Hello, everybody, this is Susan Clinton, one of your hosts of Tough To Treat. This is podcast number 151. It is the second half of the podcast 147, in which we talked about estrogen and hormonal balance. This one, we’re going to dive a little deeper into the levels of estrogen and its effect on the musculoskeletal system. In previous podcasts, Eric and I have discussed different aspects of this. And if HRT would be helpful in these populations, but we’re also going to look at this throughout the lifespan today. So enjoy the podcast, use this information to broaden your approach to your attempt to treat clients. Thank you very much. So how do we know what we’re dealing with here? So when we think about estrogen levels and musculoskeletal changes, we want to think in two different ways. So let’s look at high levels first. So when we have high levels of estrogen, and I’m not talking about normal levels of estrogen, I’m talking about high levels too much estrogen, we have an increased laxity of tendons, okay, so the tendons get really kind of loosey goosey, and so to the ligaments here, all right. Consequently, in the low levels, we have a stiffening of these tendons and ligaments. All right. And then when we look at that high levels, we have changes in collagen and muscle fibers. And this is basically, because we’re in the high levels, we have changes in these collagen and muscle fibers, but it’s due to chronic inflammation. So when we’re under chronic inflammation in our system, our we’re our muscle and our collagen is starting to break down a bit, we also have a decrease of power because of that and performance. And then we have an increased ligament and tendon injury, okay, which is going to be more of your itis as in your ligament tears. And what we have here is we’ve got kind of a storm where we’ve got the tendons and ligaments that are increased laxity, right. And then we’ve got, you know, the, we’re still trying to work with that in a system of chronic inflammation. And so we’re starting to get things like, you know, the tendons can’t hold up. So they’re getting highly irritable and inflamed. And, you know, maybe even some muscle tears, but or ligament tears, because the performance of the muscle can’t keep up with the performance that the body is trying to do. So this is where we come into those situations. And we’ll talk about specifically the ACL in just a few minutes. So when we look at low levels, when we drop or when our estrogen drops below what we consider good levels of estrogen, we have we have a different situation, we have a stiffening of the tendons and the ligaments and we have a loss of the type two muscle fibers, which means that we were losing our ability to have that anabolic burst that quick reaction that oh, let’s move really quick type of thing. And then we also have a loss of collagen and muscle mass, basically, because we’ve lost the effect of testosterone and protein synthesis in the in the case of the lower estrogen cycle. So the loss of collagen and muscle mass is not due to inflammation here on this side. But it is due to inflammation here on the high levels. So decreasing inflammation here can really help that. But here, it’s not going to be much of a changer. Okay. And then decrease tendon collagen synthesis and production. What does this mean? We’re going to this means that this we have a very easy reason to develop tendinosis in this population, which is why I say when you look at somebody with shoulder pain, who’s 30, you may have to look at, is there an inflammatory aspect to that going on? When you look at shoulder pain? Somebody who’s 60, you may have to be looking at is there a tendinosis? Is there a loss of collagen production? Is there a loss of type two muscle fiber? how stiff had those tendons and ligaments become? So let’s think about this in much more of a general sense. The articles that I found that have sifted through for a number of years, mainly focus on gender differences, and they do not study the shifts in estrogen through the cycle of the female lifespan. They don’t they they have started to look at the shifts of estrogen through the menstrual cycle, but they have not started comparing women with different menstrual cycles to each other, nor have they started comparing women across the lifespan and the different injury rates and or recovery rates and problems. What they’re doing is continuing to compare them to their male counterpart, which I think at this point is a story that does not need to be told anymore. We know we’re different from men, it’s fine. What we need to do is say but what makes us different from each other, and where do we need to focus and concentrate in on our interventions to really improve those that are in more trouble? Or really, are they in trouble? What is it that maybe we need to just do differently to just handle a situation that a general a male does theology isn’t going to go through. So we also know that there’s higher rates of muscle protein synthesis and breakdown, which have been observed compared to age match man and perimenopausal women, we know that we’re different from men. But here’s the big thing. The research is very conflicting on hormone replacement therapy for estrogen versus progesterone. And whether or not it’s helpful in muscle physiology, so a lot of times people have said, you know, get them on HRT, it’ll make their muscles better, they won’t break down as much. But actually, the latest literature coming out starting to look at women and Peri menopausal and into menopause, it’s showing that HRT doesn’t make a difference. What really makes a difference is an exercise and continual exercise, and not exercise spurts. And I’ll talk about that in just a couple of minutes. Stiffer tendons increases muscle damage due to lengthening during forces, this is another thing that’s been kind of broadcast through the literature. And now it’s coming together a little bit more. The articles I have down here, you’ll have in your references. These are the ones that first started looking at this together. So we know that muscle damage occurs greater with eccentric loading versus concentric versus isometric. And what they’re saying here is that stiffer tendons tends to increase muscle damage, because it makes the muscle lengthen during normal forces. So what we’re having that’s happening in menopause is that we’re having muscles that are working under what we consider normal forces. But because the tendons are stiffer, the muscle is actually lengthening under that normal force, rather than doing an isometric or a concentric type of contraction. And that’s not throughout the whole muscle, but they’re hypothesizing and starting to find that it’s actually at the muscular area where it joins into the tendon. So what does this mean? Now when we think about tendinosis rehab and postmenopausal woman, so now we have to kind of think about, okay, because the first thing everybody has said is, let’s throw HRT at them, well, that doesn’t have any impact on tendon health and recovery, that the literature is becoming clearer and clearer about that. Hormone Replacement Therapy has its place in women, you know, who are starting off in menopause for a short period of time, it can be very, very helpful for them for a number of things, but it doesn’t help this. So this is not a reason to get on hormone replacement therapy. But what does this mean? So, you know, what is that? What is the what is the grand exercise for tendinosis? Essentrics and loaded Essentrics? Right. And now, some of the stuff, you know, but they’ve been looking at, you know, they’ve been looking at different populations. And I don’t know that they’ve been looking directly at menopausal populations for this, or at least I haven’t been able to find it as much in the literature, I have found some stuff. And of course, loading is very, very helpful. Well, what is loading loading is actually almost isometric. And so one of the things that may be a paradigm shift for everybody to think about is, what if I took that tendon and did some isometric loading on it continuously, because that’s how we know we’re gonna get changed in the menopausal tissue is continuous loading and change, and not do it in spurts. So in other words, kind of a continuous loading exercise program, you know, across a couple of months, may do a lot more for helping the tendinosis than doing a loaded eccentric exercise that may be damaging some of the muscle fibers around the stiffer tendon, and also producing an inflammatory response, where previously there may not have been one. So something to kind of keep in mind and think about as you work with them is think about how can I load this tendon differently? And maybe do we need to go into the full maximum load with this population because we want to be protective of the muscle as well as trying to do enough to be able to get some changes within the tendon. So we know that loading is beneficial for muscle tendon health and bone density. I think we had a seminar with Mickey Townsend on and I’m sure she talked about that. high end, high intensity exercise can increase tendon collagen, but it has in this population, it has a sharper drop off. So that’s what I was talking about consistent loading, consistent loading in between high intensity activities might increase tendon and muscle health. I don’t know we haven’t looked at it yet. But people are starting to think about it in a much different way. Because once we start to realize that we can increase tendon collagen in this population, but if we don’t stay with it, it doesn’t stay there. So this is the case for getting people into exercise programs that can be sustainable over the long term. Yes, you may have to do some extra work to help them through the problem time, but it’s not a one and done deal in this population. Movement is not an option, they have to move in they have to find ways to load and it needs to include some agility and some rotation because we want to also do the other things that are prevalent in this population which is decreased falls and increase their their agility and quickness of movement. So aerobic also has a very important and plays because we still have to consider the cardiovascular pump. But do we need to work at high intensity level intervals all the time? Or maybe should we intersperse those amongst a sustainable aerobic activity for people in this age group? So when it comes to bringing in when we think about the biopsychosocial approach is what is going to be sustainable? What are they worried about? What are they most want to change in their life? How do they want to feel? And what if anything, the client choice is so so so important here is what are they missing? And is there any of the you know, it doesn’t have to be any of these things I listed, but there can be so many other forms of sustainable exercise that can include loading, agility, and rotation and balance. And that can also be you know, that can also be increased loading can go with that at any time. So let’s take a moment and flip back here just a second and talk about the younger population. And the thing that has been most studied the most, which is ACL tears. And until recently, a lot of people were looking at females versus their male counterparts, again, had more tears than than men. Okay, yes, we got that. So then they started kind of changed it up, or maybe it’s our training routine. And so they started changing it up. And that helped some, but I think the part that they were missing is the fact that we have to start looking at how that, you know, remember, estrogen increases laxity in the tent and the tendons and the ligaments, and, you know, a younger population. So it is certainly if they have high estrogen, it’s going to be much more lacs. So we want to kind of keep that in mind. So looking back at that symptoms, those lists, what else is going on with them? If there’s somebody who’s who’s doing a training program, and they’re in soccer, and we know that maybe perhaps soccer is I’m gonna pick on soccer for a second, that is one where girls tear their ACL a little bit more often. But they’re under you know, there’s there’s two problems there. It’s like, Well, number one, what do we need to do to kind of help protect these individuals? And number two? Do we just like abandon everything? Do we just say, is birth control the answer? Or do we not train during ovulation? But is that what does that mean? So I put this graph up here for you to see to see they’ve shown 77% changes during these times. But you can see all these little X’s and everything here. And this is the time when they’re probably the tenderness the most lacks, okay, and then as we move into this phase of the menstrual cycle, the 10, you know that the x’s are less, there’s still a rise in estrogen. So there is still a bit of laxity, but there’s not a sharp increase of X. of estrogen that happens, this is ovulation. And this is really difficult to track, especially on your younger girls. Because they don’t know what ovulation means they don’t know where they are, they don’t track their periods, they don’t have any idea what’s going on. But it may be kind of one way to start thinking about if you’re going to be working with young women that are in, you know, a lot of these activities such as gymnastics, and cheerleading, and soccer and basketball, and you know, a lot of these different things. Maybe perhaps it’s, you know, just being able to be aware of how they’re feeling what’s going on, are they you know, optimizing all the other parts of their life? Are they in kind of a high estrogen type of situation? You know, are they you know, really having heavy, heavy, heavy periods? Does that make them more at risk? We’re not sure. But we do know that there’s a difference in the menstrual cycle with this. So one of the things we want to think about, is birth control, really the answer? Because one of the things with birth control? Is it supposed to take your estrogen and damper on it? So it only rises to a certain level throughout the cycle? It does the same with the progesterone. But what does that do in the long term to the tissues at this age group? This is something that is only beginning to have questions asked about it. We haven’t done enough studies to know about this shot. But one thing we do know is that people when they come off of birth control, generally have a big hormonal rebound. That is difficult for them to get through for a few years. So we want to kind of think about that too. Is this the right answer? It may be for some populations, but not for everybody. It shouldn’t be a blanket thing that we talk about. And do I think that no training during ovulation is the answer. No, I think we have to be kind of, I think we have to kind of be more sensitive and about the way that we go about our training for these girls. One of the things that has come out that has been really really very powerful, but it has been very slow to be implemented and young girls training or young athlete like female athlete training is the idea of plyometrics and the idea of of strengthening and and situations that is not going to work for males. And so hip external rotation has been shown to be something that’s really great for helping females and also plyometrics helps them begin to start to mitigate the load that their tendons and ligaments particularly the ACL need to endure or, because, you know, just having them jump down from a box and not let their knee go into valgus isn’t the answer because when they’re running on the field or jumping or turning, or needing the force to get, you know, to push off the floor, they’re gonna go into that motion. But how can we learn to help them load so that their system can actually began to ramp up and have the strength, power and flexibility and all the other pieces that needs to mitigate this rather than just looking at this and saying, oh, no, they shouldn’t exercise here.