TriDot Podcast .063

The Triathlete's Recovery Toolbox

Intro: This is the TriDot podcast. TriDot uses your training data and genetic profile, combined with predictive analytics and artificial intelligence to optimize your training, giving you better results in less time with fewer injuries. Our podcast is here to educate, inspire, and entertain. We’ll talk all things triathlon with expert coaches and special guests. Join the conversation and let’s improve together.

Andrew Harley: Welcome to the show, everyone! We have an exciting new episode with Dr. B.J. Leeper, our specialist for all things physical therapy and functional movement. Today we are talking about post-workout recovery, why it's important, and most importantly today, we're going to be focusing on what tools we should be using to help our body get ready for that next training session. B.J. Leeper graduated from the University of Iowa Carver College of Medicine with a Doctorate in Physical Therapy and Rehabilitation Science. He is a Board Certified Orthopaedic Specialist, a Certified Strength and Conditioning Specialist, and a USA Triathlon Level I Coach. He specializes in comprehensive movement testing and injury prevention among athletes and has worked with numerous amateur and professional triathletes, duathletes, track and field athletes, marathoners, and ultrarunners. B.J. is an avid triathlete himself with over 50 tris under his belt, including standout races at Alcatraz and Age Group Nationals. B.J., welcome back to the podcast!

B.J. Leeper: Hey, glad to be here!

Andrew: Also joining us is coach Elizabeth James. Elizabeth came to the sport from a soccer background and quickly rose through the triathlon ranks using TriDot, from a beginner, to top age grouper, to a professional triathlete. She’s a Kona and Boston Marathon qualifier who has coached triathletes with TriDot since 2014. Elizabeth, thanks for joining us!

Elizabeth James: As always it's great to be here! We've got a great episode coming right up, I am really looking forward to this conversation.

Andrew: Well I'm Andrew the Average Triathlete, Voice of the People and Captain of the Middle of the Pack. As always we'll roll through our warmup question, settle in for our main set topic, and then wind things down with the cooldown. Lots of good stuff, let's get to it!

Warm up theme: Time to warm up! Let’s get moving.

Andrew: You all know I love getting questions from the podcast audience that I can then play for our coaches to get a direct answer for you right there on the spot while we are recording. And today we have a fun warmup question. This comes to us from Shannon from Houston, Texas. Take it away, Shannon!

Shannon: Hey TriDot family! This is Shannon, ambassador down in Houston. Hey, I had a fun warmup or cooldown question for you. Christmas is right around the corner. What's on your triathlon Christmas wish list?

Andrew: Okay, so with Christmas coming, it's no accident, B.J. and Elizabeth, that we're talking recovery tools, because I know athletes are going to be out there, they're going to be eyeballing the market, "What are those next couple tri items I should be buying," and so it's a perfect time to talk about the tools and tech purchases, the things that we can get that can help us recover. But before we even get to that, it's just a great warmup from Shannon to talk about what is that tri item on the top of your bucket list. Whether it's for recovery, for the swim, the bike, the run, your day-to-day training, what are you guys looking to pick up via your Santa Clause wish list this year? Elizabeth?

Elizabeth: Gosh, so for me, I think this year the top of my Christmas list is a new pair of cycling shoes. I spend a lot of money on my running shoes, more than I really like to admit sometimes, but I've always kind of skimped on less expensive cycling shoes, and my current pair is getting rather worn down. The smell of them at this point is nearly unbearable, so I think a replacement pair is very much in my future, and I'd like something a little nicer than what I've currently been wearing, so I may have to ask Santa Clause for a little splurge on that.

Andrew: Mr. B.J. Leeper, what are you hoping to pick up from Santa this year for your top tri item on your wish list?

B.J.: Oh man, there's a lot. Santa could bring me about anything and I'd be happy, but my family and I just moved up here to northwest Montana about three years ago, so we're kind of in the Flathead Valley area, and we're literally the gateway to Glacier National Park, and so it's just beautiful up here. There's mountains, there's gravel for days, so I've honestly been eyeing a new gravel bike, as all triathletes are. Yeah, everyone that's in triathlon obviously loves the bike part, and obviously that's where we spend the most of our money, so we always joke that the number of bikes you always need is N+1, so my next :+1" would be probably a Salsa Warbird, just a nice gravel bike.

Andrew: He already has it picked out, a specific one he's picked out.

Elizabeth: Not just a gravel bike, he knows exactly which one.

B.J.: And if it wasn't that, if Santa didn't have the pockets for that, not that it's not necessarily much cheaper, but I'm due for also maybe an upgrade in my trainer department with my bike trainer at home. I've actually been looking getting a new smart trainer. A TacX Neo is probably what I'd like to go with. So there's two, I'll let Santa choose.

Andrew: So real quick for me, my top tri Christmas item comes from a company called TriRig. They produce an aero time trial bike called the Omni that actually TriDot coach Jeff Raines just purchased for himself. I don't really need a new tri bike, but they have a lot of really clever carbon aftermarket aero accessories, and I've really been eyeballing the TriRig scoop arm cups. I've been looking at these: they're longer, really light, but really well-padded arm cups that just make holding that aero position a little bit easier. I have a nice integrated carbon cockpit that I added to my bike last year, but it came with these dinky little arm cups that aren't the most supportive or the most comfortable, so particularly as I'm training for my first full Ironman, the TriRig scoops just look awesome, and they're the item that's made the top of my tri Christmas list. But hey guys, as always we're going to throw this question out to our listeners on Facebook and Instagram: what tri item is at the top of your Christmas list? I personally just can't wait to hear what you all have to say to this one, particularly Shannon. If she thought this question up, I'm sure it's because she has some tri items on her own list for Santa.

Main set theme: On to the main set. Going in 3…2…1…

Andrew: Today our main set is brought to you by TriBike Transport. If you are traveling for an upcoming race, let TriBike Transport ensure that your bike gets there race-ready and stress-free. TriBike Transport is the original fully-assembled bike transport service for cyclists and triathletes. I love traveling for a race. After registering, the first thing I do is book TriBike Transport for my bike. You start by using the easy online reservation form to guarantee space for your bike. Then, about one week out from the race, you’ll drop off your bike fully-assembled at one of their conveniently-located partner shops. Your bike will enjoy a smooth ride all the way to the race site where you will pick it up near T1 ready to race with your bike fit position untouched. Thousands of athletes have trusted their gear to TriBike Transport and you can too. Learn how by heading to TriBikeTransport.com and as a friend of the podcast, use coupon code TriDotPod for $25 off your next booking.

So the whole point of working out and pushing our muscles more and more in training is so that they strengthen and we can improve as athletes. A vital part of this process that is often overlooked is our recovery after a training session. But what does recovery actually do for our muscles, and how can we tell whether or not muscles are recovering adequately? And of all the recovery tools out there on the market, which ones are most worth our monetary investment? All that and more today with Dr. B.J. Leeper. And B.J., a lot of our discussion today I kind of alluded to with Christmas coming, and if somebody's listening to this episode and Christmas has passed, there's always a birthday or Valentine's Day, or something around the corner where you can ask for one of these items we're going to be talking about. So we're really going to focus on the tools of the trade that are out there on the market right now for triathletes to buy and use in recovery. Before we get to that, talk to us a little bit about why recovery is important, and what is actually happening in our muscles while we recover.

B.J.: Yeah, this is a great question, and what's interesting is when you talk about recovery, and even when you try to look at the literature in the triathlon space for recovery, there's just not a lot specific to triathlon in general. Now, you're going to look at the different disciplines within triathlon – running, biking, swimming – and maybe see a little more on recovery there, but even at that there's still not a lot of good, solid, conclusive evidence on what is the best way to recover. I think a lot of it's just because there's not a great way to really measure or truly define what recovery looks like, or what to be recovered means. I think the best ways that we see it studied right now, to this point, has been looking at something that's called DOMS – delayed onset muscle soreness – which if you look at what causes DOMS, we know that exercise-induced muscle injury and slight strains in the muscles, micro-tears in the muscles, is what develops into DOMS. But DOMS is really a subjective experience, right? So when you rate a scale of DOMS, when you're looking at these different studies, it's truly a subjective scale. So what it comes back to is the athlete's perception of what they feel and how they feel. Now there are different things that we've started to see as far as recovery measurements that are kind of a window into the system, but it's still different in how it's all getting measured, and what's meaningful, what matters. Resting heart rate, for example, has been a long-lasting way: people wake up after a tough workout the night before or day before, they take their resting heart rate, and they track and see if it's changing. Heart rate variability is a big thing that we're starting to see – I mean, it's been going for years now – but people are starting to dive into that a little bit deeper. That's completely another podcast in and of itself, because there's a lot there, but it's basically a window into your autonomic nervous system to see how rested you are. How much are you into your sympathetic state versus your parasympathetic state. The parasympathetics, which we're going to talk a little bit about today, is your rest and digest state.

So along those lines, there's different measurements. In the clinic, in the lab, you can measure, draw blood, take a poll of inflammatory cell markers in the body, but realistically what we have to go off of in an everyday setting is how we feel. Not to get too off track, but spoiler alert: we could wrap up this entire segment and basically say that recovery is all in your head, and literally the whole adage of "it depends" could be applied to every single thing that we're going to talk about today.

Andrew: Shortest podcast ever!

Elizabeth: That's just what I was going to say! The end!

B.J.: Shortest podcast ever. The end. It's all in your head, it depends, we're done. But the reality is, you don't experience discomfort or pain in the body unless your brain tells you as such, and so we come back to a lot of neurology. Not to get overly scientific with it all, but really our perception is really going to drive our experience, right? I remember when I was working in Kansas City, I was at a seminar of one of the lead pain science experts in the world, one of these seminars just talking about chronic pain in particular, and the guy's name is Lorimer Moseley. He's just super charismatic speaker; he's this Australian native that did his studies at Oxford, so he's got this super-cool accent that makes him sound even more smart than he is, and he's got this really unique perspective and philosophy on pain and why we feel what we feel. And just to give an example, he tells this story that's always just stuck with me, on his own personal experience with pain. He tells this story about how he was camping out in the Outback. He's up one morning, it's a beautiful day, he's barefoot, he's walking in the bush, and he's taken a few steps and he feels this prick on the outside of his left lower leg. He continues to walk, and the next day – he basically tells this story better than I do – but he basically says the next day he wakes up in a hospital. What had happened is he had been bitten by one of the most deadliest snakes in Australia, a brown snake of some sort I can't remember, but he had this experience that was almost life-threatening. He almost died from this whole episode, and that prick that he had felt on his lower leg was the snake biting him. So he tells this story and he says – so that obviously was a traumatic experience in his life – that his brain kind of road mapped, and a year later he tells the story then of how he's in a very similar scenario: he's out camping, walking in the bush, and he's walking, talking to somebody else –

Elizabeth: Brave guy, I'd be like, "No more camping!" No thanks!

B.J.: Yeah, that's exactly right. And as he's walking, he all of a sudden steps and he feels this searing, sharp, shooting intense pain just flood into his body. He starts screaming bloody murder, he looks down, and it's a stick that he had stepped on. His whole story just kind of sums up the fact that his brain, with that previous experience, had created a scenario where the setting was right, the context was right, and his body had taken what should have been a benign experience of just a small scrape of a stick on his lower leg, to feeling what was to him excruciating pain. And what he felt was completely real; however, the pathology behind it was completely non‑existent, it was a non‑event. But his brain had ramped up a danger alert in his mind that was so significant that what he felt was discomfort to the nth degree. Taking the time to preface what we're going to get into with recovery by telling this story just kind of shows the power of the brain to not only ramp up the system to increase our experience of pain, but it also has the capacity to ramp down. So that initial prick that he felt when he was first walking, on the outside of his left lower leg. was a legitimate snake bite. He had passed it off at the time as a stick scraping his leg, and he didn't feel anything at the time, and then almost died. It's really interesting, and I really love talking about this stuff, because it's just fascinating to me the power that our brains hold to both ramp up our pain experiences, and to ramp down our discomfort or pain experiences. So holding in that light, if we can consider these recovery tools we're going to get into with that perspective of the physiology and neurology behind it, a lot of times that helps us interpret what's maybe going to work for us, maybe what's not going to work for us. And a lot of it, like we're saying, we could wrap it all up by saying it's all in your head. When we say it's in your head, it's not that we're saying it's all this made-up stuff, but what you feel is real if your brain tells you, and can we have an influence over that perspective with what we apply to that scenario. So if our brain has this chronic pain song so to speak, stuck in our heads, can we change the tune? Are there different devices, different tools on the market that can help us change that song and mitigate some of that? Because we know, again, delayed onset muscle soreness is real. It's not just your brain making it up; there's research to show that it comes from chemical inflammation, different things in the body, interstitial fluid, all these things that can influence why we feel DOMS. But understanding the brain might help us understand why some people might not get as sore as other people. Maybe it's the same sore, but it's all subjective, and they feel it more than somebody else. And what might work for one person with recovery might not work for the other. Again that comes back to our "it depends", but we'll still try to speak to it as much as we can because the science is interesting, but sometimes with recovery tools, it's almost more about the marketing than the science at times.

Andrew: Yeah, and that's part of why we wanted to hit this with an expert, and wanted to hit this with somebody who has used many of these tools we're going to talk about in your own practice with athletes, and you have your preferences for the most efficient way to help people to recover. For me, I think the most sore I feel in my training weeks is after strength sessions. I'm going to be tired and achy maybe after a hard swim/bike/run session, but after strength work, my muscles are tighter the next day. And you kind of have to stretch a little bit and limber out a little bit and try to help your muscles stay loose and mitigate the effects DOMS has on your muscles. So before we get to talking about some of the different tools, B.J., how can we tell as athletes after a session when we are feeling sore, regardless of how much of it is psychological versus physical, how can we tell we are adequately recovering in between sessions instead of overdoing it?

B.J.: Yeah, well, it's funny, because what I do is on my next session, about five minutes into my run, I just look at my Garmin and see what my performance condition is. If it tells me "fair", I get nervous. Or sometimes it says, "poor", and I'm like, "Man, should I have even started this run?" You know, all jokes aside, there's different metrics to help us know if we're recovered. Like we were alluding to before, our heart rate variability is a big one, and that'll probably be another podcast we could get into because there's so much interesting science out there with that. And I think the Garmin, what they use with some of their metrics, they use that as well. But it is a feel thing. If you're feeling soreness, again the question is: is it a time to push through that, is it a time hold back? But I think we all know we're going to feel a certain amount of soreness as we train for triathlon. It's just the nature of what we do and those types of things. So I think the key with recovery is considering those variables that we have some power to control, to make sure we can get to our next session or race as fresh and ready to hit those numbers or hit that session as we can. Some of that's going to be a feel thing, but there's other metrics I think we can use to help guide us. But when we're simply going off of feel, I think that as we're talking about different tools to help us feel a little bit better, literally you can use it at that same state of the delayed onset muscle soreness, that DOMS. That is a subjective rating, but if we can use that as our barometer in how you would rate yourself, I think we all know intuitively when we're ready to roll and when we're not. Then a lot of times we'll have technology to guide us one way or the other, but I think the key is just looking at what are the things we can control, and how do we set those variables up to help us be more successful. You guys have talked before, I know, on previous episodes, of some of these big things with regards to recovery, especially nutrition is a huge one. Sleep is another big one that's another episode in and of itself, but I think when we're talking about tools to help the body, literally if we boil it down, keep it really simple, we're talking about feel. And if there's something that helps you feel less sore, and you're ready to roll, it's likely you're going to hit that next session a little bit better maybe than you would have otherwise.

Andrew: Yeah, that's a great opening disclaimer, and so let's just kind of start diving into the market of what items are out there right now that triathletes are – maybe they have some of these, maybe they're looking to get some of these, maybe they see ads and see other athletes in their pictures using these and they wonder, "Should I have that too?" I always look at, when we're planning episodes and thinking about what to hit next: as your normal everyday athlete, what's something that I've wondered, what's something that we all think about? So to hear from an actual physical therapist how these tools are used, which of these tools are necessary, how helpful they can or can't be, I think it's going to be really beneficial. Especially as we're approaching the holiday season when people are looking to pick up a new item or two. So B.J., I'm going to start at the top with one of the higher-priced, bigger-ticket items. A lot of athletes have them. Plenty more, myself included as I said, want them. Talk to us about recovery boots. What do these do, who are they for, and are they worth the sticker price for the everyday athlete?

B.J.: Yeah, it's interesting. They've become really popular recently. They've been around for a little while now, but even more recently they've been even more popular. I think again, if you look at recovery in the literature – and there's not a lot of great research – but if you look at some systematic reviews of the best research out there, which is randomized, controlled trials, what you'll find in the very limited reviews that are out there is that at the top of the list, what's most effective in decreasing DOMS and potentially having an effect on those inflammatory markers, inflammatory cells in the body, the thing that comes to the top of that list is massage. Massage is one of those things that a lot of people have had experience with, but massage can almost be extrapolated out to compression or vibration of the muscles. Some input to the muscle that effects and evokes a change. So massage, we could almost extrapolate out to compression, we could put it as an overarching umbrella to vibration. All these different things that have an influence of moving molecules and fibers within the muscles, that can be accounted for that. So it's interesting, because of the other few on that list that have shown some significance, all the others don't really have any long-lasting data to show one way or the other, it's all more anecdotal. But the others on that list are cold water immersion and active recovery, so getting some movement after an event or after training and just having some blood flow. So when we bring it back to compression boots, compression boots do just that: like top of the list, massage, in a way that's input to the system. You can argue that there's mobilization, movement of lymphatic fluid, of fluid that's holding some of those inflammatory markers in cells. Again, there's just not a lot of evidence to show that it's doing what we think it's doing. It doesn't mean it's not valuable. I always love when Jeff Booher talks about, he uses this quote a lot and I love it, it's the Mark Twain quote of, "It's not what we don't know that gets us in trouble, it's what we think we know that just ain't so." I think there's a lot of that in this world of recovery. Again, it's a lot of times more marketing than science, but specifically with recovery boots, what they do is kind of this peristaltic compression. Think of a snake eating its prey, right? It's moving the food down the length of its body. Just like with boots, it's –

Elizabeth: I'll have a different visual the next time I get in my recovery boots now!

B.J.: Do you love that idea with the boots, it's like eating your legs.

Elizabeth: Well, I hate snakes, so now next time I'm gonna get in and be like, "Ew!"

Andrew: We've talked about snakes a lot in this episode!

B.J.: This is the snake episode for some reason, I don't know that happened. But yeah, it's intermittent compression, meaning it's giving you a little squeeze to the legs and then it's releasing, and then it's a little more squeeze, and it releases, and it moves up and moves down. There's so many different settings, there's so many different flavors of boots that you can find and buy. But at the end of the day, that input to the central nervous system with some compression on the legs, compression on the muscles wherever it's placed, can be beneficial if, again, your brain perceives it as not a threat, and something that feels really good. And if that's the case and you feel recovered, you feel less sore, whether or not we really know that it's moving fluid or it's decreasing potential inflammation, bottom line is at the end of it, a lot of times it feels good, and I've got a lot of clients, patients, and even myself that love compression boots. I just love that feel, and afterwards, I just feel like there's been a change, and I feel rejuvenated. You can't diminish that, there's a lot to that.

Elizabeth: Yeah, and I'm kind of in that camp of whether it's a psychological boost or actually something, I love the feel of it. I love getting in my Normatec boots, I feel fantastic once I get out. So yeah, it feels good, and I'm going to keep doing it.

Andrew: So Elizabeth, in your training, since you have the Normatec ones, how do you find them implementing into your training? Do you use them every day, or do you save it for hard session days? How often do you find yourself using them?

Elizabeth: So on my schedule, I will typically use them after some of those harder interval sessions. So like after a Tuesday interval bike workout, I'll use them after a Wednesday interval run session, after those long Saturday bricks for sure, after a long run. When I was teaching, I loved them for multitasking as well. I would grade papers while in the boot. So I was still taking care of my training and my recovery, because I have to be sitting down anyway. I try to find times where, I've done a hard session, I'm going to be sitting, and while I'm sitting I might as well use that time productively as part of the recovery as well.

So we've talked about these higher-expense items with the recovery boots. I think a much less expensive approach to getting some of that compression on the muscles comes through compression socks or sleeves, and those can be worn either before, during, or after an activity. I know some athletes swear by their compression socks, others feel no difference. Is this kind of the same thing we were talking about before, where it might be more of a psychological boost, or would these compression socks also be helpful to our muscles?

B.J.: Yeah, exactly what you just said. I think it has a lot of potential to be that psychological boost, and if it feels good, you're going to perform, you're going to recover. Really the literature out there on compression socks, especially, is inconclusive. There's some studies that show it has some advantage in recovery, there's others that don't. There's not a lot that says it can improve performance, so it is in a different category. Even though it is compression, it's obviously doing something a little bit different than what we're talking about with compression boots. That's a little bit higher pressure. Most compression boots are going to run a level of pressure anywhere from 30 mm mercury to upwards of 200 or more, whereas compression socks, depending on the brand, is in that 5 maybe to 10 mm mercury category of compression. So I think the reason I think a lot of people love compression socks, is that it is kind of reduces the muscle vibration. Whether you're walking as recovery or running during a race with it or training, if you do have some soreness, it dampens a little bit of that vibration of the muscle. You might not feel that soreness quite as intensely, and that can be therapeutic. I think that even though it's not maybe giving you the same massage capability component that you would find in the compression boot, if the socks can dampen the vibration of the muscle and maybe mobilize and improve some recovery flow of inflammatory markers, then go for it. I've never subscribed to them myself, just because I don't have a lot of experience with them, and I've never felt the need to use them. But like you said, I know a lot of people that love them, and I'd say gosh, if you love them, that's a cheaper form of compression that you can definitely apply and use.

Elizabeth: Well, I'll say this from my personal experience. I have some, I like them, but I don't want to invest the 20 minutes that it takes for me to put the compression socks on to get the effects. My gosh, it takes me forever!

Andrew: I kind of save them just for after those really hard sessions. My calves get a little twitchy after a harder session, particularly the harder bike sessions, or the longer swim sessions. B.J. and I have talked about that a little bit, on how there's probably something in my functional movement where I'm overusing my calves. But anyway, so I find after the hard sessions, if I do throw on some compression socks or sleeves, that twitchiness, I don't really have it as much. I don't really notice it as much, sometimes I don't notice it at all. If I don't wear them after a harder session, I'm probably the next morning or the middle of the night gonna wake up with my calves kind of twitching a little bit. So that's just my own personal anecdotal evidence, I haven't found any difference in wearing for exercise or during exercise, but –

B.J.: I've thought about this before, I haven't done it yet, but I was at a medical multisport conference in Colorado Springs, and I was talking with a few of the medical doctors there, and we just happened to get on that topic of compression garments. A couple of them were actually saying that when they traveled, when they flew, they would wear them. And that's one area that I've thought about if I used them myself, I'd probably consider it for that, because as we all know, when we travel and we fly, sometimes we'll get a little swelling in our feet and legs, and these guys were talking about how they really liked it for that. But again, I think it's all individual, but that might be a really viable area. I don't know of any research on that, but that might be something that you could consider when you're traveling.

Elizabeth: Yeah, and I know that in the race recon webinars that we do, John always mentions that as something to consider, that if you're going to be traveling, if you're going to be sitting on a plane for a number of hours, consider some compression as a way to alleviate some of that "cankle" appearance that may come otherwise.

B.J.: Yeah, absolutely.

Andrew: So B.J., earlier you mentioned that one of the things that has been proven helpful is ice therapies of sorts, and I've seen some variations of compression sleeves that actually have incorporated ways to get ice or heating pads or cooling sleeves in there with the compression sleeve to kind of enhance the recovery experience. Is this actually kind of a nice one-two punch for your muscles or joints, or do you recommend other ways of incorporating the heating or ice?

B.J.: Yeah, absolutely. I think it's huge, and I think I've seen a big difference in our clinic. We've been using a system called Game Ready for a number of years.

Elizabeth: Oh yea, I love that.

B.J.: Game Ready has kind of captured the market as far as that area of compression and cryotherapy, but we use it all the time with patients for recovery. Athletes use it all the time, and it's a really big one where again, you're taking from the little evidence we know and the literature, you're taking two of the top things. You're taking compression, or the massage of the muscle, at the same time as you're getting some cold water effect flowing through. And the way Game Ready works, for those who haven't experienced it, you're basically putting on a sleeve that has a bladder within it that can have ice water run through it and air at the same time. You hook up a hose to the sleeve, and the hose is connected to what looks like this Yeti cooler that's filled with ice water, and it pumps it, circulates it throughout. So it gives kind of an intermittent compression at the same time as it's delivering ice therapy, and the range of what we see in the literature for cold water benefits is typically going to be in the realm of below 50° F, and our Game Ready systems usually run between 34 to 50°, and most of the research you'll read for ice is going to be between 8 to 15 minutes to be therapeutic. So that's kind of the realm there. But yeah, those can be really beneficial, really huge.

Elizabeth: So moving along on some of these other tools that have been around, massage guns have kind of popped up. They've been around for a little while now. It seems like their popularity has just exploded in the recent years, with multiple companies putting out these consumer-friendly options at various price points. So B.J., I'd be very interested in your thoughts on what are the best practices for leveraging a massage gun in our training or recovery?

B.J.: Yeah, this is a big one, because this has just really exploded lately. Everybody's on the market with their massage gun. I think back to when we first started using them in the clinic, and I just remember thinking, "Why didn't I come up with this?" It's literally this hand-held tool with a knob on the end, and it's like, "How did I not come up with this?" And now it seems like everybody has one. Just like you said, I think it's exploded on the scene. We know that that vibration input feels good, along the same lines as how we know the massage is a beneficial recovery aspect. It's doing that: it's compression of the tissue, and influences the central nervous system, mobilizes fluid. I'm sure it's doing any and all of those things. At the end of the day, it's just finding what flavor works well for you. So we started out using Theragun in the clinic, and we found it was working well. But they were really loud, and you could hardly talk over them. In the fitness world, in the gym, nobody cares about loud, but in the clinic, we were always finding that if a couple of guys were using them at the same time, you could hardly speak over it. So we kind of gravitated towards Hyperice brand.

Andrew: That's what I have! That was my Christmas present last year!

B.J.: Yeah, their massage gun is called the Hypervolt, and it's great. It's quieter.

Elizabeth: I was gonna say, I may have just added to my Christmas list as we're talking about this, I was like, "Oh yeah, I want one of those too!"

B.J.: Again, there's so many out there: the Hypervolt, the Theragun, TimTam, Thumper. I mean you've got so many different kinds, but in the clinic we've been using the Hypervolt now for several years. It's quiet, it has never given us issues (knock on wood) with breaking down, and we use it every day, multiple times a day. It's got different frequencies, and everybody's preference on feel is going to be different. So does it need to be the Hypervolt, which is probably going to run you about $300, or could it be something cheaper? Totally. It just really depends on what you feel is beneficial and you go from there. But what's interesting, just an aside on the Hypervolt, is that Hyperice is a huge brand now of recovery. They've actually bought out Normatec I think back in March of this year. So Normatec, the compression boots, are technically now under the Hyperice brand. It's not simply because they're the biggest name. I think what we've found in the clinic is that they just work. They're industrial strength, they hold up, and we just have really found that patients like them. As far as utilizing them and the timing of how you utilize them, I think there's another conversation. It's more about what you're going for. Are you looking to recover, or are you looking to actually correct some of your movement prior to training, and what does your training look like? There's a lot of timing of when you administer vibration to the system, and it depends on what your goals are. Again, is your goal to simply recover, to relax, to decrease your DOMS, or is your goal to actually improve mobility of a certain joint prior to training that area, or prior to just going out for a run. I think there's a lot of different timings of it, but vibration is huge. I'm a big proponent of using that stimulus in the clinic, not only for rehab, but for performance.

Elizabeth: Well in speaking of a stimulus to the muscle, I think another category that we could dive into a little bit for recovery tools are muscle stimulation devices. Two examples that come to my mind right now are PowerDot and firefly™. I've seen advertisements for those. I know athletes that use them. Which are very different kind of application, but both fire these electric pulses through the muscles to be able to stimulate recovery. B.J., what's your take on those muscle stimulation products and how they can be helpful for athletes?

B.J.: Yeah, another big one, and you see it all over the marketplace, and this one goes back a long, long time ago. So it's all under the category of what we call TENS, which stands for transcutaneous electrical nerve stimulation.

Andrew: TENS is easier to say.

B.J.: Yeah, we'll just call it TENS, it's a mouthful. What's interesting about electrical stimulation in whatever form it's delivered: some of my early research years I did a little bit in anatomy and cell biology. Then as I was transitioning to physical therapy school, I actually got involved in some pain science, pain research labs, and the lab I worked under specifically was focused on TENS and what it actually did to the body and how it had an influence on pain. So like we're talking about with delayed onset muscle soreness or that discomfort, whatever you want to call it: some people would call it pain, some people would just call it discomfort. The way that TENS actually works is very interesting, in that it works on the central nervous system through different channels. It actually can work along the same channels as what opioid medication works on, so it can activate those channels and increase your pain thresholds, basically decreasing your pain, which was called hyperalgesia. What was really fascinating was that we studied animal models in a laboratory. We used rats as a model, which was a fun experience in and of itself. So here we are talking about snakes AND rats in one episode, that's got to be a first.

Elizabeth: Ugh, my favorites. Yuck.

B.J.: Yeah. But what was fascinating was that you could have an effect on the central nervous system and pain thresholds regardless of the area that you put the TENS on. So for example, we had a model in the rat that we had inflamed their calf, we knew there was a chemical inflammation at play in the calf. We could put the TENS pads on the exact opposite side, the contralateral limb, and see almost the exact same decrease in pain as you would on the actual side. Now obviously in ourselves, where perception guides behavior and experience, if we know, "Hey, my right knee hurts and I'm putting the TENS pads or contacts on my opposite side," I'm thinking in my mind there's no way this is going to work, right? So that obviously has some power to influence. But the physiology behind it, because it works on the central nervous system in that way, it can be so powerful that it doesn't matter where you place it. But along the lines of what we were talking about earlier with massage and compression of the muscle, having some influence as well. If you take a unit like you mentioned before like a PowerDot, firefly™ – we use Compex and different devices in our clinic – if you took it onto the muscle and you had the stimulation high enough to create that motor contraction and that muscle twitch like you'll experience, it has the capacity to do both things. It can obviously still be playing on the central nervous system, at the same time you're creating a stimulus or vibration or compression of the actual muscle. So there's a lot of rationales as to why TENS or electrical stimulation can be therapeutic, but those are a couple of them that's again what we think is happening. There is some solid evidence more with regards to TENS then there are for a lot of other things out there that it has that capacity to work. Now personally, I've experienced it myself, and there is some benefit that I find, but some people, again, they love it. Some people it's not a big factor. So whether or not it's something that you splurge on and fork out the money to have your own personal device, it just all depends on the feel for you.

Andrew: So we've talked about these fancier – compared to what we're about to talk about – because these are things that are either pulsating through our muscles or helping our muscles vibrate, or helping our muscles compress or massage. But perhaps the more bread-and-butter recovery tool known to mankind is the foam roller. Now I personally have a very love-hate relationship with my foam roller. It's like any relationship, really, the more time I invest in my relationship with my foam roller the better things are going between us. But when I start neglecting our time together, my foam roller really lets me have it the next time we're together. So B.J., talk to us about what the purpose is for the foam roller, and does it serve a purpose over these fancier tools we've been talking about already?

B.J.: Yeah, that's great. Love the foam roller. It's obviously a staple in our industry, and again I think it comes back to understanding why and how we need to use it. I think a lot of times we think it's doing something that it's really not. Everybody, especially my runners, triathletes, everyone knows this. If they've used the foam roller, it's like, "I gotta roll my IT bands," because those are inevitably the thing that gets so tight on everyone. And what's interesting is the IT band, the iliotibial band, runs from the hip to the knee. Most people know where it is because it usually hurts if they're running for any long period of time. But what's interesting, there is solid evidence with regards to how much force it actually takes to create what's considered "deformation" of the IT band. There's an interesting study a long time ago really that showed that to actually create a 1% change in tissue deformation of the IT band, it would take up to 2,000 pounds of force to change that tissue 1%. So that's a lot of force, right? There's no way, no matter how much you weigh or think you weigh, there's no way you're applying that type of force through your foam roller on your IT band to actually change that tissue. So why does it work? Again, we don't necessarily have to know why it works, it just does. For a lot of us that's fine, but what's interesting to think about is what is it actually doing? Well, it's probably not actually changing the muscle length as much as we think. In that case, with the IT band, it's not changing that connective tissue length directly because of that rolling effect. But again, it has the capacity to be compression to a muscle to evoke that afferent stimulus to the brain, that can allow the brain to interpret it as, "Oh, I can let my muscle that's been lights-are-on-but-nobody's-home, that muscle that's been on so long, we can flip the lights off on it, and go back into parasympathetic stage of rest and recover." So your brain, if it perceives it initially it can be a threat, because it's pretty intense sometimes. If it can get to a point where you can let the muscle go and that conscious relaxation over the foam roll can have a huge therapeutic change, and huge therapeutic benefit. So the foam roller, again, it's another type of the input to the system. That vibration or compression to the system to relax a muscle, even though it might not be doing what we think it's doing, can definitely work.

The thing to think about, too, is a lot of guys will play slave to their foam roller thinking that that's going to fix them, and the reality is the foam rolling will never fix you. We call these techniques "resets" in our clinic, and we always tell patients up front, and any athlete that comes in our doors we always tell them: the reset gets a lot of press, but the reset will never fix you. The reset can be a means to an end, but if your goal is to change a muscle, you can foam roll the rest of your life and you'll have to keep foam rolling. The idea is, can you use that in a meaningful way to actually get to another level with where your muscle needs to be. So if foam rolling work is working, you shouldn't need to keep foam rolling for the rest of your life. This is another topic altogether, that a lot of it's what we do after that reset. But we know that it is a powerful reset, for sure.

Andrew: So a similar but different application of the foam roller, there are devices that you can roll over your muscles to kind of provide that deep tissue massage that you could get from a foam roller. These are usually some form of a stick or a rod that you can kind of roll the knots out on different parts of your body, or there's other products like the R8 recovery roller that applies roller-skate-looking wheels to roll over the muscle groups. So are these kind of rolling rods and different forms of a deep tissue massage, are they just kind of a different form of foam rolling, or do they serve a different purpose in our arsenal?

B.J.: Yeah, that's a great question. I think it's along the same lines, it's just a different flavor of it. Sometimes the reason you'd go to one of those forms versus the other is convenience and location. Depending on the area you're trying to influence, if it's the legs, a lot of times foam rollers, the big cylindrical ones work well, but it's hard to travel with a 3- or 4‑foot roller in your bag. So the portability of the sticks and the other tools you mentioned can do the same thing. I've had patients even at home that don't have access to any of those tools, but I've had them grab a rolling pin out of their kitchen before. It doesn't have to be fancy, it just has to be able to give you the right input at the right location. There's different tools that are obviously smaller to get into different areas, whereas bigger foam rollers can't reach as well, but you might find that one works better than the other, and it comes back to that whole adage of "it depends". If it feels good to you and hits the spot, then take the time. It's funny, because I had a high-level runner in just the other day, he actually runs for Hoka out in New York City. I was asking him what his recovery arsenal was when he was on the road and traveling and whatnot, and he literally said his go-to was a lacrosse ball. He had a lacrosse ball in his bag at all times, and he likes it just because it's easy to throw in a backpack, and it does the trick for him. It hits the areas he needs to hit, and gosh, how inexpensive is that, a couple bucks and you're good to go!

Andrew: So one final recovery tool I've seen making the rounds, and I literally was on the Google machine just looking up all sorts of things, trying to make sure we covered anything that an athlete might be looking at on the marketplace to buy, and so all my social media ads right now are now for recovery tools, thanks to research for this episode. So something really different that I saw was muscle scraping and myofascial release tools. An example I came across was the Sidekick muscle scraper. That's literally what they call it, it's a muscle scraper. Olympic gold medalist in triathlon Gwen Jorgensen has this one and uses it after a lot of her workouts. She's somebody I follow on social media. Another I've seen ads for is the Wave tool. But both of these options and others like them, they're kind of shaped in a sort of dull blade that allows you to scrape the edge of the device across your skin to work the muscle. Are these just different means to the same end, or is this kind of something different we haven't talked about that should be looked into?

B.J.: Yeah, again, I think it follows under that same category of input to the muscle: compression, massage, it has shown capacity to improve interstitial fluid flow. Going back to what we were talking about before with that input to the brain, this is a technique especially that's been around for centuries. This type of scraping technique started in ancient Eastern medicine; it's one of those techniques that sometimes you don't have to reinvent the wheel. Some of those techniques that have been used for centuries are actually still good to this day. Sometimes we learn a little bit more about why we use what we use and what's actually happening. What's really interesting, this is a technique we use a lot in our clinic. It's been coined, "instrument-assisted soft tissue mobilization", or IASTIM, but a lot of times in the clinic we just refer to it as scraping. Which sounds daunting when a lot of people come and we're like, "We're gonna scrape you today," and they're looking at us like, "What??"

Andrew: That sounds more like dentist procedure.

B.J.: Yeah, right, like who wants that? But it actually can be really therapeutic, and its ties to ancient Eastern medicine is interesting. They used to call it "gua sha", which stands for "scrape fever", and back in the day they used to think the more bruising that was evoked – what we call petechiae, the small breaking of the blood vessels that creates the red dots, or the bruising look for effect – the better release of whatever evil spirits were causing your body to hurt. I think that it's interesting because I think they were on the right track back then. But man, you look at gua sha techniques and you'll see some crazy self-mutilation pictures, it just looks horribly painful. The techniques we use today in that form uses these smooth-edged tools. Back in the day it used to be like jade stone, or they'd take horns or bones of different animals and the rounded edges of them they'd manipulate the tissue to create the increase in blood flow, and we use the same types of techniques to this day as far as mobilization of tissue. There's tons of different types of tools, like you mentioned a couple, and they're all a little bit different, but in essence kind of do the same thing. A lot of it's just feel, not only for the person getting it done, but also for the practitioner involved.  Sometimes it's a feel. We use some really expensive scraping tools in the clinic here called Hot Grips, there's other different brands, but they're literally made from surgical-grade stainless steel, and we found that you can feel a little bit better through the instrument or the tool. You can almost feel the vibration and the little knots of the muscles a little bit better than your run-of-the-mill plastic whatever type of tool. But at any rate, it's honestly doing the same thing. So whether you're using it to yourself or your having somebody do it to you, the technique is there, for an input to the central nervous system to release adhesions, relax muscles. We may not completely know what it's doing, but we know that in the clinic we see it work, and it can definitely have an influence.

Andrew: So B.J., like Elizabeth said, we've talked about a lot of different products, and obviously a big overarching theme is that there is a lot of personal preference that comes into play. Should you get the boots? Sure, if you like them and prefer them. Should you get a massage gun? Sure, if you like that and prefer that and find it helpful. Then which one do you get? Well, there's several, they do different things. It seems like just across the board, there's a lot of personal preference that comes into play. So if you just are kind of wrapping us up with this peek into physical therapist B.J. Leeper, "this is what I recommend you look into to have a well-rounded recovery section of your pain cave," what are maybe the few things that you would recommend folks get?

B.J.: So there's kind of two categories. There's obviously the budget category and the all‑in category, right? What's funny is that I have access to all these tools at the clinic. The ones I actually own personally are very few and definitely budget-friendly. So the tools I have individually at home are actually a medium-density foam roll and a lacrosse ball. I've got those sitting out in my bedroom, close to our bathroom, and those are your daily musculoskeletal hygiene, it's like flossing for your teeth. I have them sitting out just because every time I walk by them, I think to myself, "Oh yeah, I should get on that and do my own proactive, prophylactic care." A foam roll and a lacrosse ball, you could snag those for about $25 total, and maybe less. But two I have really found myself gravitating towards just in the last five years probably, that I don't actually own myself – again, I'm kind of spoiled that I can get access to them in the clinic anytime – but if I were going to purchase for myself, I would definitely probably grab a Hypervolt handheld vibration gun by Hyperice, and probably some Normatec compression boots for my legs. I just have found that those two for me are just moneymakers. I love the Hypervolt gun because my kids can use it on me, and they think it's fun. I'll say, "Hey c'mon over here," and they'll pound on my neck and back for a little while with it. Those are a couple go-to's that I find myself gravitating towards, not only in the clinic for other individuals, but just personally for myself. I just love them.

Cool down theme: Great set everyone! Let’s cool down.

Andrew: We spent a lot of time today on our main set, and for good reason. That was just a tremendous amount of valuable insight from Dr. B.J. Leeper on recovery tools. We already have plans to record more with him to further learn about different recovery techniques, functional movement screenings, injury prevention, and so much more, so be out on the lookout for those episodes.

So today, just going so long on the main set, I want to keep our cooldown a little short. I just wanted to take a quick moment and thank all of the athletes and listeners who responded to our TriDot podcast survey. The podcast has been out for just over a year now, and we want these conversations to just be as beneficial as possible for you, the athletes listening in. So as we plan out future episodes and guests, your feedback would just be invaluable in helping us craft a triathlon show for the people. If you missed the opportunity to take the survey and provide feedback, it's probably because you're not on our email list for the podcast. To get your email added so you don't miss any future podcast communication, head to TriDot.com/podcast and click on the email message symbol, which will allow you join the TriDot podcast email list.

Well, that's it for today, folks! I want to thank Dr. B.J. Leeper and pro triathlete Elizabeth James for talking recovery tools with us today. Shout out to TriBike Transport for partnering with us on today's episode. As you prep for next year's races, head to tribiketransport.com to get your bike to the starting line. Enjoying the podcast? Have a great idea for a warmup question like our friend Shannon? Head to TriDot.com/podcast and click on "Leave us a voicemail" to record your voice for the show. We'll do it all again soon! Until then, happy training!

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