Hello,
First I wanted to thank you guys for all the content you’ve produced, especially Dr. Ray for letting me bug him with lots of questions in the knee rehab template.
- A few weeks back I asked a question in the Knee Rehab Template regarding RPE programming. Specifically, I was wondering why the template programmed hitting a final set of RPE 10 for each exercise during phase 1 and phase 2 of the program–this seemed contrary to what BBM has suggested to not consistently hit session-RPE’s of 9 to 10. Dr. Ray responded by saying that it is ok for an athlete to hit RPE 10’s (and I think it’s safe to assume that this could translate to sRPE’s of 9-10) during a rehab template because they are operating well below their “normative training capacity.” His quote:
Correct - we are discussing consistently hitting session RPE 9 - 10 may not be the best approach to training in the long run. I think the disconnect here is we are discussing athletes operating at their normative training capacity, which is different when rehabbing through an issue and accounting for symptoms. The template is likely well below the capabilities of most athletes for most of the prescribed exercises given they are completing the template for a variety of issues such as: symptomatic tendinopathies (quad and patellar) and PFPS and we are regulating other variables as mentioned above (tempo, volume, external intensity, etc). I would not recommend every session ever completed by an athlete functioning at normative capacity be at session RPE 9-10 and given what we know about how fatigue functions - this likely isn’t realistic nor possible. We have also not discussed the types of load vary in the template compared to normative training. For example, phase 1 isometrics is a very different stimulus than phase 2, and the sped up pacing of phase 3.
However, this assumption doesn’t necessarily make sense to me. Even though the external load may be relatively low compared to what an athlete can lift at his normal capacity, the internal load is still very high at an RPE 9-10. How do we know that it’s not session RPE’s of 9-10 (internal load) that contribute to tendinopathies and PFPS, and not necessarily the external load/combo of internal and external load, which is what his quote seems to be implying? My concern is that by training at a high internal load in the rehab template, we may be exposing the athlete to the same forces that led him injured in the first place, even though we are training at a lower external load. Thoughts?
2. Is it ok to maintain the same weight on an exercise if the RPE goes up through fatigue? (I guess this question could apply to both rehab and non-rehab templates). For instance, if I have the choice of doing 6 sets of 15 lbs for a bulgarian split squat, and the RPE is slowly going up due to fatigue, versus doing a set each 5,10,15 20, 25, 30 lbs–what’s the better option?
My counter would be what would make you think that the internal load is contributing to tendinopathies and PFPS?
We have a decent understanding regarding the physiological principles underpinning the development of tendinopathy and most papers place a large emphasis on the external load component. Load in and of itself is a misnomer as it does not qualify magnitude, duration, intensity. Tendinopathic changes tend to occur as a result of a low load, cyclic loading pattern where what would be considered more ideal tendon adaptation tends to occur more a higher magnitude loading. There is of course an impulse component to this as well as activity such as jumping would qualify as high magnitude, just much shorter duration. This also seems to have a detrimental effect on tendons (beyond a certain volume). This is why the recommendations, and the papers addressing such refer to the process as heavy slow resistance training (Beyer, Kongsgaard if you’re looking for authors). There is likely an internal load component as with all things but part of the impetus for training closer to RPE 10 is to give a metric of what hard is and if we can begin to redefine that and athlete should begin to be able to tolerate more load.
To your second question, RPE is predicated on the entire set. I’m not sure what your question is getting at regarding the two rep/set schemes as there would likely be dramatically different weight needed to perform a set of 5 at RPE 8 and set of 30 at RPE 8. The best option is the one prescribed. Each can have a place in both training and rehab and sometimes variety is good in order to learn RPE.
Hey Dr. Miles, thanks for responding to my post.
My counter would be what would make you think that the internal load is contributing to tendinopathies and PFPS?
I honestly wasn’t sure if internal load or external load contributes more to tendinopathy. I just thought that since internal load seems to be a big component of load management (i.e. sRPE and acute:chronic workload ratios) then that could be extrapolated to tendinopathies–so too much internal loads = tendinopathy. But that’s a big jump and logic error on my part. I guess I need to separate load management principles in a healthy athlete and tendinopathies in my head.
We have a decent understanding regarding the physiological principles underpinning the development of tendinopathy and most papers place a large emphasis on the external load component.
Interesting, I didn’t know that most papers place an emphasis on the external load component for tendinopathies.
Tendinopathic changes tend to occur as a result of a low load, cyclic loading pattern where what would be considered more ideal tendon adaptation tends to occur more a higher magnitude loading. There is of course an impulse component to this as well as activity such as jumping would qualify as high magnitude, just much shorter duration.
What do you mean by low vs. high magnitude loading? What does ‘magnitude’ mean in this context? Also, you say that more ‘ideal’ tendon adaption tends to occur at a higher magnitude–what does ideal mean in this context? Because in one of Kongsgaard’s paper they seem to say the opposite: “when the tendon is exposed to repetitive high-magnitude loading, it can result in tendinopathy, which is a painful and disabling tendon injury that can persist for months to years” (https://doi.org/10.1177%2F0363546515584760).
This is why the recommendations, and the papers addressing such refer to the process as heavy slow resistance training (Beyer, Kongsgaard if you’re looking for authors). There is likely an internal load component as with all things but part of the impetus for training closer to RPE 10 is to give a metric of what hard is and if we can begin to redefine that and athlete should begin to be able to tolerate more load.
I’m confused now–by heavy does this mean high external load? Then why doesn’t the template prescribe doing less reps with heavier weight? And where does the ‘slow’ component come in?
This is gets back to why I said “loading” is a poor term. All of this is still contingent upon the overall volume of loading and in the Kongsgaard sentence you quoted the operative work that is related to the development of tendinopathy is repetitive. This is why I made the delineation between jumping and other exercises. Both jumping and squatting would place a high magnitude of load on a tendon but this is why the slow component is in place. By more ideal tendon adaptation, repetitive (fully aware you’re likely going to play the “what’s repetitive” card let me nip that in the bud now and say it is contingent for each athlete, there is no magic 10k rep rule) loading tends to cause adaptations such as increased collagen degradation via an uptick in MMPs, increased angiogenesis via increase in VEG-alpha, increased cell proliferation, increased cell rounding and some other biochemical processes. Xu 2008 is a good place to start but you can look up Bohm, Mersmann, Docking and start down the research path on this. So if you have repetitive high magnitude loading (i.e. ton of jumping Mersmann 2014) or too much repetitive low magnitude loading Mousavizade 2014 tendinopathic changes tend to occur. And on top of that, tendinopathy is not a homogenous adaptation which is why the “treat the donut, not the hole” approach is being pushed more.
To my knowledge the template is based from that prescribed by Kongsgaard and Beyer. I want to reiterate that it is a template, this is not biblical. It is perfectly fine to start with sets of 8 and there is no magical rep number for treatment. What seems to be the important variables is that it is sufficiently heavy to elicit an adaptation although you could make a case from the Beyer papers this may not be necessary for subjective outcomes to improve. For the slow component I would refer you to Mersmann 2017 for a starting place.Imbalances in the Development of Muscle and Tendon as Risk Factor for Tendinopathies in Youth Athletes: A Review of Current Evidence and Concepts of Prevention - PMC
Also, did you happen to check the citations for the quote from the Beyer paper you posted? The first one is for “jumper’s knee” getting at the high magnitude, repetitive loading component once again. The other one I would have to read but appears to be more a case making for some “novel technique” of tendon stripping.
Hi Dr. Miles,
Thanks for the response. So are you essentially saying that, based on the literature, tendinopathic changes seem to occur on both high magnitude and low magnitude repetitive loading exercises, with the key differentiator that “beneficial” changes seem to occur on heavy, slow exercises?
The original paper (https://onlinelibrary.wiley.com/doi/…8.2009.00949.x) where the idea of heavy slow resistance training was defined the programming was the following:
The repetitions/loads were: 15 repetition maximum (RM) week 1, 12 RM weeks 2–3, 10 RM weeks 4–5, 8 RM weeks 6–8 and 6 RM weeks 9–12.
Does “repetition maximum” mean that they did it to failure for each set? I feel like they didn’t really go into the “heavy” part into very much detail, still kind of unclear (to me at least) what they define as heavy. Like, when I think of a “repetition maximum”, I think of a bone-on-bone 1RM (or a 3RM) that’s a solid RPE 10. Is this what you think they were going for here in terms of internal load–i.e. it should be an RPE 10?
The slow component makes more sense based on what they wrote in the paper, it seems they defined it by specifying a 3-0-3 tempo for each exercise:
Subjects were instructed to spend three seconds completing each of the eccentric and concentric phases, respectively (i.e. 6s/repetition).