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Keith Baar25 February 2025

#797: Dr. Keith Baar, UC Davis — Simple Exercises That Can Repair Tendons (Tennis Elbow, etc.), Collagen Fact vs. Fiction, Isometrics vs. Eccentrics, JAK Inhibitors, Growth Hormone vs. IGF-1, The Anti-RICE Protocol, and How to Use Load as an Anti-Inflammatory

4Frameworks
12Insights

Frameworks in this episode

Insights & moments

The myth-busts, hot takes, explainers, and tools worth keeping.

Myth Buster· 3

Myth Buster44:00

More Flexibility Is Not Always Safer for Tendons

Baar says injury risk follows a U-shaped relationship with flexibility: very inflexible people face high risk, people with useful mobility face low risk, and hypermobile people see risk rise again. He points to the high Achilles-rupture rate in women's collegiate gymnastics as a challenge to the idea that passive flexibility alone protects tendons.

  • Very limited mobility can increase injury risk
  • A middle range that supports full useful motion has the lowest risk
  • Hypermobility can raise tendon and ligament injury risk
  • Isometric holds can improve range of motion while adapting muscle and tendon

So injury related to flexibility is a U-shaped curve.

Keith Baar · 45:00

If we become hypermobile, we actually have that injury rate go up as well.

Keith Baar · 45:30
#flexibility#hypermobility#injury-risk#mobility
Myth Buster1:06:30

BPC-157 Showed No Direct Benefit in Baar's Engineered Ligaments

Baar says BPC-157 neither improved nor impaired engineered human ligaments made from ACL cells in his lab. He suggests that reported benefits from injections could instead come from needling the stronger tendon regions, reducing their ability to stress-shield weaker tissue, while leaving open the possibility of indirect effects elsewhere in the body.

  • Baar reports no direct mechanical or collagen benefit in isolated engineered ligaments
  • Needling itself can damage strong tissue and redistribute later loads
  • A growth-hormone receptor finding does not establish improved tendon mechanics
  • Baar distinguishes no direct tendon effect from the possibility of indirect anti-inflammatory effects

For PPC 156, we know that at least for the tendon and ligament cells themselves, it doesn't do anything.

Keith Baar · 1:07:00

BPC 157 doesn't change anything at least in the in the isolated ligaments.

Keith Baar · 1:11:30
#bpc-157#peptides#tendons#evidence
Myth Buster1:29:30

Protein Does Not Need to Arrive Every Four Hours

Baar says the old emphasis on consuming a specific protein dose every four hours partly reflected studies of fast-digesting purified proteins. He points to Luke van Loon's steak study, where amino acids were still being absorbed 12 hours later, and shifts the practical emphasis toward achieving roughly 1.2 to 1.6 grams per kilogram across the whole day.

  • Fast-digesting supplements create a sharper rise and fall than whole food
  • A large steak continued supplying amino acids throughout the 12-hour measurement window
  • Baar places less emphasis on a rigid four-hour feeding cadence
  • He recommends focusing on roughly 1.2 to 1.6 grams per kilogram over the day

When we look at it over more time, it doesn't really matter if you're taking every 4 hours that high protein.

Keith Baar · 1:30:30

It's more just saying, look, we want to get in about at least 1.2 g per kilogram body weight of protein over the day.

Keith Baar · 1:31:30
#protein#meal-timing#muscle#nutrition

Hot Take· 1

Hot Take1:12:00

Why Baar Is Unconvinced by PRP and Other Orthobiologics

Baar says injected material in a lower-body tendon is likely to be squeezed out as the patient walks, while immobilizing long enough to retain it creates its own rapid tissue-loss problem. He cites a blinded patellar-tendon trial with no difference between PRP and saline, while noting a small positive effect reported in the rotator cuff.

  • Lower-body loading may disperse injected material after treatment
  • Immobilization can rapidly weaken tendon tissue
  • Baar cites no PRP benefit over saline in a randomized patellar-tendon trial
  • He says upper-body sites may retain treatment more easily
  • He notes a small positive rotator-cuff effect rather than claiming every result is null

The only thing that works is getting load through the tissue.

Keith Baar · 1:13:30

When there's been a randomized controlled trial, there's no benefit.

Keith Baar · 1:14:00
#prp#orthobiologics#patellar-tendon#rotator-cuff

Explainer· 7

Explainer10:30

Rapamycin May Slightly Trade Muscle Adaptation for Lower Inflammation

Baar says longevity-level rapamycin doses should have only a minimal effect on skeletal-muscle adaptation for most people, while still exerting some negative effect. He explains that both muscle and immune cells use mTOR activity to respond to stress, so suppressing the pathway can affect hypertrophy and immune function as well as inflammation.

  • mTOR complex one helps skeletal muscle respond to resistance exercise
  • Baar expects ordinary longevity dosing to have a small negative effect on muscle adaptation
  • The trade-off may matter more to elite competitors pursuing maximal hypertrophy
  • Immune cells also need mTOR activity to respond to challenges

The short answer is that at the doses that they're taking for longevity, you have a minimal effect on the adaptation of skeletal muscle, but…

Keith Baar · 11:30

Our immune cells, they are doing similar things. They need mTOR activity in order to respond to an immune challenge.

Keith Baar · 12:30
#rapamycin#mtor#hypertrophy#inflammation
Explainer04:30

Strength Depends on Force Transfer, Not Only Muscle Size

Baar recounts arriving at the English Institute of Sport believing strength should rise with muscle cross-sectional area, only to see cyclists becoming stronger while staying the same size or getting smaller. He explains that muscular force must travel through tendons, connective tissue, and other force-transfer proteins before it can move bone.

  • Muscle size is only one contributor to strength
  • Force produced by muscle must be transmitted to bone
  • Tendons and connective tissue are part of the performance system
  • Athletes can become stronger by improving force transfer without adding mass

I've got five years of data that shows me I'm getting these athletes stronger without making them any bigger. And in many cases making them…

Keith Baar · 05:00

And that force has to be transmitted from our muscle where we're producing it to our bone where the movement is going to occur.

Keith Baar · 05:30
#strength#force-transfer#tendons#muscle
Explainer51:00

How Strong Permanent Sutures Can Shield Native Achilles Tissue

Baar argues that reinforced non-resorbable sutures can carry so much load that the repaired native tendon remains stress-shielded and loses capacity. He describes a rat study from his lab in which resorbable and non-resorbable repairs had similar strength and Achilles length at four weeks, while the resorbable repair showed better collagen-synthesis markers.

  • Very strong sutures can take load that would otherwise reach native tissue
  • Stress-shielded native tissue may become smaller over time
  • Baar's rat study found no four-week strength difference between the two suture types
  • He says resorbable repair works best with a team skilled in early loading
  • The episode presents this as research, not personal surgical advice

So if you load that, where do you think the load is going to go? It's going to go to the sutures.

Keith Baar · 51:30

We saw that the resorbable actually had better like collagen synthesis markers than the non-resorbable, just kind of like what we would anticipate.

Keith Baar · 55:30
#achilles#sutures#surgery#stress-shielding
Explainer1:16:00

The JAK Inhibitor Signal That Made Engineered Tendons Stronger

Baar's team compared gene activity in developing rat tendons and found JAK-STAT inhibition associated with growth in the patellar tendon. He says three inhibitors targeting different JAK combinations all made engineered tendons bigger and stronger, but a development study also produced animals that were 40 percent smaller, underscoring that the work is early and has major trade-offs.

  • The team used transcriptomics to compare growing Achilles and patellar tendons
  • JAK-STAT inhibition was the major signal in the tendon increasing cross-sectional area
  • JAK1, JAK1/2, and JAK3 inhibitor experiments all appeared beneficial in engineered tendons
  • The exact responsible target remained unresolved
  • Developmental exposure impaired longitudinal growth in the animals

So, what we found is that when we used those drugs, the tendons that we engineered got bigger and stronger.

Keith Baar · 1:17:30

And one of the first things that we found is that the animals were 40% smaller.

Keith Baar · 1:18:00
#jak-stat#tendon-growth#drug-research#transcriptomics
Explainer1:19:00

A Finnish Registry Linked Sartan Drugs to Higher Tendon-Rupture Rates

Baar describes a Finnish registry study that examined medications used by people who ruptured an Achilles tendon. He says fluoroquinolone antibiotics were associated with roughly a 3.5-fold increase, while angiotensin AT1-receptor drugs—the sartan class—were associated with a 7.6-fold increase, and he stresses the need to balance cardiovascular treatment with musculoskeletal function rather than giving personal medication instructions.

  • The reported evidence comes from a Finnish registry analysis
  • Fluoroquinolone antibiotics were associated with about a 3.5-fold higher rupture rate
  • Sartan-class drugs were associated with a 7.6-fold higher rupture rate
  • Baar says the association is not widely recognized despite common use
  • Reduced activity after major ligament injury can itself raise cardiometabolic risk

So you you find the fluoroquinolone antibiotics, yep, they're there, but they increase rupture rate about three and a half fold.

Keith Baar · 1:19:30

and they increase the rate of tendon rupture 7.6 fold.

Keith Baar · 1:20:00
#sartans#fluoroquinolones#tendon-rupture#medications
Explainer1:23:00

How Estrogen and Testosterone Alter Connective-Tissue Stiffness

Baar explains that estrogen reduced engineered-ligament stiffness without reducing collagen content by inhibiting the enzyme that cross-links collagen. He contrasts this with testosterone, which he says increases cross-linking while decreasing collagen, potentially producing a stiff but brittle tendon when stronger muscles place greater force on it.

  • Women are four to eight times more likely to rupture an ACL, according to Baar
  • Estrogen reduced stiffness in the engineered ligaments without lowering collagen content
  • Collagen cross-linking changes stiffness independently of total collagen amount
  • Baar links testosterone-related products with stiffer, lower-collagen tendons
  • Tendon stiffness affects how quickly muscular force can be transmitted

And what we found is that the stiffness of the ligament went down.

Keith Baar · 1:24:30

It actually activates lysyl oxidase and it decreases collagen. So what you get is you get a stiff tendon that has less collagen and that's…

Keith Baar · 1:26:30
#estrogen#testosterone#acl#connective-tissue
Explainer1:33:00

The Ketogenic Diet Trade-Off: Mitochondria and Longevity vs. Speed and Bone

Baar compares ketogenic eating with low-dose rapamycin because both reduce mTOR activity, and reports that mice in his controlled study lived 13 percent longer on the ketogenic diet. He also says the diet can promote mitochondrial quality through mitophagy, but warns that athletes lose high-speed carbohydrate-supported capacity and that bone mass is a serious concern, especially with osteoporosis risk.

  • Baar's mouse study combined ketogenic eating with one meal daily and modest calorie restriction
  • The ketogenic group lived 13 percent longer than controls
  • Low carbohydrate availability pushes greater reliance on mitochondria and promotes mitophagy
  • Baar says ketogenic diets are unsuitable for athletes who need to sprint
  • He identifies bone loss as the diet's largest downside

What we found is that the ones on a ketogenic diet live 13% longer than the ones on the control diet.

Keith Baar · 1:34:30

The important thing is, and we wrote a paper on this, is that if I'm an athlete, ketogenic diet is not for me.

Keith Baar · 1:38:30
#ketogenic-diet#mitochondria#longevity#bone-health

Takeaway· 1

Takeaway38:00

Why Veteran Athletes Often Choose Machines Over Dynamic Free Weights

Baar favors well-designed machines when he wants to load large muscles safely because they reduce reliance on underdeveloped stabilizers and can match resistance to the user's strength curve. He says veteran NFL players often understand that availability across a season can matter more than a marginal performance gain from riskier dynamic work.

  • Small stabilizing muscles can limit stimulation of the larger target muscles
  • A well-designed machine can vary resistance through the strength curve
  • Free weights apply the same external weight in both weak and strong positions
  • Veteran athletes may prioritize availability and contract longevity over marginal speed gains

One is that I don't have to worry about the small muscles because we always injure the small muscles.

Keith Baar · 38:30

All those all pro veterans, they're all over in the machines because they know that those machines are going to keep them healthy.

Keith Baar · 39:30
#machines#strength-training#injury-risk#athlete-longevity