April 6, 2023

"Nutrition for the Prevention and Treatment of Sports Injuries in Athletes" with Professor Craig Sale

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Episode 186 of the Institute of Performance Nutrition's "We Do Science" podcast! In this episode, I (Laurent Bannock) discuss "Nutrition for the Prevention and Treatment of Sports Injuries in Athletes"with Professor Craig Sale PhD (Manchester Metropolitan University, UK)

Discussion Topics Include:

  • Epidemiology of injuries in athletes
  • The scientific evidence and relevance to athletes
  • Nutrition to prevent and treat muscle injuries
  • Nutrition to prevent and treat bone injuries
  • Nutrition to prevent and treat tendon and ligament injuries

Key Paper(s) / Book(s) Referred to:

Related Podcast Episodes:

Check out our other podcasts, publications, events, and professional education programs for current and aspiring sports nutritionists at www.TheIOPN.com and follow our social media outputs via @TheIOPN






[0:00:00] LB: Welcome to episode 186 of The IOPN, We Do Science Podcast, the Institute of Performance Nutrition's Podcast. I'm the host, Dr. Laurent Bannock. What did we get into in today's discussion, today's episode? Well, I invited back Professor Craig Sale from Manchester Metropolitan University, who as you know, if you're a regular listener, has contributed many podcasts on topics from buffering agents to protein and bone.


Today, our conversation revolves around this very important topic of whether or not nutrition can play a significant role in the prevention and treatment of injuries in athletes, whether that's recreational athletes, or elite pro athletes, of course. There's all sorts of angles here. We discuss the various areas that nutrition has been shown to support athletes and exercises in the sport and exercise nutrition literature. We also talk about the value of looking broader than that in maybe the more clinical literature, public health literature, for example. We'll discuss that and you'll understand why there could well be some value in looking at that.


Just generally, we have a good chat and I know that you're going to enjoy what we talked about. Before you go ahead and listen to that episode, please go to our website at www.theiopn.com. You can learn about our online post-graduate level diploma in sports nutrition, our master's level diploma in sports nutrition, our software called SENPRO to support professional sports nutritionists and nutrition coaches and so on. You can check out our new community called our Professional Development Program, our PDP, everything from a safe community for you to basically, interact with other current aspiring sports nutritionists, access journal, all sorts of resources, research appraisal guides, all sorts of cool stuff is going to be found in the PDP.


Also, you can learn about our podcast, of course, previous episodes, that sort of thing. Also, our new, or most recent research publications to include making sense of muscle protein synthesis and our very latest publication, which is evidence-based practice guidelines for sports nutritionists. Anyway, you can access all of that at our website, www.theiopn.com. Now, here's my conversation with Professor Craig Sale, all about nutrition and treatment and prevention of injuries.




[0:02:30] LB: Hi and welcome back to the Institute of Performance Nutrition’s We Do Science Podcast. We almost started this podcast conversation about 20 minutes ago, but my good friend and colleague here, Professor Craig Sale, welcome back. We've been messing around. Look, it's wonderful to have you back, Craig. I always enjoy a good chat with you, not just because you're a good friend, but also what? I mean, you've been contributing one way or the other to these podcasts, or my own development as it happens for many years now. I must have done something right to convince you to come back for another good chat.


[0:03:02] CS: No, thanks for having me, Laurent. It's always good fun. Always enjoyable.


[0:03:06] LB: Well, let's see where this goes. Look, we've done some interesting podcasts in the past. We even had a semi-serious podcast all about context, which is quite a few years ago now. I can't even remember how far back that was, but we just looked up when we last spoke, which was a few years ago now, just before the pandemic. Remember that, everyone, where you and Dr. Brian Saunders were on, and we were talking about beta alanine, which links to other conversations I've had with you about buffering agents and so on.


Also, you've been involved in a number of other podcasts, where we've talked about a variety of different things, including, of course, bone health. We had your better half. I know is the required statement there. Now, Professor Kirsty there was on the podcast with you when we were talking about a variety of things, but where we also talked about female athlete health and bone health and so on. You've got all sorts of areas of expertise and years of research and so on behind you. Before we get into today's topic, which is going to be about nutrition for the prevention and treatment of injuries in athletes, which is a pretty broad topic, why don't you just bring us up to date? You've moved around a bit since we last had a podcast conversation. Tell us where you're at now and what you're doing.


[0:04:24] CS: Yes. Now I've moved on from Nottingham Trent University and the SHAPE Research Centre there. I'm now, and I've got to try and remember the new title. I've been forgetting it recently, but I'm now Professor of Human Physiology and Nutrition at the Institute of Sport and Manchester Metropolitan University. It's a great initiative on behalf of MMU. The Institute of Sport is really there to be a transdisciplinary focal point for everything going on across the university that could be relevant to sport, health and wellbeing.


It drags in a lot of influences from different parts of the university, all under the banner of sport and exercise and health and wellbeing. It really is creating – I'm only just getting going, but really is creating some very interesting potential synergies, even across into things, like art and design and law and sport business and all of these sorts of things. It's a really great initiative and it's broadening my horizons quite a bit, which is good.


[0:05:27] LB: Well, since we both entered the field, but particularly you entered academia earlier than me, particularly as a researcher, etc., well before me. You've seen this field explode. I mean, so much has happened. It was the Wild West, that wasn't quite the Wild West days, 10, 15 years ago, but things have changed a lot to the point now, as you've just described, you've got more than just a PE, or a sports science department. I mean, we're talking about many different disciplines within sport science, sport and exercise science, sport psychology, nutrition, sports medicine. I mean, there's just loads of sports analysts, sports management, and so on. Does it feel like a roller coaster at this point? I mean, how are you feeling about all this?


[0:06:10] CS: It's exciting. I mean, I think, yeah, you're absolutely right. I mean, when I started my degree, I'm trying to think back early 90s here. I think when I applied to do sport and exercise, there were maybe something about eight places in the country that did sport and exercise science-based degrees. Obviously, as you know, I ended up going to Liverpool, John Moore's to do mine. I think, I wouldn't be able to hazard guess as to how many different universities do sport and exercise science courses now.


Of course, it's not only sport and exercise science now. There's so many different courses. There must be hundreds of different courses now in relation to, or in broadly in the context of sport and exercise. It really is a huge, a huge business for universities now. I mean, I think it creates some exciting opportunities to look. I think particularly and around things AI and technology and art and design, like I said earlier, different ways of marketing sport, how you develop sports, business sports, all of these sorts of things. Wearables, of course, are interesting in that former category as well. It really is interesting and it creates a lot of opportunities for new study and new considerations in the area. Some of it well beyond me, I hasten to add.


[0:07:28] LB: Beyond us both, mate. I mean, it is hard to keep up with some of this stuff, particularly when you start talking about technology and AI. Of course, and we've talked a little bit about these things with various guests in the past. A lot of this stuff still has the illusion of being super cutting-edge, whatever that phrase means. But more importantly, accurate, reliable, blah, blah, blah. Even thinking about things like body composition testing, something as basic as a skinfold caliper, actually, if used properly, might be more useful, or reliable than the many gadgets you can buy at many shops and stores on the high street nowadays, and even indeed possibly some of the laboratory grade equipment. But obviously, context is going to matter, as we always like to talk about.


Look, and yes, there's the growth and explosion of all these different disciplines. A lot of it is yes to do with supporting and enhancing athlete and athlete performance and athlete health, something we're going to touch on a bit today as well. Of course, exercise is a recreational passion for many people. Some people will also engage in exercise for health purposes. They may not really want to do it, or at least not initially, but they're doing it anyway, because they've been advised to. There are many different reasons why somebody might engage in physical activity.


With that comes a number of side effects, of course, one of which hopefully is improved health for athletes, improved health and performance, loss of body fat, gain of muscle mass, improvements in bone density, blood lipid profiles, cardiovascular profile, whatever. There are other kinds of side effects, too, and one of which of course might be the inevitable injury. Our topic of conversation today is going to be about that really, or I wanted to focus this idea of nutrition, we're all about nutrition, that's our main focus here, whether we're researchers, or practitioners, or just very high-end consumers of this information, and we want to learn about the evidence.


It's a really interesting one, because I guess, maybe we'll start this question off with, well, we'll come into some definitions, because I think that's important. Just a quick jump in question for you, Craig. I mean, in a nutshell, nutrition, does it really have a relevant role in the treatment and prevention of injuries? I mean, that's the first question I think we need to ask. Is this a flyby thing, or does it have some legs? No pun intended, obviously.


[0:10:00] CS: Well, yeah. I mean, it's a really difficult one, isn't it? Because I mean, you think you can go back to saying, well, what's an injury? What type of injury you're talking about? which tissue is primarily being affected, etc., etc.? Then when you go back and think maybe about some specific tissues, and obviously, I mainly work in the area of the musculoskeletal system. But I mean, I think when you look at certain tissues, we know that they're modulated to a certain extent by nutrition, it is probably not the only – well, certainly, isn't the only factor, probably isn't the main factor. I think it probably is a relevant factor that can certainly help.


I mean, I think all else being equal than taking care of some of the other more fundamental things, like training load, adaptability, then you've got those, and I explain things trying to protect yourself against contact and contact injury and all of those sorts of things. I think all of those things being equal, then certainly, we know that nutritional elements are capable of modulating the tissues that we're talking about. Therefore, stands to reason that they can help support the adaptability in terms of a recovery from an injury, as much as they can to a response to training.


Again, like I say, I don't suppose it's going to be the predominant factor, but I think there is a pertinent factor there in terms of the effects of nutrition on recovery from injury. Prevention, that's a trickier one. Again, depends on the injury you're talking about, or how it develops. I mean, again, I think if you take it indirectly from the point of view that these things can help support a more robust musculoskeletal system, then obviously, then that stands the reason that there's potentially a greater resistance to some types of injury there.


[0:11:51] LB: Absolutely. Yeah. Look, you've touched upon bits of this in various areas of your research and subsequent publications. Part of this conversation has been influenced by the review that that Graeme Close, yourself and Keith Baar, and Stephane Bermon did on nutrition for prevention and treatment of injuries. Okay, in this case, it was more focused on that special addition in track and field athletes, but it's entirely relevant to our conversation today. We'll get into that a little bit. There are certain areas in that review, of course, that are particularly your areas of specialty.


I just want to remind the listeners that I have done a podcast about nutrition and injury back in 2019 with the late, great Kevin Tipton, Professor Kevin Tipton. I mean, basically, that entire podcast is central to probably the most important areas that we're going to talk about today. You should listen to that. Before we get into this, how do you address the evidence, how strong is the evidence? What does it even come from? Maybe there's evidence in other populations that might have some value from outside of athletes, but could be used maybe to support athletes. We'll explore that. I know that we've had a good chat about that before. But very much, it's going to be focused more on treatment, rather than prevention, right?


Before we do that, I thought the prevention issue is quite interesting, because depending on how we look at this and you frame the question, thoughts in my head and your head and the listeners will be, well, nutrition impacts certain areas significantly, like body composition, for example, which will have a clear impact on injury prevention by virtue of reducing dead weight, so to speak, and the risks that that can have and/or under-eating, low-energy availability and the various issues that that might lead towards injury, which actually, you'd be better explain that than me, of course.


Then there's the other side of it, of course, which I do find really interesting is how nutrition impacts cognitive function, decision-making. Of course, you have to make a few wrong decisions and you can get injured just by virtue of doing some things wrong, or like I have done recently, where I've overdone a bit of training and got injured. That was a decision that was involved in my injury, as opposed to being someone else's fault.


Before we get into that, maybe you could just tackle the prevention side of things, but from that perspective, particularly things that are energy availability. I'm thinking bone, obviously. Chronic. This doesn't have to be an acute issue, does it, Craig?


[0:14:22] CS: No, and I think that's right. I mean, again, it depends on what you're talking about. If we take bone as the primary example, you've got an example of each one of those there. You could have those very acute injuries that are usually, what you might term contact fractures, for example, which, for example will be relatively common in things like football, rugby, where these are contact sports and you get the single and significant application of a load more than the system can taken, and then you get a break in the bone. That's quite an acute injury.


Then also, you've got these adaptations in the bone that occur over longer periods of time, these overuse injuries in bone, things like stress fractures and other bone stress injuries. Of course, these are much more chronically developed. They don't occur with the acute application of a force. It's the repeated mechanical load over time that causes an injury. Are those things the same with the nutritional input into the prevention of those things be the same? Probably, some things yes, and probably some things no.


I think, one of the things, certainly from a contact fracture perspective is, well, of course, you can't control the contacts. You can't control necessarily always when you're going to go into contact, although there is definitely some decision-making elements there. I think that makes it even more complicated. You can't necessarily control what somebody else is going to do, or when you're going to go into contact, or when that contact is inappropriately applied just as you turn in a particular direction that leads to a specific collision that causes the injury. All you can really do under those circumstances is make sure you've got as prepared a tissue, for example, as you possibly can. In other words, a stronger bone as you possibly can.


We know, there are some elements of the diet that are important in the development of a strong skeleton. All of those sorts of general nutrients that your granny used to tell you, are good for healthy bones and teeth, all of those things remain relevant. Under those circumstances, of course, avoiding the deficiency is one of the things that we definitely want to do. If you can promote a strong bone, then that is good.


Obviously, there is a bit of evidence that it works both ways, that actually, stress fracture injuries, for example, these overuse injuries of bone, they can occur even in those individuals with otherwise, very strong bones. It's not just about necessarily preparing a stronger bone as possible under those circumstances, also about maybe reducing down some of the potential things that might damage the bone over time. One of the things we want, you've mentioned low-energy availability. I think, one of the things that's reasonably clear is that chronic low energy availability over time is not something that's particularly good for the bone. The bone doesn't like it. The bone doesn't respond very well to it. Certainly, I think, increased injury is a likely outcome in relation to prolonged and chronic low energy availability.


What we're less sure on is the shorter-term, or intermittent types of low energy availability and whether that really increases susceptibility to injury, particularly bone injury. If we just talk, for example, about chronic low energy availability, then I think that's relatively clear. Then other things are also, along that same vein of becoming more evident, things like low carbohydrate availability, as well as low energy availability, for example; adequate protein, etc., etc. All of these things probably do contribute to the prevention, or flipping it the other way around, the increased risk of an injury.


[0:18:02] LB: Yeah. It felt important to me to discuss that, because as I said, this topic is normally approached purely from the, I've got an injury now, what can we do about it? Whereas, prior prevention prevents what performance? Well, that may or may not be relevant to most people, but it strikes me that being in as robust a position as is possible is going to help, particularly if you need to immediately start to recover from said injury. If you're in a bad way, nutrition need to begin with, it's going to take a bit longer, presumably.


Let's just come to that, that word injury. In the context of an athlete and/or somebody's just recreationally active, goes to the gym, runs throughout the week, that sort of thing, what do you guys mean by injury when you state that in your publications here? What are the most common ones anyway that most people are likely to be dealing with?


[0:18:56] CS: That's a very difficult question to answer in some respects, because it's so broad. I mean, I think injuries are massive. They could be pretty much anything to any part of the anatomy. I think, the two things that we separate out when we're talking about athlete injury in terms of, I suppose broad classifications, let's say, for example, of those injuries, for example, that are a little bit more severe and they may well cause, for example, a bit of lost time out of training. It may require a decent proportion of immobilization of a limb, for example.


Of course, under those circumstances, your activity is significantly reduced, let alone, of course, your ability to be able to train, let alone, of course, your ability to be able to train effectively. Those longer-term injuries have more serious implications, of course, for recovery and for eventual performance when you return. Then maybe the second type, which is maybe they are slightly more minor injuries, the stresses and strain type injuries that are, yeah, okay, they're going to cause a little bit of a short period of time out of training, or maybe a little bit of reduced movement, but they're not going to completely stop you necessarily from training, or from doing some form of training over a more prolonged period of time.


I think there's two slightly different classifications there, whatever injury you're talking about. Whether you're talking about contact fractures, stress fractures, muscle injuries of the hamstrings, for example, or tendinopathy, ligament damage, ligament injury. They're the main things that – certainly, the musculoskeletal space, we would be thinking about, would be muscle injuries and the common ones are hamstring injuries. Bone contact injuries, bone stress injuries, and then tendinopathy and ligament damage, of course, would be the other things we would primarily be focused upon.


[0:20:51] LB: Again, I'm just raising the topic, because we use simplistic terms, like an injury. Well, that means a lot of things, as you've already pointed out. Also, to a diagnostician, to a clinician, their assessment of it will vary from minor to severe levels of injury. But of course, that your own perception might differ from that. I'm thinking, I mean, those of you that are parents, you'll know for well, your kid scratches himself and can have a complete and utter meltdown, thinking they're about to die. Just like soccer players with a scratch, all the way to rugby players. We've all seen these guys, American football players, etc., ice hockey players, you see them sustain huge injuries and they just keep playing.


There's something there too, because of course there's a decision is made by the individual and/or a coach, or a referee and thinking contact sports, combat sports, is this life threatening? Is this career-ending? What do we even mean by this? It's quite an interesting topic. I guess, what we're interested in –


[0:21:49] CS: Think injuries, Laurent, right? I mean, I think that's the other big thing is repeat injuries to the tissue, or joint, for example, or sometimes one of the things I think that is under known is how one injury might, or during the recovery from one injury, you might end up causing a slightly different injury, because you're modifying the way you're training, or you're not prepared to come back properly, or maybe you're not properly fueled, or prepared to come back to training. Then all of a sudden, one injury follows another injury, follows another injury. We can all think about players in our own sport for whom that would be directly relevant.


[0:22:25] LB: Well, for me as a nutritionist, that's almost the most exciting area, actually, is a buzzword within elite sport, for example, is return to play. We want our player to get off the bench, or wherever they are and back on pitch as quickly as possible. Or, we want our fighter back in the ring or whatever. They're not much use outside of those arenas. For those of us that take their training in exercise seriously, a week off training is it doesn't help your goals, whether it's for health, or performance, or your mental health, for example.


There's lots of different things. Of course, nutrition may not solve the problem like a medical procedure, surgery, analgesic, anti-inflammatories, etc. It's this business of return to play, or return to function that I find interesting. You raised an area that wasn't really in my head, but I think almost more important actually, is this issue of repetitive injury. This business of you return to play, or you get back to the gym, or you go back to start running again, maybe a little bit too soon without having given your body the opportunity to recover and of course, recovery is huge in the sports science sports, nutrition space.


But injury recovery, how quick do these things recover is an interesting area and of course, it's very individual, but a factor that can influence this, of course, is nutrition, which we'll delve into as we get into this conversation. There's going to be different areas that we could chat about, Craig, and there's going to be areas that you want to spend more time on giving your own very high levels of expertise in some of these areas. I wanted to loosely cover the main areas that nutrition can play a role. For example, nutrition and its role in preventing and treating muscle injuries. Is there some things there that you want to get into that's worth discussing in this conversation?


[0:24:14] CS: I think, some of the interesting bits there is just what that means. What evidence is there? Evidence is difficult to come by in this space. If we start in a more generic, there's very limited, what I would say would be quality research evidence on nutrition to prevent musculoskeletal injuries and probably, even less in the relation to management and recovery from musculoskeletal injury. I think, quite often that's, because conducting prospective, randomized controlled trials, which we would consider as being quite high levels of scientific evidence are extremely difficult to do, because you can't take a human, induce an injury in that human, and then follow them up prospectively with either a placebo, or your active nutritional ingredient.


It's very, very difficult to conduct those kinds of studies on humans. That's why a lot of our research, I think, is probably conducted on animals and cells in that space. Or, we refer from other lower levels, I suppose, of injury. What I mean by that is, and primarily related to the muscle injury is that we extrapolate, or have to extrapolate a little bit from things like muscle damage studies, through to what we think we are going to know about muscle injury. Of course, muscle damage, muscle soreness is not necessarily the same thing in terms of the extent of tissue damage, or the development of the injury, or the level of immobilization that may go on afterwards and all these sorts of things as a full blown muscle injury.


I think it's very, very difficult to say, okay, we've got clear evidence here of a particular nutrient benefiting, clearly benefiting the recovery from muscle injury. It's also very difficult, even if you think, okay, well, what I'm going to do is I'm going to prospectively wait and see how many people get an injury, then I'm going to randomize them and follow them over time. You're waiting for people to have an injury, which is always a strange little thing. You're sitting on the sidelines that hoping that players and people don't get injured, but at the same time, knowing that if they don't, you've got no study.


Of course, the incidence rates, particularly if you're only focused on a single team, or a couple of teams, the incidence rates of some of these injuries would be relatively low. It may take you years to get that kind of level of evidence, by which time, everything's changed anyway. again, even that's very difficult. I think what we're really, I mean, somewhat limited to here, and it's not even much, I think you know more about this than me is, is we need more high-quality case studies, I think, in athletes, that at least give us some information specific to humans and specific to athletes that otherwise, we wouldn't be able to get. I'm treading on your areas of expertise there.


[0:27:04] LB: No, I completely agree. I think what you're saying that there's an issue here is that what we're assuming everyone's the same and they're not obviously. I mean, as human beings, we've all got more in common than we do with each other than maybe with another species, or whatever. Yeah, this business of conducting research on elite athletes is not impossible, because they're not – I mean, what Premier League football player is going to volunteer to have his hamstring torn, or whatever? They're not. Then even if they were, they're not going to let you put them into the placebo group. They want to go in the group that's going to give them the highest chance of recovery. It wouldn't be just them. It would be their agent, their insurance company. Absolutely.


[0:27:42] CS: Yeah. You’d never get past the ethics board anyway, in the first place.


[0:27:46] LB: Let's not get into ethics boards, Craig. Let’s not do that.


[0:27:48] CS: Yeah, these studies are just not possible. Under those circumstances, it's very, very difficult, whether we're talking about muscle, bone, tendon ligament. It's very, very difficult to talk about an evidence-based intervention, because getting that evidence is very, very difficult. We have to extrapolate. I think that's probably from the many of the people listening to this podcast. That's where the skill of the practitioner is. It's taking these little bits and pieces and figuring out, okay, well, what is the best thing that we can do under these circumstances and make it as evidence-based as possible?


I don't think we can really say, okay, there's definitely a clear evidence-based intervention here that's going to work for muscle injury, or that's going to work for bone injury, or tendon ligament injury. I mean, of course, that said, there's going to be a fair amount of crossover and there's going to be some basic givens that probably we should all be looking at for one, no matter what injury it is. But, I mean, a lot of that really is just common sense to be perfectly honest.


[0:28:46] LB: Well, that's it. It's important, because as practitioners, as even a recipient who's the owner of a fresh injury, we still are going to sit there and go, “Well, hang on. This is all very well, but I still want to improve the problem if I can.” I guess, we can look at this in several ways. If you're going to use evidence, but it's poor evidence, or it's not really relevant to you, it has the capacity to make things worse. It's sort of, if it ain't broken, don't try and fix it type thought. It may be blemished, but it's not actually broken, so stop fiddling around with it.


It's this desire to solve a problem, the desire to interfere, rightly or wrongly, or for good reasons or for bad, and/or face it, the desire of a commercial interest to try and get involved in this, said supplement is going to solve this problem for you. At the end of the day, you're trying to make a decision of what are the things that I can be confident that will help, or at least won't harm this, I guess is one – as Graeme makes a point in, I think it's paper, paper to podium, I think. In that one, they talk about at first, did no harm. There’s got to be a perspective here.


I think, where we were talking about this before is this business of, okay, there's not a huge amount necessarily in the sports science, sports nutrition sphere. If we look a bit wider at some of this stuff, people who have had horrific injuries and find themselves in hospital and so on, there's a little bit of data that comes from the medical research sphere. Can we translate that into this scenario? What would you think about that, Craig, that general topic and then specifically what I just delved?


[0:30:25] CS: Yeah. I mean, I think that's it, isn't it? I think we've got no choice but to try and extrapolate across, as we've said, because that evidence is difficult to get to. I think, certainly, that there is some good evidence out there, for example, from trauma wards and things like this that show, for example, that trauma, particularly, things like burns and those kinds of severe injuries, induce a hypermetabolic state, which is showing that actually, recovery from these sorts of injuries and these processes do require quite a significant support for metabolism.


Coming back to an earlier point, energy availability, for example, becomes quite an important and interesting topic there, because there's a bit of a balance. Certainly, if you've got quite a severe injury that's caused in a mobilization and prolonged periods of a mobilization where, for example, your mobility is reduced a little bit, or quite a lot, then you may logically want to try and limit the amount of energy, so that you're not putting on fat mass, etc., in your athlete. But at the same time, if it's a severe injury, the recovery process from those injuries requires quite a high amount of energy.


Similarly, with things protein and the other big one, which everyone seems to go to immediately, it's either doing it pharmacologically or nutritionally, is trying to create an anti-inflammatory response. Of course, again, there's a double-edged sword there, I think under certain circumstances, that's probably quite relevant. On other circumstances, of course, the inflammatory response is an important part of healing and adaptation. Again, there's a bit of a tightrope to walk there. We can't just assume that throwing a load of anti-inflammatory nutrients are a particular problem, if indeed that even works, which is a different conversation.


I think throwing a load of anti-inflammatory medications, or nutrients at something is potentially not the way to go without proper consideration. I think it has to be balanced. Certainly, where you've got real extremes of inflammation, and this is prolonged, and it's not resolving itself, then of course, then it makes sense.


[0:32:34] LB: It does make sense. It makes sense, because we also can't, and bear with me when I say this, because it's a bit of a tongue twister, but it makes sense, because it also doesn't make sense insofar as we can't make sense of it, because we don't have sufficient evidence to be able to understand what's truly going on. This business of fiddling with things, going, right, “Okay, I'm going to bung into anti-inflammatories, I'm going to do this, I'm going to do that.” Well, you don't know what you're doing. Maybe, is that a good idea?


Maybe in research, that's an experiment. I'm thinking, well, obviously, you need to give the body what it needs, sufficient energy, and so on. Then I'm thinking, well, what about the concept of reverse engineering, where you go, right, well, we know that in a healthy person, in order to induce muscle protein synthesis, etc., which, of course, is an adaptation to an injury stimulus, we know how to support that process, or at least we know a little bit more about how to support that process. Some people might look at it very basically and go, well, we're still trying to increase repair of muscle tissue. There's a protein synthesis that's going on. Do you think there's some legs in looking at that way? Is that what some researchers are looking at? What do you think?


[0:33:44] CS: Yeah, it's quite interesting that whole thing as well. I mean, again, you've got things there of, are the effects, the direct effect of the injury, or are there other indirect effects of things like the immobilization? I think, if we go through some of those injuries that require immobilization, again, a lot of the evidence base that we come back to are things like bedrest studies, for example, or studies where individuals have been casted, so their mobility is reduced of one leg. Then they're looked at then as an internal control. You compare the casted leg with limited – it's obviously, it not no movement, it's limited movement, versus the non-casted leg that can move more freely.


Even in a lot of those immobilization studies, these immobilization studies are conducted in otherwise, healthy individuals, for example, and without injury. I think under those circumstances, we know, for example, or I say we know, there are studies out there that suggest that that immobilization induces a kind of an anabolic resistance type of response in the muscle. Certainly, again, there's a little bit of evidence around from Renee's old group and some bits from Stu Phillips and more recently, from the likes of Ben Waller Exeter that are shown that maybe protein to a certain extent can help limit that level of anabolic resistance, but doesn't necessarily fully recover the response.


I mean, again, that's looking at it very much from the immobilization perspective as there's less information, like I say, in relation to, well, what happens if that were an also injured person who was also immobilized? I think, that probably stands to reason that that would induce some further perturbations in things like muscle protein synthesis and breakdown rates. I don't know if we really know – certainly, I don't think we know what that would be from injured elite athletes. I'm not even really sure whether we've got good information in humans generally under those circumstances.


[0:35:41] LB: I'm pretty sure we don't. I've tried looking. I can't really find anything to aid this conversation. This is some interesting stuff is now on bilateral exercises. Okay, you left leg’s damaged, but let's exercise the right leg. There’s some interesting stuff that's come up there. I've talked to people about that before. But I think the one that tends to be the spanner in the works is this concept of anabolic resistance. You've mentioned it a couple of times there. I think, could you just, for those that don't understand what that actually means, do you want to just quickly explain what anabolic resistance is?


[0:36:13] CS: Yeah. It's just basically, the response, I suppose, of the body in terms of particularly, we're talking about generally, that the muscle under these circumstances, the response to a normally given dose, for example, of protein, of amino acids would be diminished, compared to where you would normally expect it to be. In other words, there's a certain resistance to the normal muscle building response of the body to that provision. That's what it really is, just as it sounds, it's resistance to the anabolic effect that you would normally see with something that was provided. Usually, we're talking about protein and amino acid provision here, provided to induce an anabolic effect.


[0:36:54] LB: Is there anything that might exacerbate that? I'm thinking, either locally in the environment of the injured muscle, or bone or whatever, or tissue in this case, muscle tissue, and/or globally to the body, to the person. I'm just taking a wild stab at things, like you may have sufficient protein, but there's still a reduced energy availability, energy deficiency state is having a more global effect on how the body's –


[0:37:21] CS: The obvious one that that's normally studied, of course, this is something that you and I will start to know more and more about is aging, of course. That's the one –


[0:37:28] LB: I don’t know what you’re talking about.


[0:37:31] CS: That's the one thing that is clear. Yeah. I mean, I think we know that these particular processes are highly energy-driven processes, and so it stands to reason that maybe there would be some reduction in that response, if in individuals who are under chronic low energy availability. I'm not really completely sure that that's been really, really well studied. I mean, I know it is starting to be, and there are a few studies around suggesting that that would be the case. But intuitively, that does – it does make sense that if you aren't providing the system with enough energy, then some of these processes, things like muscle protein synthesis that you would want to be elevated to induce recovery and adaptation in muscle may be adversely affected, I think that is.


[0:38:15] LB: Yeah. Presumably, things like a very stressed individual might be less likely to recover, but I don't know. I mean –


[0:38:24] CS: A really interesting one actually, isn't it? I mean, I think that's something that we've been thinking about a little bit more in relation to bone stress injuries. Mainly in terms of the development of bone stress injuries, rather than in terms of hampering recovery. It stands to reason that probably is, is this an increase in anxiety, an increase in psychological stress, which may manifest as things like poor sleep, or certain physiological responses to the stress. Of course, that would be highly relevant to an athlete in competition, be highly relevant to an athlete who's injured and is worried about things, like losing their place in a team, or missing a competition, or losing their livelihood for some athletes who are not maybe as well protected from that perspective as others.


I think that is an understudied area, actually, both in relation to injury prevention and risk, but also, in terms of recovery from injury. It gets even more complicated and I'm certainly no expert in the area, but it is certainly something that we've started to think about.


[0:39:25] LB: The reason why I'm thinking about this, Craig, is because a while ago, I did this podcast with Prof Neil Walsh about athlete immunity. Of course, his argument is that we've got to stop focusing on the micro level on this stuff. The total load of stress, which includes emotional stress, travel stress, environmental stress. It is the total accumulation of that needs to be factored in. Well, this surely is a similar concept when it comes to the body trying to heal itself, to recover something, where we're not just focused specifically on the injury to the specific muscle, but to what affects the body, the human being as a whole. You just summarized all that in terms of sleep and everything else. Of course, to you as a researcher, that just makes things even harder to study, though, doesn't it?


[0:40:17] CS: Yeah. I mean, it becomes – because anything and any injury generally, is a pretty multifactorial thing. It's not something that can really isolate particularly easily. I mean, some things more easily than others. But take something that we've studied for a little while, bone stress injuries, it's definitely multifactorial. It does become very, very hard to nail down, nail down one factor is being more important than another, because it's very, very hard to study all of these things, as we've already mentioned, in the same person, under the same situation, under the same conditions. That person's response under those conditions could be completely different to another person's, who's essentially gotten the same injury, because some other factors have been more pertinent and come to play in those individuals than in those individuals. It is very, very difficult in something that's quite so multifactorial, particularly as well, when sometimes you can't necessarily even predict the circumstances under which the injury is going to take place.


[0:41:19] LB: Of course, first, another sparrow in the works is the body is remarkable in its ability to survive. Even in cases of high degrees of stress and so on, the body still finds a way of fixing itself, albeit maybe not optimally in the way in which we're imagining here return to play. You look at people sustaining injuries in combat, and then imprisonment. I mean, all sorts of stuff, which we don't have time to talk about.


Where I was going to go down here was, what we can do as nutritionists is at least ensure that they're getting what they need in terms of energy, protein, good nutrition to provide the body what it needs and let the body solve its own problems. Of course, there's this inherent need that we have to get super clever and provide pills and potions to solve problems, which again, has a commercial backing to it, of course.


Genuinely, there are places where these things can help. I'm thinking, for example, not just necessarily protein supplements, particularly in maybe plant-fed vegans, etc. There may be an argument there and I've discussed this to the nines in various podcasts, particularly with Kev Tipton in all of those. I'm happy that we've done those conversations a great deal of justice.


Another one we did a podcast on, which was with Chris McGlory was in the area of EFA, central fatty acids, fish oils, that sort of thing. I can summarize Chris's comment about this essentially comes down to that supplement. By virtue of the word supplement is that it has a value, if you're not getting enough of these omega-3s, for example, in your diet, but taking it on top of a sufficient diet, probably has no benefits at all. Now, that's where that conversation ended. I don't know if there's any new research to change my mind. Is there anything on that topic that changes your mind?


[0:43:18] CS: No. I mean, again, not something I'm a particular expert in. But no, not that I'm particularly aware of. I mean, I think certainly if we go back to looking at a lot of the omega-3 supplementation studies, I think they were, again, coming back to that point initially studies, because of potential anti-inflammatory properties, I suppose. I think in a lot of those early studies, including some of Chris's, I think, if I'm, again, I might be remembering this wrong, but I think they were reasonably short periods of supplementation a couple of weeks, or something like that. With quite significant amounts of fish oils, compared to what you might find in the diet, several times higher than what you might get in a typical diet, before you would see an induced positive effect.


I think, there's always got to be that balance. As you said before, thinking about, okay, well, is the benefit – does the benefit outweigh any potential risk? Do we even know what the risk is? First of all, do no harm. I think the trouble with an awful lot of supplements is we don't have – and we probably have reasonably good, safety data in relation to the way in which most, or in relation to the time frames in which most studies have applied to them. Because people don't necessarily always take them like that, or behave in that way. Particularly, if we're taking some of these things prophylactically. In other words, we're taking these things on a relatively constant basis to try and prevent an injury, for example, or for some other purpose.


We don't really have an awful lot of really good safety data, or most supplements over a prolonged period of time. Here I'm thinking, not necessarily weeks, but more months into years as some people might take them. I think, even that's got to be born in mind when really thinking about supplements. A lot of the time, these things are – because it's inherent necessarily in what we're saying. A lot of the time, it's supplementing what's already in the diet, to extend what goes well beyond the diet.


Not always, of course, and we're trying to correct deficiencies and things that might be slightly different for some things. A lot of the time, we are talking about things that go beyond what we would normally find in a typical diet.


[0:45:29] LB: Also, Craig, you're reminding me of a lecture you gave on our program a few years ago, as with much of the stuff currently. You actually gave a lecture about supplements. I remember, you were talking about all this stuff, but also, there's something, there's another area, which is the combination effect of all these things. They all form ingredients. Even gunpowder is made from a number of relatively innocuous substances, but when combined in a certain way, it's nasty stuff. Do you want to just quickly mention that?


Because the thing about nutrition, or health, or alternative health, whatever, people love to throw supplements at these things. It hopefully, just comes from a meaning well perspective. Apparently, some research shows it does some good, so more is better, blah, blah, blah. They haven't necessarily considered the combined effects of these things and the risks that that might have on, for example, recovery from injury, or immune status, or whatever. Is there any thoughts you had on that you wanted to quickly share?


[0:46:27] CS: Yeah. I mean, I think that's the thing. It comes back to that level of complexity. Again, and something that's already really, really hard to study, you're then throwing in multiple ingredients, which by definition, all thought to be active, otherwise they wouldn't necessarily throw them in. It's then trying to discern, first of all, is there an effect? Is the effect greater in the combination than one particular ingredient by itself? Quite often, the answer to that is no. The prime example of this, for example, is pre-workout supplements really, where whether they work, whether they don't work, that's a debate for a different day for somebody else. These multi- ingredient things that are thrown together for a particular purpose. Maybe it's really only one of those ingredients that really is having an effect to anyone.


I think, this is becoming a little bit more popular. I've had a number of conversations with people recently. This has become a little bit more popular in terms of the supplements to help with injury recovery is that they're starting to add multiple different ingredients into supplements to prevent against injury. We know that some things go reasonably well together. Vitamin D and calcium as an example. That's probably one of the things, particularly in the bone field that's been studied over some time.


I mean, I think it becomes very, very difficult to isolate effects. Obviously, the flip side of that as well is it becomes even more difficult to determine what the safety profile of those things might be over time, particularly taken in some of the amounts that we're talking about.


[0:48:02] LB: It's going to happen, because a product, in my view, become – this is more convinced me personally, I just believe buyer's behavior is swayed towards a more plausible solution to their problem and the more ingredients that were in there. That's what they do. The new revised formula, it's got another two useless ingredients in there, but it looks more plausible, because it's got a new fab formula.


[0:48:24] CS: Well, they put a little bit more of it, or more or whatever it is in, right? Because buyer's behavior is there to believe that more is better, generally speaking.


[0:48:34] LB: Yeah, indeed. Of course, if we go, well, we do know that sufficient energy intake is important. We think, sufficient protein intake is important. We apply that more as better. It's probably better to have more than not enough. Then again, there are consequences to that when you're injured, you're immobile. If you're consuming too many calories, you might actually gain weight, which might make you more susceptible to injury once you return to play on less than a 100%.


[0:49:04] CS: Again, it's that knife edge we talked about earlier, isn't it? Particularly with energy intake. Because, like I said, we know, for example, that let's take that under consideration of individuals who are immobilized. Well, it stands to reason probably that their energy expenditure is going to go down. Then we want to probably almost certainly reduce our energy intake a little bit. We also know that depending on the injury that that might induce some hypermetabolic state, for one of a better word. I don’t necessarily particularly like the term, but you know what I mean.


These are requiring quite energy driven processes, and so a little bit more energy is possibly required. It depends on how mobile you are during a mobilization and how you're getting around. If you're hobbling around on crutches, then certainly your energy expenditure is going to be higher than if you were walking around. Okay, so you're not training. You don't have the training induced energy expenditure, but your energy expenditure, if you're doing a fair amount of walking on crutches, is going to be more than it would be if you were just walking around.


You probably need a little bit more back onto the energy intake side of things. I think, balance is key, but what balance really means is still pretty difficult. You've got to try and monitor that in terms of the athlete trying to maybe make sure that they're not putting on too much fat mass, or losing too much fat-free masses, as much as you can when they're in mobile.


[0:50:30] LB: Yeah, that's great. If sports nutritionists in particular are what they should be well trained in assessing body composition in the field, Isaac methodology is an incredibly useful method, particularly if you've assessed them beforehand. You've got a baseline to compare that limb, or whatever to and see what's happening with the muscle and/or body fat, etc.


[0:50:52] CS: That's another interesting one there, of course, though. You may, for example, be immobilized due to a bone injury. If you're immobilized due to a bone injury, that's still going to affect your muscle and it's still going to affect your tendon potentially and your ligament potentially. Again, it comes back to that idea of one type of injury following a different type of injury. Actually, I think that's probably something that to a certain extent, is also under-considered as well, is that when we're talking about an injury that induces immobilization, we're probably talking about something that's not only going to affect the injured tissue, but also the tissues more generally and indirectly affected by the immobilization. Thinking about that is also probably quite pertinent.


[0:51:34] LB: Yeah. I mean, look, at this point, I can almost hear people's heads exploding going, “Oh, wow. I thought it was just going to be a band-aid, take this pill, take this, eat a bit more protein.” Obviously, it's not as simple as that, because you've got to consider all this stuff.


[0:51:49] CS: We’d be multi-millionaires, if we knew the answer to that single pill.


[0:51:52] LB: Yeah, I'm off to the bookies now, Craig. That's what I'm doing. You mentioned bone, and I do want to get into tendons and ligaments, and so on. I think that's a really interesting area. You know more about bone health than most people in this context. I know you've referred to it already a number of times, but since we're talking now specifically about bone injuries, what are your thoughts on that? What do we need to know as it pertains to trying to do something about it?


[0:52:19] CS: Again, it's one of those things. I think there are a number of things that probably would seem relevant for prevention and treatment of bone-related injuries. I mean, I think on a general nutrient intake level, we know certainly that there are going to be a number of key nutrients that are particularly pertinent for bone formation. Things like protein, calcium, phosphorus, magnesium, vitamin D. They're some of the big ones. Of course, there are a few other things that we know are related to, or co-factors in bone metabolism, so things like vitamin A, vitamin K. A few lesser-known things potentially, developing things like boron, silicon, zinc, magnesium, again, probably iron. Some of these things where people might be thinking generally, “Oh, I know athletes who are deficient in some of these things anyway.”


I think it stands to reason that because those nutrients are key, if you've got an athlete who is deficient or insufficient in one of those nutrients, it stands to reason that would be beneficial to try and get them to a point where they are sufficient. In that sense, they are, I suppose, what you would say, taking in a well-balanced diet. I think under those circumstances, the low-hanging fruit of the well-balanced diet, and if you can't match those requirements of the well-balanced diet, then some consideration of supplementation to correct the deficiency. That stands to reason.


One of the big problems there is that maybe this is another thing just to briefly touch upon is that just correcting a deficiency isn't necessarily optimal. They're not the same thing. If we go towards things that are recommended daily amounts, for example, of certain nutrients, those things are designed to prevent a deficiency in the majority of the population. That's not necessarily saying, those intakes are optimal for particular tissue adaptation in an elite athlete. It's not the same thing. I don't think we know the latter. We don't know the latter.


In fact, I think we can all get to the point of what recommended daily amounts are. But are there any of those nutrients for which going above that recommended daily amount may be more optimal for adaptation in the athlete, is a different question. I'm talking about adaptation in terms of recovery from injury is specifically, of course, or prevention of injury. We're going back to the bone question. I think there are a few key things. Obviously, avoiding chronic low energy availability would seem to be particularly pertinent. Avoiding low carbohydrate availability, particularly over a chronic and prolonged period of time would seem to be pertinent.


Certainly, sufficient protein intake would be important. I think in individuals where there may be a higher protein intake, then it's making sure that calcium is at least sufficient, because there is a potential problem with high animal protein intake in particular in the bone, if calcium consumption is low. I think we've pretty much poo-pooed the idea that higher protein intake is bad for bone now. That's pretty clear. It's not the case, except maybe in certain circumstances, where calcium intake is particularly low.


Under those circumstances, keeping calcium to a reasonable level, and then that would be the same again anyway for bone calcium, and vitamin D would be the other ones that are pretty obvious. At least, I think avoiding deficiencies in most of those other things and making sure your athlete is not energy-deficient and carbohydrate-deficient over prolonged periods of time will all be relatively sensible and known things as far as the bone is concerned. There are some other things. For example, dehydration and rehydration, which at least have a theoretical potential linkage, but are really massively understudied.


[0:56:00] LB: Yeah. I was just thinking as you were talking about vitamin D and calcium and so on, and of course, it's worth mentioning and this links to my comment about being prepared to deal with injuries on the basis that recovery of a deficiency, or even an insufficiency of certain nutrients can take a very long time, can't it? Do you want to just quickly, calcium and bone, for example, it's not like you take some supplements today and it's all fixed for tomorrow, is it?


[0:56:27] CS: No. I mean, I think generally responding to the acute nature of training, then obviously, most athletes don't train like I do, train today and not really fancy it tomorrow, so I might do it the day after that, or maybe even the day after that. Depending on what athletes you're talking about. Some athletes are training a couple of times a day, most days. You take elite triathletes, for example, and those guys are bonkers. They're training multiple times per day pretty much every day. Under those circumstances, I think this is what I was coming back to as well in terms of what might be optimal for the athlete is potentially a little bit different under circumstances like that.


Generating insufficiencies after deficiency again, depending on how severe the deficiency is, particularly in things like vitamin D, iron. Some of those things that are a little bit more difficult to manipulate from a dietary perspective. Can take time. Can take weeks.


[0:57:23] LB: I've done some podcast, I'm thinking with Dr. Dan Owens, we've done one on exercise-induced muscle injury, which links a little bit to what you were talking about with muscle injuries. But obviously, a huge amount of his work's been on vitamin D and we talked about that. There's a lot of stuff there that is pretty mind-boggling, but none of it's going to be a quick fix, obviously. When we think about return-to-play, we're after a quick fix, aren't we? There's lots of things that we can do, but what are the things that have the greatest, the most likely to have the most rapid impact, I guess, is what we're interested in with all this, which I guess for muscle and bone, for example, it still comes back to getting enough energy availability and protein intake and so on, doesn’t it?


[0:58:09] CS: Well, best guess as it currently stands, yeah, that's it.


[0:58:11] LB: Best guess.


[0:58:12] CS: I mean, I think coming back to your earlier point, just to reiterate, I mean, a lot of it is probably better if you're not deficient in the first place. That's probably going to be the thing that's going to help most. I think, it becomes even more complicated when you think, is there any beneficial effect when you go beyond? If your individual is sufficient in a particular nutrient already, is there any benefit in that nutrient under certain circumstances in going beyond that level of sufficiency?


Vitamin D is the obvious one, and Dan's obviously done quite a bit of work on this over the years in terms of increasing. There was that, going back a few years now, there was that drive, again, for more and more vitamin D is better, and you were seeing athletes with extremely high 25OHD levels.


[0:58:59] LB: Well, there's also the translation of advice problem, isn't there? I had a football player who was taking his once a week dose every day. 12,000 IUs. No, 50,000. He took 50,000 IUs in one day.


[0:59:13] CS: Yeah. I mean, you see the same thing with things like creatine supplementation as well, which is another thing potentially, that may be beneficial for recovery of muscle. Again, not really too many high-quality studies in that area. But again, translation of that information. You've got people taking amounts well beyond what they need to take to really load the muscle.


[0:59:34] LB: Well, you made me think, actually, because particularly with athletes, we're trying to return them to play as fast as possible. We're also trying to think post-injury, beyond the injury, when they land, we're getting – the undercarriage is down, we're getting ready to land whilst in the air, their body's been fixing itself. We want to hit the ground running, not limping. I guess, there's some thoughts there about, we're not necessarily trying to focus on the injury, we're just trying to make sure that they're prepared for performance as soon as they're able. Then the worry would be, is any, are any of those strategies going to inhibit recovery in the damaged tissue? Your facial expression already answers the question, mate. Maybe.


[1:00:15] CS: Yeah, I mean, the obvious one there again is coming back to that issue of things that promote an anti-inflammatory response, isn't it? Or allegedly promote an anti-inflammatory response. To a certain extent, maybe acutely, if you've got a high level of inflammation that's not really resolving itself, then maybe you want to definitely go down that route. I think, the closer you get to looking at adapting back into performance, you want some of those performance related adaptations that may well be, again, arguably negatively impacted by some of those anti-inflammatory nutrient intakes.


Again, there's multiple ifs within that statement, but I'm just coming up with an example there for things that might match what you were saying there in your scenario, in terms of what factors – there's multiple transitions there, isn't there? I suppose there's transitions in that early phase of injury. There's transitions through that, if it's a prolonged injury, how do we manage that middle portion where the athlete is starting to get particularly stressed about not being able to play? Getting anxious and mental health, maybe suffering, all those other things that we've already talked about Probably some of the energy intake stuff is becoming particularly pertinent there as time goes by.


Then there's that third phase as we're starting to prepare people for return to play, where we may be taking a slightly more performance focused to our nutritional approach there, rather than maybe a recovery from injury focus, or an adaptation, or stabilization process to our nutrition. I think it's probably three, certainly three key phases there. Again, making it even more complicated. What do you really mean by recovery from injury, at least at times?


[1:01:57] LB: Yeah. Well, I can see multiple podcasts coming out of this one and multiple PhD projects for sure. We can't have this conversation about bones and muscles, etc., without talking about what keeps these things all connected and stable and so on, without getting into tendons and ligaments. Tendonopathy is an extremely common musculoskeletal issue, particularly in the sports I've worked in. I've frequently had athletes with tendinopathy issues that I've been asked, can I help anywhere in this?


I think back to Keith Baar's work, obviously., I was lucky to go out and co-present with him on the sports nutrition topics out in Doha, I mean, a few years ago now. It was fantastic to hear him talk about this stuff. We've done a podcast on this, by the way, for those listening, we can listen to Keith talk about this stuff.


Bringing this up to date to where we're at now in 2023, what are your perspectives on this? Again, no pun intended. Is there much legs as it comes to nutrition in this, or it's very much a depends situation, I guess?


[1:03:02] CS: Yeah. Again, not necessarily a thing that I focus on the most and certainly, Keith would know a lot more about it than I would. I mean, I think probably hasn't changed that much since you spoke to Keith about it. I suppose, that's one of the problems. Again, we've talked several times about the problem about studying these things. Even when you can study them, these studies take a long time. It's when you're talking about, we may feel quite a bit older in three, or four, or five years, but actually, the science generally hasn't moved on massively in that time and awful lot of the time, particularly these focused and relatively niche areas.


I mean, certainly tendinopathy, particularly patellatendinopathy and Achilles tendinopathy and ligament injuries and the obvious one there is ACL injury are certainly very pertinent injuries. They're still pretty common injuries. They're not really debated that much. Certainly, there is a definite requirement to try to prevent and treat these injuries. I think, probably some of the things that Keith would have talked about would have been things like bioactive collagen peptides, I'm assuming. Things like glycine, for example, which is the main amino acid found in collagen. These things have been played around within terms of potential recovery for tendon and ligament.


Again, a lot of the time that studied in either cell, or animal models of damage, where and are quite often under those circumstances, these things are artificial models of injury, for example, induced by things like collagenase injury, which is an enzyme responsible for the degradation of the collagen. It's a clean injury compared to the injury that you might get in all the other multifaceted things that you might see with a human injury. I don't think there's a silver bullet necessarily with regards to factors that would underpin tendon and collagen injury.


Like I say, people played around with these bioactive collagen peptides, glycine, and coming back to those other things. We're talking particularly about things like gelatin and hydrolyzed collagen, and some of the studies that Keith have done and shown in part, some reasonably positive outcomes in relation to isolated injuries, I guess.


[1:05:17] LB: Isolated. Yeah. He said everything you just said, and there's so much more work to be done on these areas. Of course, some of the stuff has been picked up and run way out of bounds by the commercial field, very expensive products –


[1:05:32] CS: Yeah, exactly.


[1:05:32] LB: Like, for training or whatever. I guess, one area that I have found of interest in my own practice is purely anecdotal lower, than vegan stroke plant-based athletes who have very low glycine rich diets, that sort of thing. It seems plausible to me that there can be something there. But I have plenty of athletes that have done nothing for at all, but then they've been immobilized. It's been very difficult to get them to do weight-bearing exercise.


[1:05:56] CS: Well, I think that's the thing. If you look at quite a few of the studies around this area where there'd been a positive effect of some of these nutrients that we've just been talking about are indeed some of the other nutrients that may underpin, be factors in collagen formation on. Vitamin C, copper, for example. Those kinds of things. Generally speaking, a lot of the positive responses that you see. But when you also associate that with some mechanical loading. You see beneficial effects on some of these collagen-related outcomes. When you've got a combination of the nutrient intake and the supplement, and some physical activity.

Of course, one of the problems is if you've got an injury that causes you to be significantly immobilized, then you don't necessarily make it. It's not quite so easy to really be physically active in the same way. Obviously, it's very difficult to match that in terms of recovery from an injury. Maybe intuitively, these things would potentially be less effective under those circumstances, and certainly in that, again, like I say, intuitively probably is the case. But again, from a very specific, well-controlled, randomized controlled trial, they don't really exist in humanly athletes, unfortunately.


[1:07:09] LB: No. Well, that's what's important about these conversations that I have with you and everyone for this podcast. It's all about addressing the evidence, and then unpacking it and talking about, well, what does this even mean? How relevant actually is this to said challenge? Actually, as we've discussed today, we still don't know much about this stuff. It's very easy for somebody to Google stuff, or just read a review without necessarily understanding how high quality that review is, or how relevant that review is to the specific situations that you're dealing with.


There's something that I hope that we've helped people with. If you and I can have a conversation for an hour, where we're not able to pinpoint any magic bullets, or anything, it shows that there is still so much more to learn about this. The value that that gives researchers and practitioners, I think, is huge.


[1:08:04] CS: Yeah. I mean, I think we can generally only, as you rightly say, can we really talk in relatively general terms most of the time? We can't really talk about a specifically clear evidence-based intervention that's definitively going to work for a particular type of injury under a particular circumstance. I think, again, it really comes back to one where I've got respect for you guys as practitioners, is trying to work through all of that fog of information and go, well, get it. Because at the end of the day, you've got to either decide to do something. If you're going to do something, well, and quite a lot of the time, you're probably under pressure, I would imagine, to do something. It's then, well, what do you do? How do you make that decision? I think that's where the skilled practitioner is particularly valuable.


[1:08:50] LB: You’re right. You talked earlier about – we’re sort of out of time here, so we'll wrap this up, but action is important in one form or another. That's where things can go wrong, because you start doing things for the sake of it and it ends up being worse than doing nothing. However, to the patient, to the athlete, not doing anything is a very worrying scenario. It's an anxiety producing situation, where sometimes you go, “Look. Okay, here's your collagen shots. Here's your extra protein, whatever.” In my head, I'm 100% not sure if this is going to work. I think it might help. The evidence is not strong either way, but I do know the placebo effect is also going to have some value here. If the expectation is, “Doc whatever, give me something,” that is another factor you have to go through as a practitioner.


It's difficult being a practitioner in the trenches. There's a lot of this stuff to contemplate, either which way, which is, again, why we had these conversations, because you need to be able to make those decisions in pretty chaotic scenarios. Where the other thing is, is your patient, your client, your athlete, if you don't give some a recommendation that is perceived to be a satisfactory recommendation, they're going to go find a solution elsewhere.


[1:10:06] CS: Yeah. I mean, there's so many problems packed up in there. Probably as a practitioner, your job’s under threat, if you are constantly saying, “Well, there's no evidence. I think, nothing is probably here any sensible thing.” The athlete is getting strained here. As you say, the athlete then said, “Right. Well, I'm going to Google this,” and that's even more dangerous. They're going to do something. If what they're doing is what they're finding on Google, that's going to be even more problematic.


Yeah, I mean, it is difficult. I mean, I think sometimes action has to, as you say, has to happen as a practitioner. It's just then trying to make that as evidence-based and as sensible as possible, without something that's going to do that athlete harm. But really, trying to pinpoint an evidence-based intervention a lot of the time is particularly difficult, particularly in this area where it is very, very difficult to undertake the source of studies that you would need to generate said evidence-based. I think that is the biggest problem in this area is it's just very difficult to – It's a very, very contentious thing, isn't it?


[1:11:08] LB: No, it is. Yeah. I'll have announced this before this podcast comes out. We've just had a paper accepted for publication all about evidence-based practice guidelines and a framework for critical thinking for practitioners to apply evidence into practice. Because it is difficult. It's really difficult to do this stuff. Hopefully, that will help everyone.


We've managed to chat this long, Craig. Once again, two geeks obsessed about this topic managed to – I think, have a pretty broad conversation about this very important topic. I for one have benefited hugely from this chat. Thank you. I know the listeners will benefit, too. To remind everyone, you have moved, etc. If people want to follow you and your work and on, what's the best way to keep tabs on you, Craig?


[1:11:59] CS: Yeah. The Twitter and the Instagram haven't changed. They're the same as they always –


[1:12:04] LB: Always to those.


[1:12:05] CS: Haven’t changed those. Don't ask me what they are, because I can never remember them, but they haven't changed. That's the main thing. If people want to search me out, then Google me for Institute of Sport Manchester Metropolitan University. I should come up with contact details, email, etc.


[1:12:21] LB: Brilliant. Well, look, thank you, Craig. It's always great to chat with you. I know we're going to have other things to talk about down the line. I'll look forward to welcoming you back.


[1:12:32] CS: No, thanks, Laurent. Enjoyed it as always. Always a pleasure, never a chore, as they say.


[1:12:36] LB: Always, always. Thanks, mate. Cheers.