeon, she had also seen had a consult and the ortho had set to her, you know, we've have mild cartilage like on imaging. You're the cartilage in your knee is thinning. Maybe you want to consider like cortisone injections. So she was getting kind of all of these different, you know, opinions from different physicians and different, you know, different disciplines. But nobody had ever asked her what she was doing in the gym, right? Nobody had ever assessed whether her connective tissue had been asked to do the work of progressive overload, right? No one had ever explained to her probably because they didn't know themselves that 20 years of high cadence, you know, low load repetitive movement had been creating this like cumulative mechanical stress on her knee structures without ever giving those structures the appropriate mechanical stimulus. They need to remodel and strengthen in the right lines, right? So I'll say this, Diane's connective tissue had been basically underfunded for 20 years in a gym, in a gym that she showed up faithfully to, right? So that is really the villain here, right? It's not her, she's not lazy, she's not making bad choices, she's making great choices. However, when you are a woman in a fitness culture that hands women protocols only around aesthetics, right? Here's how you can be healthy, but Aka is really smaller and we avoid heavy things. We call that, we call that health. This is where a lot of women can go wrong and that can be so particularly unforgiving in midlife because estrogen, your estrogen levels are now in midlife declining and we'll kind of get into something that I like to call the estrogen paradox, but your estrogen generally compensates for this in your younger years, right? It's supporting like with high estrogen, it's supporting collagen synthesis kind of in the background where you don't ever sort of think about it. And then when you get into parimenopause, that compensation stops happening, right? The hormonal scaffolding that was propping up that connective tissue health prior begins to start to decline and give way. And suddenly all that cumulative debt that has been building up for decades in your connective tissue, lands kind of, you know, in your knees or in your shoulder or in your neck or in your wrist like all at once, right? And this is why so many women in midlife, they describe midlife as like falling off a cliff, they describe it like all of a sudden my body doesn't feel like mine anymore, right? And it's because that connective tissue now doesn't have the appropriate hormonal scaffolding to hold it up. And so we start to see accelerated breakdown and she's not doing anything in the gym that's actually supporting that connective tissue to remodel in a healthy way, okay? Let's get into some of the biology. I want you to really understand what these structures are, how the JTL behaves differently than muscle and what you need to do with your body, what your body needs to keep the JTL functional, okay? And by the way, if any of you used to watch Jersey Shore back in the day, remember it's Jersey Day, I don't know if you remember like JTL is sort of derived from GTL. I don't know if you guys remember GTL, Jim Tan and Laundry from, I don't even know why I remember this, but JTL is that's where it comes from and it's just like, that's my little Easter egg for you. If you remember that great, if not just know JTL joins tendons and ligaments. Okay, so let's talk about, we've talked about tendons before. We know that tendons tether muscle to bone. It's sort of like the bookend of, it's, you know, the muscle is not muscle all the way through. It's like you have a muscle belly. And at the end of each muscle, you have tendons that are going to attach to bone, right? So a tendons job is to transmit the force that your muscle generates onto the skeleton, onto the bone to make that lever system work, right? Without healthy tendons, your muscles contract and the force doesn't go anywhere, it doesn't do anything useful, okay? Ligaments connect bone to bone. So they will tether bone to bone. The job of a ligament is to guide and constrain joint motion. So it acts like a guard rail so that when you're moving, the joint moves in the arc that it was designed to move in, not just wherever gravity and momentum decide to take it, okay? In both cases, both with tendons and especially important with ligaments, these structures do not contract, okay? So muscles we know that they contract, ligaments do not contract. Ligaments also do not generate force, muscle generates force, right? A ligament responds to force, okay? And so the health of ligaments, and this is also true for tendons, the stiffness of ligaments, and their capacity to transmit and absorb load is all determined by its collagen architecture. So what that means is how the collagen fibers are oriented and organized, how dense those collagen fibers are, how well they are cross linked, right? And this is where the difference from muscle to ligament becomes really, really important because they are not the same structure. Muscle, we talked about this in the tendon episode, but muscle responds to training on a timeline of like days to like, maximally, maximally, like a week or two, right? The neural response, right? That neuromuscular response is almost immediate. Your body will learn to recruit more motor units more efficiently within like the first few training sessions, right? And then hypertrophy follows that, right? hypertrophy follows that strength gain after weeks. So you have like strength gains, which compound over months, you have hypertrophy gains, of course, which compound over months and years, etc. Your muscle is very responsive that way, right? It is built, like muscle is built to adapt that way. Connective tissue is on a, like, literally like on a different planet. It's on a different schedule. So tendons and ligaments and especially ligaments have a much lower blood supply than muscle. Okay? So there is some, you have some tendon blood supply just because it's right beside the muscle ligaments. They almost have, like, they do have a blood supply, but it is very, very. Low compared to muscle. When we look at collagen turnover in connective tissue, meaning like how fast the collagen fibers can adapt and we can create new ones, this is measured in weeks to months, not days, right? Like it will, you can't compensate. And especially on the opposite end of the spectrum, if you've been under loading with those little pink two pound weights, you cannot compensate for months of under loading with like one or two sessions, right? And this is why injuries really tend to happen in, even in well-trained women. Like if you remember Claire, you know, years and years and years of consistent training, right? And she failed her with like literally no warning, right? Her muscles were ready for the load. Like her muscles can handle it. It's a weight that her muscles has seen hundreds and hundreds of times before, but it was her connective tissue that had been falling behind silently, by the way, like with no warning signs for longer than she knew, right? So this is, this is really, really important because this is the timeline mismatch, okay, between muscle adaptation and connective tissue adaptation. And in my professional opinion, this is the most under-disgust concept in women's strength training because we talk about mechanical load. You know, we talk about mechanical load, we talk about mechanical tension, but when a ligament or a tendon is placed under tension, so when a force is pulling on it, your ligament is going to deform a little bit, okay? The collagen fibers in the ligament are going to stretch, like those collagen fibers are going to stretch. Now, for my nerds who want to know, these are called mechanoreceptors. Okay, so these are basically little like little receptors in the collagen fibers that are going to start firing once they are stretched and then the nervous system is going to respond to that, okay? And this is kind of the cruxia. Over time as you are firing off those mechanoreceptors as you're stretching with repeated appropriate loading there's something called a fibroblast inside these tissues and these are the cells that are responsible for building collagen. They are literally going to receive the signal like, hey, we keep getting this signal. The mechanoreceptors keep firing. We probably should produce more organized, denser, stiffer collagen. That's how collagen, that's how connective tissue gets stronger, okay? And like I love yoga, but you don't get stronger connective tissue from yoga or pilates or foam rolling. Not from gentle movement, like you get it from load and I'm sorry to be the bear of bad news, but it has to be progressive load, ideally compound movements, which we'll talk about that, and then appropriate dosing for the load to become more challenging over time. Okay? Without load, without progressive load, collagen turnover continues because collagen always turns over, but the new collagen that you're producing will not organize itself along the lines of force. It gets kind of messy and sloppy. So your collagen actually gets a little, it gets less stiff, okay? The tissue gets weaker and something that we call compliant over time. So we have more ligamentous compliance over time, meaning that the ligament gets a little bit softer and weaker and you can kind of push it around. It doesn't get stronger. The way that I like to explain this is, imagine like a handful of uncooked spaghetti, okay? It's organized, you open it from the package, it's all organized parallel and rigid, right? Now you put it in boiling water, what do you have? You have soft, disorganized pasta, spaghetti, unable to hold its shape, right? The difference between those two states is what adequate mechanical loading does for for tendon collagen and what inadequate mechanical loading does for tendon collagen and ligamentous collagen, right? You want uncooked spaghetti, okay? So if we were to think like, what's the ideal kind of ligament? You want it as uncooked spaghetti and this is why I love compound movements, okay? So let's talk a little bit about compound movements. When you sit, let's say to do a leg extension machine, so you're sitting in it and your knees are bent and then you're trying to extend the knees. Think about what structures are primarily loaded. It's primarily the Q-tendon, right? It's a quadricep tendon, maybe a quadricep muscle, of course. And then maybe the patellar tendon as well, the distal side. The knee joint itself is loaded, but the hip isn't loaded, the ankle is not loaded. The connective tissue complex is that manage like what we call multi-directional force transfer is also not loaded. So if you compare something like a knee extension machine to, let's say, a deadlift where now you have a hip hinge that is going to load the posterior change, so glutes and hammies and of course all the joints that those muscles attach into, the knee complex, the ankle complex, the lumbar and thoracic spine, like, you know, the shoulder girdle also has to stabilize during the lockout. The tendons and ligaments in every major joint of the lower and upper body are working, right? The ligaments are managing force transfer through each of those joints simultaneously. So I'm not saying never to do a leg extension machine. I do those occasionally as well, but I am going to say if you are someone who doesn't have the desire or the luxury to spend hours and hours in the gym, compound movements are your besties, okay? Because the mechanical receptors and every single one of those structures, so we said upper body for thinking about a deadlift, its hips, its knees, its ankles, shoulder girdle, the thoracic spine, lumbar spine, all of those are all firing. The mechanical receptors are firing in each one of those structures, so it's registering the load, its signaling adaptation, and now those collagen fibers are going to orient themselves along the lines of stress, okay? So this is, like, again, I'm not saying don't do the leg extension machine, like, I don't need to get confused, like, I do the leg extension machine myself, okay? But if you are a woman who is trying to maintain or rebuild her JTL in midlife, probably because it's been underserved for your entire life, the difference between compound movements and single joint movements is not trivial, okay? So compound movements, I'm talking about deadlifts I've already mentioned, but anything that is a hip hinge, like a squat, a press, a row, carries, these are how we're going to create multi-directional load across many, many different joints, okay? And they are not optional for connective tissue health, right? They are the way. It's like, this is the map, this is the way that you get better, better connective tissue overall. And before we go any further, we surprisingly get a lot of comments about hypermobility from women, so I actually just want to talk about this population right now, because I think that there is a large enough subset of women who have this specific relationship with their connective tissue that is hypermobile, okay? So if you're a woman who's like, you've always been flexible, you could always do the splits, you can sail through yoga, you get compliments on your range of motion, maybe you've had coaches in the past if you're in gymnastics or something, praise you for your mobility. Anyone who's ever told you, yeah, your flexibility is an asset. I want to reframe that a little bit if you are hypermobile, not because flexibility is a problem, but often what these women are experiencing is not flexibility as a skill, it's flexibility as a symptom, okay? We're doing lots of clinical, lots of clinical stories today. So I want to tell you about a specific example of this, okay? So we're going to call her Mia. Mia's 38, I remember she came into me, she had this like mystery pain, okay? So this is, if you are someone with hypermobility, this is going to be very familiar to you, okay? So her primary complaint was like, joint aches that moved around. Like one week it was her shoulder, the next week it was her hips, then it was back to her shoulder again, and it was like pain that didn't match a specific injury, and it was pain that imaging can't fully explain. Like I would always send patients for imaging of some sort, but it was like this exhaustion at her activity level that like rest and recovery and sleep like could not account for. And she'd seen, you know, like most patients that came through my clinic other like many other clinicians before she saw me. She had, she was told that her imaging was normal, people had suggested like stress management for her. You know, I would, I saw, I remember seeing on her chart, like idiopathic, like IDK, which is funny for like, I don't know, we would always say like idiopathic origin. So IDK or idiopathic origin. I had one clinch, I remember one clinician had given her like a core strengthening program that had like literally not changed. It was like the most bizarre thing. It's like, oh, you have like joint pain in your shoulder. Here's a core program, like made no sense. So when I assessed her, she had significant generalized hypermobility. Right. So her joints were moving well beyond their typical end ranges in almost every assessment that I ran. Right. And when we were talking about her history, it was pretty consistent. She's all had been, always been like super bendy, never really thought much of it. And then started having this like unexplained pain in her mid-30s that no one had really been able to explain for her. And again, all of her imaging was normal, like you know, X-rays were normal, ultrasound were like nothing looked odd. But that's what hypermobility is. So hypermobility kind of exists on a spectrum. At one end of that spectrum, you have like generalized joint hypermobility, which is very, very common in women, where multiple joints routinely exceed typical end range, you know, ranges of motion. And then at the more complex end, you have like hypermobility-related conditions. Right. So you have healers, down low syndrome, you have hypermobility spectrum disorder. Like, you know, these are connective tissue disorders that are involving like systemic collagen dysfunction. For both cases, usually the clinical screening tool is the bait and score, which is like a nine, you know, for those of you that are interested. This is like a nine point scale assessing specific joints, right. So can you lift your little finger back past 90 degrees? Can your thumb, you know, when you're pressing it down, can it reach your forearm? Do your elbows or your knees hyper extend past straight, right? Can you place your palms flat on the floor with your knees extended, right? So usually we kind of graded out of nine, five or above is generally consistent with like generalized hypermobility. But here's why I'm telling you all this. Like I think Mia's story illustrates what I think matters most for this conversation, which is hypermobility isn't like a skill. It's not like a flexibility skill that you've like, you know, honed over many, many years. What it is, it's a ligament or many ligaments that cannot adequately restrict end range motion. Okay, so that is that missing restriction has a cost, right? And that accumulates over years. It is definitely a big contributor to injury. So when you have a hypermobile joint, the ligament's ability to like, restrain the joint arrives very late or not even at all. So that means that the nervous system has to outsource the stability. The job of the ligaments is to provide stability, but since they can't, the nervous system has to outsource that stability to the muscles. So now your muscles are constantly working, not just to generate movement, but to do the job that ligaments aren't doing adequately. And this is why someone like Mia and maybe you are exhausted because your body, your muscles are literally doing double the work, right? The stabilization work for every single movement that Mia or you are making, like whether you're standing or you're walking or you're training or whatever, you have your muscles are doing double duty, right? And this also explains the migratory pain, right? So if sometimes like Mia would come in and it was like sometimes the pain was in her hips, sometimes it was in her shoulders, right? And then it would go back to her hips and it was like there was like literally no orthopedic explanation for it. But when your muscles are chronically overloaded with stabilization work, they fatigue, right? And they start to complain in return. So sometimes it's going to be the shoulder, sometimes it's going to be the hips, sometimes it's going to be the knee, you know, it's basically, it's like a map of which muscles are losing the battle this week, like which muscles are overloaded this week. And it also, you know, if you've ever gone to a doctor with migratory joint pain and you've been told your imaging is normal, well, you know, the ligaments are technically structurally intact, right? Imaging, most imaging cannot capture that dynamic, you know, can the, can the tissue do its job under load in real time across a lifetime of repetition? Like no imaging, God, if there wasn't imaging, that could do that. Like I would buy it, but most imaging is static, right? So if you are hope hypermobile, and this is what I did with Mia, this is what I need you to understand, okay? And this is so, so, so important for women. First, more range of motion for you is not the goal. You already have the range of motion. You have too much of it, okay? And I know that this probably runs counter to, you know, you've heard me say like full range of motion all the time, but for a hypermobile joint, specifically for this population, training deeper into the end range before building muscular strength through that range creates microtramas, okay? So at the exact, and it's usually at the exact point where that passive restraint is absent, okay? So for you, right now, if you are hypermobile, you are going to train in the mid range. You are going to train in the controlled mid range. This is where you're going to build your strength. First, the second thing that I love for hypermobile girlies is isometric holds. These are your foundation. So an isometric hold is basically you're holding a position under tension without moving. Wall squats are really great, right? This teaches the nervous system how to stabilize a joint under load without movement, right? Because the movement variable usually exposes the instability, right? Now, I'll say isometrics also get poo-pooed on in the fitness, you know, industry, but for my hypermobile girlies, yes, they're on glamorous, but they are absolutely transformative, okay? So we have that. And then the third thing I want to talk to you about is proprioceptive work. And this work is going to matter more for you than almost anything else, okay? So in a hypermobile joint, those mechanoreceptors that detect stretch, okay? In the ligament, they are already working at a disadvantage because the ligament is not providing feedback. It's not providing that restriction and that tension feedback at the end range. So what you need to work on is things like unilateral work, single leg work, for example, controlled balance challenges and any kind of like feedback rich movement to help rebuild that sensory map. And then fourth, and this actually applies to everyone, but especially my hypermobile women, slow escentrics, okay? Ligaments love. Dare I say, "lurev." They live slow escentrics, which is just basically slowing down the movement as the muscle is lengthening. So any movement, hopefully compound, but any movement where you're stretching, like the muscle is stretching, think about slowing down the escentric phase three to five seconds on every movement, okay? This escentric stretch is going to help drive that connective tissue remodeling because you're going to get higher input into those mechanoreceptors. For hypermobile women, this is not optional, okay? This is the intervention. So the goal for a hypermobile woman is, again, not more range. It's more strength within the ranges that you already have because you already have too much, okay? So, and I'll also just say to like Mia, I always would get these like, I always had patients that would come. They're like, "I've seen five people and everyone's telling me normal." So she ended up doing really, really well. It took about, you know, have to go back into her chart, but I probably say like 12 weeks, like something like three to four months before she stopped describing that mystery floating pain and she started describing herself as like finally understanding what was happening, okay? So that's really important for you if you are hypermobile. And I dropped earlier, I talked about the estrogen paradox and I want to come back to this because this is so, so, so, so important to understand like mechanically what's happening, but also what happens in midlife when we start to lose estrogen, okay? So I kind of mentioned before that estrogen's role is kind of like this like silent, we'll say co-regulator if you will, of connective tissue health, right? So estrogen helps that connective tissue remodeling, but we have to go a little bit deeper here because there is this diabolical, absolutely wild and cruel role that estrogen has when it comes to connective tissue health and you need to know about it, okay? So and there's a there's a patient that I think about actually whenever I talk about estrogen's diabolical role in connective tissue, I reminded of this one patient that I cared for. We're going to call her Sandra. She was like 47 years old when she first came in. She had started hormone therapy. I don't know, maybe six months before she came in to see me. And the first two months that she was on HRT, like she literally felt like a new woman, right? She had less stiffness. She felt more fluid. She felt more like herself again. She was like estrogen, like I am going to die with the estrogen patch on me. Like I love HRT. You know, it's like vent, you know, like that if you ever seen that Brooklyn 99 episode where Raymond holds like vindication with the balloon arch. If not, I know too much about Brooklyn 99, but anyway, she felt vindicated, right? For in her decision to pursue hormone therapy, like she felt amazing on the first couple months. But then, and I've seen this so many times, maybe you'll see yourself in here too, something started shifting for her. So over the following months, her tendon started to feel a little more Lucy Goosey, right? She started avoiding that overhead pressing because her shoulder was starting to feel more and more unpredictable than before, not less, like she wasn't feeling better. Her knees, which she had reported had initially improved when she started HRT, were starting to catch again. And they were starting to feel like, you know, stiff, right? And she was saying like I feel like these hormones were working, but now I feel like they're working against me now, right? So spoiler, they weren't working against her, but she had walked directly into what I call this very cruel estrogen paradox. Okay? So we know that estrogen is not the enemy of connected tissue. I want to be absolutely clear about this before we go any further. When estrogen is present in adequate amounts, stable amounts, this is very supportive of collagen turnover. It helps, you know, skin tissue quality, joint hydration, tissue resilience, like you name it. Okay? When you combine estrogen with adequate mechanical loading, underline, double underline that adequate mechanical loading, estrogen will actively and positively support tendon stiffness, ligament stiffness and force transmission. Estrogen gets an A plus in that scenario, but here is the part that nobody talks about in the absence of mechanical loading. Okay? So you're on HRT, so you have excess estrogen, but you don't have adequate mechanical loading. The increase in collagen turnover can result into shoe that is weaker, not stronger. So without the mechanical signal of load from weights, estrogen drives collagen remodeling, but the new collagen doesn't organize along the lines of force from the gym. It just kind of turns over, but it doesn't organize it. So it's literally rebuilding without a blueprint. This is like the spaghetti analogy all over again, right? Estrogen is like the boiling water, okay? Load is what tells a spaghetti to stay organized. Without that load signal, you get collagen turnover activity producing soft, disorganized tissue that is not transmitting the force properly. So estrogen is important, but all that estrogen does is amplify the signal it receives. This is why you can't just go on HRT and call it a day. You can absolutely go on HRT for, you know, for all the things that we've been talking about, but you must, you must must must must, pair it with mechanical loading because when you load your tissues, your JTL properly, estrogen will make your connective tissue stronger. If you neglect mechanical load, estrogen makes your connective tissue softer. Okay, so for that patient who was on HRT, she had accelerated her collagen turnover, but she hadn't changed anything in her training. She hadn't increased her mechanical load to give new collagen an organizing signal. So the tissue was like kind of like organizing without a blueprint. It's like, you know, it's like the passengers on the plane deciding how to fly the plane, right? So when she, you know, under my, obviously we didn't change her HRT, right? But I did change her training, right? So I got her doing heavy compound work with the eccentric emphasis that we were talking about, deliberate loading of the shoulder complex. Okay, so this also kind of goes a little bit backwards. Like a lot of people like when it hurts, stay away from it, no, deliberate loading of the shoulder. And then within 10 weeks for shoulder, you know, had a different story to tell, right? So for you, if you were listening and you're in parimenopause, estrogen signaling comes a little, like it gets a little erratic in parimenopause, right? Sometimes it's high, sometimes it's crashing, sometimes it's unpredictable. We don't know. Sometimes she's here, sometimes she's there, right? When hormone signaling is unpredictable and inconsistent, guess what becomes the most important thing? If you said mechanical loading, you have, I put an A plus on your chart, okay? Mechanical loading in parimenopause is the primary organizing signal for connective tissue health. It's not just a supporting factor, she's not like a nice to have. It's the managing director. Yeah? Okay, so this is why this, and this is why I, again, I love Pilates, but this is why I rally against this like two pound crap, when you reduce your load in midlife, which is exactly what most women do. They're scared of getting injured. That's exactly what the fitness industry wants you to do, right? It's so physiologically damaging for you. When we trade the barbell or dumbbell for lighter and lighter and lighter implements, it's the exact moment that estrogen stops being a reliable regulator. We remove the only constant signal that tells connective tissue how to organize. So what ends up happening, my dear, dear Betty, is that your system starts to adapt downwards, right? And this is why you wake up in your 40s or your 50s, you're like, my body fell off a cliff, right? Overnight, I woke up and I'm a different person. It wasn't overnight. It was a long, slow, systemic decline and withdrawal of the signals that were keeping the system running smoothly. Okay, lots of doom and gloom there, but the good news is, like, as with most things, this is completely reversible, right? Connective tissue doesn't just stop responding because you're 45. It responds to a load at any age. So you could be 75 and by the time you're 76, you could have a rocking connective tissue system. Okay, all you have to do is just give your beautiful connective tissue the system and the signal. Okay, we have covered a lot of territory here. Lots of science here, but I wanna make sure that you walk away from this episode, not just like informed, but also equipped. So I wanna give you some specific actionable items that you can bring to your next training session. Okay, so the first is, I wanna talk a little bit about hip-hinged mechanics because if there is one movement pattern that I will put above every other one for posterior chain connective tissue in women, ham tendons, like ham mutendons, hip ligament complex, the sacriiliac joint, the lumbar ligaments, it is your hip hinge, okay? And I wanna be precise with you around what makes it work. Okay, a hip hinge is not a squat, I it's not a back bend. It's the movement of the pelvis rotating around the femoral head. Okay, so that's like fancy speak for, basically if you think about your hip proper, it's not your hip bones where most people think it is. The hip joint is actually where the leg comes into the hip. It's a little bit lower down, right? The hamstrings when you're doing a hip hinge, they will lengthen under load. So will your glutes, right? Your glutes are gonna load essentially before they fire concentrically, which is when you come up from a hip hinge. So the in the posterior chain, so the tendons and ligaments and the muscles altogether, when you're doing a hip hinge, they learn to absorb and transmit forces across the entire posterior line of the body. So if you are not already doing it, this week I want you to pick one hip hinge movement and just aim for the next six months to master it. Okay, personally I find the Romanian deadlift like the most accessible version of it. You can do kettlebell swings, trap bar deadlift. So those are nice two, if you're a beginner, single Romanian deadlift, if you're more advanced and my preference for, main, if we want, maybe I'll do another episode on 3D glutes, but if you want 3D glutes, single leg, RDLs are the way to go. But you're gonna just start with one movement, loaded appropriately, meaning that the weight should create a challenge by sets three, you know, if you're doing three sets or four sets, okay? And own the hinge, don't rush it. Just slow down the eccentric, make it like, take your damn time, you know what I'm saying? The other thing I want you to think about is we've been talking a lot about it, but this eccentric loading protocol, okay? The primary mechanical signal that drives tendon and ligament remodeling is eccentric loading. So that's the lowering phase of a movement. Consentric builds muscle. E-centric also builds muscle, but it builds connective tissue. Most of us rush this eccentric because it is the most uncomfortable part of the lift, okay? So when you're going down in a squat, at the bottom of a squat, it is the most uncomfortable versus when you're standing up. Same with the deadlift. It is the most uncomfortable when you're at the bottom of the hip hinge or if you're doing a pull up, at the bottom is the most uncomfortable, okay? Most of us, and I'm saying this with love, use the weights momentum on the way down, right? And we only work hard on the way up, like against the weight. And it's understandable, I get it, right? E-centric is harder, it's definitely more uncomfortable, more fatiguing as well. But it's also where that connective tissue adaptation lives, okay? So whatever your workout is, hopefully, hopefully your member of lift and you're doing that program 'cause we talk about that a lot there. But if you're not a squat, a press, a row, something, extend the lowering phase three to five seconds. Minimum, okay? Five seconds if you can manage it. Five seconds is a long time. Pause at the bottom to make it, you know, even more gangster before you start working on the concentric or return phase, okay? The weight at the bottom, especially during that pause, should feel super heavy, okay? It's not a sign of weakness. This is where the JTL system is being asked to do a job, right? So those mechanical receptors are firing. The other thing I wanna talk about, I talked about this in tendon, in the tendon episode, but it's worth talking about here is tempo, right? Most of us are lowering and lifting with the same count. I would love if we can, and this is the eccentric bias, kind of two sides of the same coin, I think the lowering and the pause and maybe even like a lockout, depending on the exercise you're using, is the most important way to lift. So instead of going down for two and up for two, you want to bias, like play with the tempo so that the elongation phase is longer. In my humble opinion, this is the most underused tool in women's training for connective tissue development and one of the most effective for not only hypertrophy of the muscle, but also for really, really stiff tendons and ligaments, okay? You can do this with any compound movement that your beautiful heart desires, okay? What you'll probably find immediately is that you're probably gonna need to reduce your weight. So check your ego at the door, have a lighter weight so that you can maintain control through the entire range of movement, okay? This is not a regression, you're not getting punished. It's just an honest assessment of what your connective tissue can actually manage with integrity without getting injured as opposed to what your muscles can power through, all right? The long-term benefit of applying these things is you're gonna get tendons and ligaments that have been trained through controlled tempo work that are stiffer, more resilient, and better organized to transmit force, right? These are like some of the patient stories that I've been sharing with you. These are what these patients build. It takes time as well, like a minimum, give yourself a minimum of like 10 to 12 weeks to start really seeing that. And really the way that I want you to look at your training is like muscle, she's always the pop, you're like, she's the star, right? She's the star of the show. Everyone wants more muscles, right? But it's the JTL system, right? If you think about muscle as like a pop star, right? Everyone's like, wow, look, it's Beyonce. JTL is the stage that Beyonce is singing on, okay? You can have the most powerful performance in the world, right? But if the stage is rotting underneath, ready to collapse, you know, you can't have a concert, right? So that's what we're doing. We're building the whole system, not just the part that looks impressive and yes, Beyonce is super impressive, but we also wanna build, we also wanna build the stage that she's standing on, right? So she can jump around and do all the things and it doesn't collapse, okay? So. Here is what I want you to think about. Okay. As you begin this journey, know that connective tissue adaptation is slow. We are going to give ourselves some f-ingrace, and we are going to respect the collagen and the connective tissue timeline. We're not going to fight it. Okay. We're going to load progressively. We're going to own our escentrics. We're going to build the stage that Beyonce stands on, right, before we put any big superstar on it. Okay. So that's why I made this episode, because so many patients when I take them through this are like, why didn't anybody tell me this before? Why did it take me? Why have I been working out for 15 years, and you're the only and all every single person has said, your ligaments are fine. There's no structural debt. This is why I made this episode. Okay. So if you want to start loading your JTLs properly right now, not in theory, but in practice, highly, highly recommend lift. This is built around exactly this. It's progressive overload. It's compound movements. It's intentional to join friendly. It's for women in midlife. Every single session is designed to load the full system, not just the muscles. Okay. So the link for that is in the show notes if you want. And if this episode landed for you, share the love. You know, if there is a woman in your life who's been complaining about her joints for years, maybe she's hypermobile. She has hypermobility. Nobody can figure it out for her. You know, she's waiting for someone to give her a different story. Send this one to her. Right? Okay. That was my solo, soad, my soliloquy, my love letter, if you will, to ligaments, my favorite of the JTL. I will see you next week. I hope you enjoyed today's episode. And now, I must give you the obligatory legal and medical disclaimer. This podcast, better with Dr. Stephanie, is for general information only. The advice and recommendations we discuss do not replace medical, chiropractic, or any other primary health care providers advice, treatment, or care. In the consumption of this podcast, there is no doctor-patient relationship. And the use and implementation of the information discussed are at the sole discretion of the listener. Please, take this information to your primary health care provider to make the best choice for you. Remember, I am a doctor, but I am not your doctor. And these episodes are meant for educational purposes only.